Title: PS3013: Clinical Psychology
1PS3013 Clinical Psychology
- Dementias
- Dr Claire Gibson
- cg95_at_le.ac.uk
- School of Psychology, Leicester
2Overview
- Aging
- Dementia
- Defining/Classifying
- Identification
- Causes
- Treatment/Interventions
3Normal Aging
- 1 population aged 60-70 suffer from dementia
- 18-85 population suffer from dementia by age of
85 - Clinical need to distinguish between age-related
dementia and pathological causes of dementia,
e.g. AD
4Aging cognitive changes
- Cognitive changes
- Long-term memory, problem solving (habitual)
- Novel reasoning, efficiency of solving new
problems - New learning, abstract and complex new problem
solving, behavioural speed, - Individual variation
- Inevitable consequence of aging
- Other factors?
5Aging brain changes
- Gross changes
- Decreased size
- Flattening of cortical surface
- Increasing amounts of intracranial space
- Neuroanatomical changes
- Loss of neurons,
- Changes in neuronal size,
- Altered dendritic processes
- Tangles and plaques
- Neurotransmitter changes depression, memory
problems - Not uniform
6Dementia - Clinical Challenge
Patient with cognitive dysfunction
Incipient Dementing Disease
Increasing Age
Mild Cognitive Impairment (MCI)
7Mild Cognitive Impairment (MCI)
- Concept is clinically important
- Slowly developing memory impairment
- Clinically manifest dementia absent
- Preserved activities of daily living
- High rate of progression MCI ? AD
- Early identification
- Stabilise symptoms?
- Delay progression to dementia?
8If it is dementia, what sort of dementia is it?
9Defining Dementia
- De apart, away
- Mens mind
- Progressive decline in cognitive functioning
beyond that expected for normal aging - Memory, attention, language, problem solving
10Defining Dementia
- non-specific term
- Symptoms reversible or irreversible (gt10)
- a cluster of behavioural symptoms that may or
may not point to a disease
11Causes of dementia
12Classification of dementia
- Cortical vs. subcortical
- Static vs. progressive
- Reversible vs. irreversible
131. Cortical vs. subcortical
- Cortical cerebral cortex e.g. AD
- Subcortical white matter, neuronal connections
between cortical areas and gray matter structures
below the cortex e.g. PD, HD - BUT too restrictive, refer to PRIMARY area of
damage rather than EXCLUSIVE area of damage
142. Static vs. Progressive
- Progressive ALL dementias that result from a
disease process - Static result from a neurotoxic substance (e.g.
alcohol) or infection (e.g. herpes encephalitis) - Progression repeated neuropsychological
treatment, family/carers,
153. Reversible vs. irreversible
- Reversible delirium or dementia?
- Delirium does not dementia
- Delirium transient cognitive problem associated
with an acute confusional state - Delirium and dementia memory impairments and
disorientation - A true reversible dementia patient must show
dementia in absence of delirium
16Clinical Assessment
- To determine IF dementia is present
- If so, what TYPE of dementia is it?
17Clinical Assessment
- Biological Assessment
- Brain Imaging
- Neurochemical Assessment
- Neuropsychological Assessment
- Psychophysiological Assessment
- Psychological Assessment
- Clinical Interviews
- Psychological Tests
181. Biological Assessment
- Brain Imaging
- CT Scan
- MRI structural functional
- Pet scan
191. Biological Assessment
- Neurochemical Assessment
- Amount of neurotransmitter, quantity of
neurotransmitter receptors, - PET scanning
- Post-mortem
- Metabolites
- Urine, blood, CSF
201. Biological Assessment
- Neuropsychological Assessment
- Neuropsychologist
- Psychological testing
- Psychophysiology
- Bodily changes
- Autonomic nervous system (ANS)
212. Psychological Assessment
- Clinical Interview
- how respondent answers (doesnt answer)
- great skill
- rapport
- Empathy (humanistic therapists)
- Structured Interviews
- e.g. Structured Clinical Interview (SCID) for
DSM-IV, Spitzer, Gibbon Williams, 1996
222. Psychological Assessment
- Psychological Tests
- Standardised procedures
- Intellectual function
- WAIS, NART
- Memory and learning
- Rivermead, WMS, Fuld
- Language
- Executive function
- frontal lobe, Wisconsin card Sort, Trail Making
Test
23Pathological causes of dementia
- Alzheimers Disease (AD)
- Parkinsons Disease (PD)
- Huntingtons Chorea (HC)
- Reversible dementia
24Alzheimers Disease (AD)
- Alois Alzheimer
- Cortical dementia, irreversible
- Most devastating and prevalent of dementias
- 50 of all diagnosed dementias
25Alzheimers Disease (AD)
- Degenerative brain disorder
- Unknown origin
- Progressive memory loss, motor deficits, eventual
death - 1st identified 100 yrs incidence ? ? -
diagnosis, aging population - Sufferers and carers
26Alzheimers Disease (AD)
- Occurrence
- 7 of population over age of 65
- 40 population over age of 80
- 18 million people worldwide
- 1 million people UK
27Alzheimers Disease (AD)
- Early signs
- 7 of population over age of 65
- 40 population over age of 80
- 18 million people worldwide
- 1 million people UK
28Alzheimers Disease (AD)
- Symptoms
- Memory impairment
- Progressive memory loss (initially declarative
and episodic) - Loss of function
