Center of Gerontological Nursing

SN3209 Health and Ageing

Week 12
Promoting wellness in psychosocial function:
Cognitive Health

Rick Kwan, RN PhD

Assistant Professor
School of Nursing, PolyU
 Intended Learning Outcomes
• The concept of cognitive function and impairment
• The difference between cognitive impairment and dementia
• Staging of Cognitive impairment or dementia
• Various causes for cognitive impairment
• Clinical presentations of dementia
• 2 pathologies of dementia
• Risk factors and prevention of dementia
• Dementia derived problems: self-care & BPSD
• 2 BPSD theoretical models
• Management of dementia
 Cognitive function
• A general term, also known • The ability of a person to :
as brain function -Remember
• Is related to intelligence, it -Concentrate
makes us able to -Use language
perform various tasks, to -Reason
reason, and to solve -Problem solving
problems reflects one’s level of
cognitive function
• It involves
1) Acquisition and use of
knowledge
2) Thinking process
Mobile Cognitive Assessment Clinic, Psychogeriatic department, Castle
3) The ability to handle, Peak Hospital
http://www3.ha.org.hk/cph/mcac/e-knowledge.htm

store, retrieve and use

information
 Cognitive function
• From birth to adulthood, our brain nerves grow and
develop
• Our ability to process knowledge increases day by
day
• Acquired from what we see and we learn
• Our cognitive function increases gradually
 Cognitive impairment
• Activities of brain cells create cognitive function
• When brain cell is damaged (for any reasons),
cognitive function can be impaired
 Reasons for cognitive decline/impairment
• Common reasons include: (some may be reversible and some
are not):
• Age
• Elderly dementia (e.g., Alzheimer's disease)
• Stroke
• Brain infection (e.g., syphilis, encephalitis)
• Trauma (e.g., car accident)
• Medical conditions (eg., low level of thyroid hormone)
• Medication (eg., anti-Parkinson drugs)
 Cognitive impairment and dementia
• Cognitive impairment
• Cognitive ability declines as you age
• When the decline rate faster than expected, it is
cognitive Impairment
• Dementia
• It is a progressive and irreversibly cognitive impairment
declines to a level that affect functioning/independence
• The cognitive impairment in dementia cannot be
better explained by other mental disorders
• In a normal person without dementia, cognitive
function can remain “normal by age” until death
Simplified DSM 5 definition
 Presentation of cognitive impairment
• Decrease in concentration/attention
• Cannot concentrate in a multi-stimulus environment (e.g.,television)
• Decrease in ability to perform a task
• Stop doing more complex activities that used to do in the past
• Decrease in ability to learn and remember
• Repeated words, need others to remind repeatedly to complete a
simple new task
• Decrease in use of language
-The ability to comprehend and express decreases , the use of vocabularies
reduces, Less fluency in the use of language
• Decrease in visual-spatial perception
-Get lost even in a familiar environment
• Decrease in social cognition According to DSM5
- not following social etiquette
Presentation of independence decline
 Staging of cognitive impairment

• Commonly • By two principles:

• Subjective Cognitive • Cognitive function
Decline SCD • Global functioning
• Mild Cognitive
Impairment
• Common instruments to
MCI stage:
• Early stage dementia
• Global Deteriorating
• Moderate stage ES Scale (GDS)/Functional
dementia
Assessment Staging Test
• Severe stage dementia MS (FAST), (Reisberg et al, 1982)
• Clinical Dementia Rating
SS Scale (CDR), (Morris, 1993)
Staging of cognitive impairment
Staging of dementia
 Prevalence of dementia

Yu et al (2012)

Estimated and projected numbers of people living in community with dementia in Hong Kong, by age group and sex, 2009 and 2039.
Types of Dementia
Different types of dementia

The Carlat Psychiaty

Report (2013)
 Pathological causes

Common Other disorders linked to

• Alzheimer’s disease • Huntington’s disease
• Vascular dementia • Traumatic brain injury
• Mixed dementia • CJD
• Lewy body dementia • Parkinson’s disease
• Frontotemporal
dementia
 Dementia-like conditions
• They are called so because the following conditions
can be reversed with treatment:
• Infections and immune disorders
• Metabolic problems and endocrine
• Hypoglycemia, low thyroid, inability to get enough vit B6,12
• Nutrition
• Inadequate folate, vit B6,12
• Medication
• Cholinergic drugs
• Brain tumor
 Alzheimer’s disease
• Natural history
• Alzheimer disease is
coined by Dr. Alois
Alzheimer
• Two microscopic
features he observed
• Amyloidal plaques
• Neurofibrillary tangles
 Pathological features of AD

