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Chapter 14

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Chapter 14 Cognitive disorders • Geropsychology: 10-20% of those over 65 have psychological problems severe enough to qualify for a diagnosis and to warrant treatment; even higher rates in those over 85 • Cognitive disorders: impairments in cognition caused by a medical condition (such as Alzheimer’s) or by substance intoxication/withdrawal; include memory deficits, language disturbances, perceptual disturbances, impairment in the capacity to plan and organize and the failure to recognize or identify objects; formerly called organic brain disorders Dementia • Prevalence: most common cognitive disorder; 5-10% prevalence in people over 65 due to Alzheimer’s; 20-50% in those over 85; increased public attention in the past decade; over ½ those with dementia live in institutions • Symptoms: memory impairment, including impaired ability to learn new information or to recall previously learned information (men more likely to have memory problems); aphasia (deterioration of language); apraxia (inability to carry out motor activities despite intact motor function); agnosia (failure to recognize or identify objects despite intact sensory functioning); disturbance in executive functioning (such as planning, organizing, sequencing and abstracting information) o Changes in emotional/personality functioning: declines in judgment; inability to control impulses; often don’t recognize or admit to cognitive deficits; paranoid or angry with family members o Echolalia: repetition of what people hear; advanced stages o Palialia: repetition of sounds or words; advanced stages • Clock Test: symptoms develop insidiously; fail to identify in 50% or more cases; clock drawing/setting require higher cognitive functioning, including visuospatial skills; approximately 95% identified • Alzheimer’s disease: most common type of dementia; accounts for 50%; begin with mild memory loss but memory loss and disorientation become profound as disease progresses; 2/3 of patients show psychiatric symptoms of agitation, irritability, apathy and dysphoria; can become violent and experience hallucinations and delusions; early onset (pre-65) progresses more quickly; die within 8-10 years of diagnosis; first described by Alois Alzheimer in 1906 o Neurofibrillary tangles: filaments within nerve cells become twisted; common in brains of Alzheimer’s patients but rare in those without cognitive disorders; interfere with basic functioning of neurons o Plaques: deposits of a class of protein called amyloid that accumulate in the spaces between the cells of the cerebral cortex, hippocampus, amygdale, etc o Cell death: occurs in cortex of A’s patients; shrinking or atrophy of cortex and enlargement of ventricles; remaining cells lose many dendrites • ApoE4: 25-50% of relatives eventually develop the disease; defective gene associated with rare protein on chromosome 19 associated with increased risk for late onset form; ApoE4 transports cholesterol through the blood; binds to amyloid protein and may play a role in its regulation; gene accounts for 45-60% of all cases of Alzheimer’s; people without gene much more likely to maintain high levels of intellectual functioning (Sisters of Notre Dame study) • Protectors and predictors: increased age, low education level and absence of ApoE4 gene predict onset; regular physical activity important protective factor • Other genes: abnormal gene on chromosome 21 (Down syndrome patients more likely to develop AD); gene responsible for producing a precursor of the amyloid protein (APP gene); defective gene on chromosome 14 linked to early onset AD and responsible for protein on cell membranes called S182; gene E5-1 on chromosome 1 also implicated • Neurotransmitters: deficits in acetylcholine (critical in memory function), norepinephrine, serotonin, somastostatin (corticotrophin-releasing factor) and peptide Y • Vascular dementia: second most common type; symptoms or lab evidence of cerebrovascular disease, which occurs when blood supply to areas of the brain is blocked, causing tissue damage; caused by high blood pressure and accumulation of fat in arteries which block blood flow to brain; can also be complication of head injuries and diseases that inflame the brain; dementia can occur after one large stroke or several small ones o Stroke: sudden damage to an area of the brain due to the blockage of blood flow or to haemorrhaging; 25% of stroke patients qualify for diagnosis of dementia • Head injury: can be caused by penetrating injuries (gunshots), closed head injuries (blows to head); dementia following a single CHI is more likely to dissipate over time than that which follows repeated injuries; young men most likely to suffer this kind of dementia o Dementia pugilistica: dementia due to repeated head injuries; seen in boxers, hockey players, etc; characterized by cognitive symptoms, personality changes, shaking and loss of motor function • Other medical conditions: Parkinson’s, HIV, Huntington’s, Pick’s, Creutzfeldt- Jacob, brain tumours, endocrine conditions, nutritional conditions, infectious conditions; chronic use of alcohol, inhalants and sedative drugs; 10% of chronic alcohol abusers develop dementia; slow insidious and often irreversible o Parkinson’s: degenerative brain disorder that affects one of every 100,000 people; primary symptoms are tremors, muscle rigidity and inability to initiate movement; results from death of brain cells that produce dopamine; can be caused by certain drugs or brain inflammation o HIV: enters brain in early stages of infection; memory, concentration, mental processes impaired; behaviours change; fatigue, depression, irritability, emotional instability; speech and understanding of language can become impaired  HIV associated dementia: deficits and symptoms become severe and global; 20-50% of patients will develop dementia; decrease as antiretrovirals are more widely used; drugs better in treating opportunistic infections than HIV’s effects on the brain o Huntington’s disease: rare genetic disorder that afflicts people between 25 and 55; develop severe dementia and chorea (irregular jerks, grimaces and twitches); transmitted by single dominant gene on chromosome 4 • Treatments for dementia: cholinesterase inhibitors like donzepezil (Aricept), rivastigmine (Exelon) and galantamine(Reminyl) prevent breakdown of acetylcholine and have a modest positive effect on dementia symptoms; memantine (Namenda) treats moderate to severe Alzheimer’s by regulating glutamate (memory and learning); give Parkinson’s patients drugs to improve dopamine; antioxidants (vitamin E, selegiline – selective monoamine oxidase-B inhibitor) slow cognitive decline in Alzheimer’s; ginkgo biloba stabilizes and improves cognitive functioning in some Alzheimer’s patients; work by reducing levels of monoamine oxidase-B in brain, which increase at excessive rate in hippocampus, causing cell damage • Impact of gender and culture on dementia: more elderly women than men with dementia, particularly AD; women show greater decline in language skills (language more localized in men); cultural validity of instruments used to assess cognitive impairment; poorly educated people misdiagnosed with dementia; education and cognitive activity throughout life increase brain resources and forestall development of dementia; most powerful predictors are educational attainment, occupational attainment and estimated premorbid IQ Delirium • Delirium: disorientation, recent memory loss and clouding of consciousness; difficulty focusing attention; sig
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