- Insight, judgement, language (words, names)
- Personality changes
- Apathy social withdrawal, depression
29Alzheimers Disease (AD)
- Pathology
- 1. Atrophy
- 2. Histopathological features
- 3. Neurotransmitters systems
30Alzheimers Disease (AD)
AD severe degeneration of the hippocampus,
cerebral cortex and ventricular enlargement
31AD brain regions
32Alzheimers Disease (AD)
- 2. Histopathological features
- A. Plaques
33Alzheimers Disease (AD)
- 2. Histopathological features
- B. Neurofibrillary Tangles
34Alzheimers Disease (AD)
- 3. Neurotransmitter Systems
- Acetylcholine (Ach)
- Basal Forebrain Cholinergic Complex
- Neurons nucleus basilis of Meynert, diagonal
band of Brocas area, globus pallidus - Axons hippocampus and cerebral cortex
- Ach involved in learning and memory (PS2014/8)
- Others glutamate, catecholamines, somatostatin,
corticotrophin
35Causes of AD (PS2014/8)
- Early onset
- Hereditary
- gene mutations on chromosomes 1, 14 or 21
- lt5 cases
- lt60 yrs of age
- Late-onset
- Majority cases
- gt60 yrs ages
- Most cause unknown
36Subcortical Dementias
- Do affect cortical functioning
- However, structures predominantly damaged
subcortical - Examples
- Parkinsons Disease (PD)
- Huntingtons Disease (HD)
37Parkinsons Disease
- Does not always dementia
- 40 PD patients criteria for dementia
- 12 PD patients aged 50-60
- 70 PD patients aged over 80
- Is PD the cause of dementia?
38Parkinsons Disease
- Loss of dopaminergic cells in substantia nigra
- Presence of Lewy bodies
39Parkinsons Disease
- a behavioural syndrome characterised by motor
symptoms of tremor, rigidity, slowness of
movement - Visual spatial deficits (without motor component)
- Executive dysfunctions
- difficulty in tests that require strategy shifts
to solve problems - word finding
- Memory
- relatively spared, although deficits in
organisation and retrieval of declarative memory - Depression
- disease or medication?
40Huntingtons Chorea (HC)
- Rare
- Progressive, subcortical dementia
- Hereditary
41Huntingtons Chorea (HC)
42Huntingtons Chorea
- Difficulties associated with frontal lobe
functioning and motor functioning - Motor
- Chorea twisting, writhing movements of face and
body - Cognitive
- Memory retrieval problems
- Poor ability to differentiate what they know and
dont know - Affective disturbance depression, high suicide
rate, anxiety, aggresiveness
43Reversible Dementia
- Benign Tumors
- Chronic subdural haemotoma
- Metabolic and endocrine disorders
- Wilsons disease
- Infections
- HIV
44Dementia - Interventions
- Pharmacological Interventions
- e.g. AD may slow progression from mild to
moderate severity (Aricept) - Non-pharmacological interventions
- Reality Orientation (RO) (Holden Woods, 1995)
environmental changes consistency from staff - Extensive memory aids, orientation sessions (with
whiteboard), personal diaries for recording - Holden Woods review of 21 studies consistent
improvements in verbal orientation variable
generalisability to other cognitive function
questionable translation to behavioural/functional
change - Music interventions (Sherratt et al., 2004)
45Mental Health Problems
- Dementias - 5 aged 65, 20 over 80.
- Some individuals showing little deterioration for
up to 4 years - Diagnosis clearer in mod/severe category
- Cognitive changes universal, other common
features include challenging behaviours, anxiety,
hallucinations, depression. - Latter contribute more to carer strain
46Reminiscence Therapy
- Remembering the past positive experiences
- Individual/group sessions
- Increase well-being/provide pleasure
- Impact?
- Other benefits
- Pre-morbid aspects of personality
47Dementia and depression
- Similar symptoms?
- Frequently co-exist
- Depression or dementia?
- Accurate diagnosis
- Uncertainty
- Depression may exacerbate dementia
- Behavioural changes
48Carers
- Caring most challenging part of the lifespan
- Primary (time, effort, energy) vs secondary
(family and job conflict, self-esteem, loss of
self) stressors - Mediated by coping and actual/perceived support
- Emotional distress mediated by previous
relationship with carer, gender, views of
reciprocity - Increasing use of non-familial care
- Maintenance of individual in community
- Institutional care and impact on staff (empathy,
burnout) - Elder abuse
49References(all available online via Athens
logon)
- Cooper, S. Greene, J.D.W. (2005). The Clinical
Assessment of the Patient with Early Dementia.
Journal of Neurology, Neurosurgery and Psychiatry
76 (Suppl V), v15-v24. - Douglas, S., James, I. Ballard, C. (2004)
Non-pharmacological interventions in dementia.
Advances in Psychiatric Treatment, 10, 171-179. - Jelic, V., Kivipelto, M. Wonblad, B (2006)
Clinical trials in mild cognitive impairment
lessons for the future. Journal of Neurology,
Neurosurgery Psychiatry, 77, 429-438. - Nordberg, A. (2004) PET imaging of amyloid in
Alzheimers disease. The Lancet Neurology, 3,
519-527. - Sherratt, K., Thornton, A. Hatton, C (2004).
Music interventions for people with dementia a
review of the literature. Aging and Mental
Health, 8, 3-12. - Abnormal Psychology textbook - see module
homepage for recommendations