Amyloidal plaques Neurofibrillary tangles

 AD pathological hypotheses
• Amyloid cascade hypothesis
• Cholinergic hypothesis
• Tau hypothesis
• Inflammation hypothesis
 Amyloid cascade hypothesis
• APP is normally cleaved by
secretase and aberrantly
processed by secretases
• Abnormal cleavage results
in an imbalance between
production and clearance of
Aβ peptides.
• Aβ peptides spontaneously
aggregate into soluble Aβ42
oligomers and coalesce to
form fibrils => plaques
 Amyloid cascade hypothesis
• Aβ42 oligomers also promote tau
hyperphosphorylation => tau oligomers => NFT
Amyloid cascade hypothesis
 Vascular dementia
• Some vascular
pathologies, associated
with clinically observed
cognitive impairment
include:
• White matter lesions
• Lacunar infarct, often
involving subcortical
areas (e.g. thalamus,
frontobasal, limbic
system)
 Vascular dementia pathologies

White matter lesions

Lacunar infarct in
subcortical area
 Mixed dementia
• It means co-existing of
AD and VaD pathologies
• However, more
evidence shows that
there is a strong
overlap between
pathology of AD/VaD
• Evidence tends to
advocate that dementia
is caused by an
interaction between AD
and VaD pathologies.
 Diagnosis of dementia

Diagnostic criteria Methods

• DSM5 • Clinical, i.e.
• ICD10 • Cognitive performance
test
• NIA-AA • Interview (both clients
• NINCDS-ADRDA and informants)
• Recently integrated
biomarkers (now for
research purpose only)
 DSM5
• Dementia is called • NCD-Maj (AD) criteria
“neurocognitive • Memory impairment must
be present
disorders” – • Gradual and progressive
Major/Minor course
• NCD-Maj is formerly • Decline must not be due to
medical conditions
known as dementia
• NCD-Min is also known as
• Criteria MCI
• Significant cognitive • Criteria
decline • Objectifiable cognitive
• Interferes with complex decline, do not interfere
activities, e.g. paying independent functioning
bills, cooking
 Risk factors of dementia
• Cause of dementia is very much associated with
vascular health (both cardio and cerebral vascular)
• Many risk factors of dementia are in common with
CAD and stroke
 Risk factors of dementia
• The greatest risk factors
of “sporadic” dementia
are mostly non-
modifiable, which are:
• Age
• Family history
• Genetic susceptibility
genes, e.g.
• ApoE ε4 allele
 Modifiable risk factors

Cardiovascular factors Lifestyle 1

• DM • Current smoking
• Mid-life obesity, • Alcohol
• Being overweight/even • Small or moderate
possibly being obese in alcohol consumption
later life has been may decrease risk of
associated with cognitive
reduced risk of decline/dementia
dementia • Do not suggest those
• Mid-life hypertension who don’t drink to start
drinking
• Hyperlipidemia
 Modifiable risk factors

Lifestyle 2
• Cognitive training • Social engagement, e.g
• Physical activity • Doing volunteer work,
joining a club, or going
• Reduce risk of CI/
to church
improve cognitive fx
• Good even with mild PA
such as walking
• Should be regular, more
vigorous
 Modifiable risk factors

Other risk factors

• Years of formal • Depression
education • Depressive symptoms
• Greater literacy are independently
associated with
• Traumatic brain injury cognitive decline
• Repeated head injuries,
e.g. boxers, football • Sleep
players, combat • Sleep disturbance
veterans) increase risk for
cognitive decline, e.g.
• Insomnia, sleep apnea
Summary of risk factors for CD
Summary of risk factors for dementia
Pharmacotherapy for dementia
Pharmacotherapy for dementia
 Prevention of dementia
• To date, there are no
proven
pharmaceutical/nutrac
eutical methods to
prevent dementia
• Prevention of dementia
remains mainly on
modifying the
modifiable risk factors
of dementia
Revisit some risk factors
 Prevention of dementia methods
• Depression: live a happy life, management of
depression
• CV diseases (e.g. HT/CVD): good control by drugs
• Life style: smoking cessation
• Diet: Mediterranean diet
• Cognitive activity: remain participating in
cognitively active environment/living
 Is it effective?
• Target:
• 60-77 yr
• At risk for dementia by
CAIDE dementia risk
score
• Age, sex, education, SBP,
BMI, lipid, PA
• Multiple domain
intervention:
• Diet, exercise, cognitive
training, CV risk
monitoring)
• Outcome: cognitive fx
Is it effective?
 Problems of dementia
• Deterioration of self-care
- may affect the safety of themselves and others
• Misuse of home appliances
• Family members need to take more time to take care of the
patients(e.g., financial management, household chores)
• Change in behavior and emotion
• may cause conflict with others
• (e.g., suspected of property being stolen, day-and-night reversed lifestyle

• Alienate from others

• (e.g., unable to communicate with others )
資料來自﹕
衞生署長者健康服務
 Dementia derived problems

• Behavioral Psychological Symptoms of Dementia

(BPSD)
• A number of studies looking at the occurrence of
BPSD in nursing home populations have found these
symptoms to occur in up to 90% of patients

Adopted from the BPSD education pack at IPA, downloaded at http://www.ipa-

online.org/ipaonlinev3/ipaprograms/bpsdarchives/bpsdrev/1BPSDfinal.pdf
 BPSD

• Behavioral symptoms
• Usually identified on the basis of observation of the
patient, including physical aggression,
• screaming, restlessness, agitation, wandering, culturally inappropriate
behaviors, sexual
• disinhibition, hoarding, cursing and shadowing.

• Psychological symptoms
• Usually and mainly assessed on the basis of interviews with
patients and relatives; these symptoms include
• anxiety, depressive mood, hallucinations and delusions.
 BPSD

• Untreated BPSD contribute to:

• premature institutionalization
• increased financial cost
• Decreased quality of life for both the caregiver and the
patient
• Signifiant care giver stress
• Stress to nursing staff in residential facilities
• Excess disability, i.e. people with BPSD function at a lower
level than those without. Once symptoms are ameliorated
or removed, functional level improves
 Theoretical models on BPSD
• Need-driven Dementia-compromised Behavior (NDB)
model
Donna L. Algase, 1996

• Socio-psychological Theory of Personhood in

Dementia
Tom Kitwood, 1997

Theoretical backup of many non-drug methods

 NDB model

Background factors Not much

modifiable
- Neurological
- Cognitive
- General Health
- Psychosocial NDB
- Wandering
- Vocalizing
- Physical aggression
Proximal factors
- Personal
- Physical Environment Quite
- Social Environment modifiable Donna L. Algase, 1996
 Personhood
• Inherent approach • Interpersonal approach
• A personhood is born
• Never change
• Capacity-based
approach
• A personhood bases on
the cognitive capacity
• “the dementia person is
no longer a person that
they once was”
• Personhood is not
• Inherent
• Based on capacity
• Personhood is constructed
and maintained in a social
environment
• Change with environment
• “Personhood is a position or social
relationship that is bestowed on one
human being by “others”, in the
context of relationship and social
being” (Kitwood, 1997)
 Person centered care
• It disagreed with the • Person centered care
“capacity based focuses on individual’s
personhood” • Unique qualities
• Believed that • Unique abilities
• BPSD is an interactive • Unique interests
result of • Preference and needs
• Dementia pathologies • It focuses on outcomes
• Ignorance of
personhood of
• BPSD itself is also an • Dignity of the PWD
ignorance of (person first), not
personhood • Problematic behaviors
• Treat person as a
collection of symptoms
to be controlledTom Kitwood, 1997
 NDB and Personhood
• Message from these theories
• Take care of the person, not the disease/symptoms
• BPSD can be partially explained by unmet needs
• Management of BPSD focuses on provide cares to meet
clients’ needs interacted with dementia
• Care based on this philosophy commonly called
• Person Centered Care (PCC)
 Person Centered Care
• VIPS framework
• V: a Value base that
asserts the absolute
value of all human
• I: an Individualized
approach
• P: understand the world
from the Perspective of
the PWD
• S: positive Social
psychology
 Person Centered Care
• A study published in Lancet
Neurology in 2009 by
comparing PCC and DCM
and usual care
• A clustered randomized
trial
• 15 care sites with 289
residents
• Found that PPC significantly
reduce agitation when
comparing with DCM and
usual care
Chenoweth et al, 2009
 Other management on dementia

Drugs Non-drug
1) Cholinesterase inhibitors 1) Cognitive stimulation
2) NMDA receptor 2) Multi-component
antagonists interventions for the PWD
3) Psychotropic drugs 3) Behavioral interventions
• Target on outcome of:
-Cognitive function
4) Professional CG training
-Neuropsychiatric symptoms • Target on outcome of:
-Cognitive function
-Behavior
-Mood -Neuropsychiatric symptoms
-Quality of life -Quality of life
Santaguida p, et al, 2004 -Caregiver stress

For more info about non-drug treatment, please read Olanzaren et al, 2010
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