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PS3013: Clinical Psychology

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Title: PS3013: Clinical Psychology


1
PS3013 Clinical Psychology
  • Dementias
  • Dr Claire Gibson
  • cg95_at_le.ac.uk
  • School of Psychology, Leicester

2
Overview
  • Aging
  • Dementia
  • Defining/Classifying
  • Identification
  • Causes
  • Treatment/Interventions

3
Normal 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

4
Aging 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?

5
Aging 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

6
Dementia - Clinical Challenge
Patient with cognitive dysfunction
Incipient Dementing Disease
Increasing Age
Mild Cognitive Impairment (MCI)
7
Mild 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?

8
If it is dementia, what sort of dementia is it?
9
Defining Dementia
  • De apart, away
  • Mens mind
  • Progressive decline in cognitive functioning
    beyond that expected for normal aging
  • Memory, attention, language, problem solving

10
Defining Dementia
  • non-specific term
  • Symptoms reversible or irreversible (gt10)
  • a cluster of behavioural symptoms that may or
    may not point to a disease

11
Causes of dementia
12
Classification of dementia
  • Cortical vs. subcortical
  • Static vs. progressive
  • Reversible vs. irreversible

13
1. 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

14
2. 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,

15
3. 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

16
Clinical Assessment
  • To determine IF dementia is present
  • If so, what TYPE of dementia is it?

17
Clinical Assessment
  • Biological Assessment
  • Brain Imaging
  • Neurochemical Assessment
  • Neuropsychological Assessment
  • Psychophysiological Assessment
  • Psychological Assessment
  • Clinical Interviews
  • Psychological Tests

18
1. Biological Assessment
  • Brain Imaging
  • CT Scan
  • MRI structural functional
  • Pet scan

19
1. Biological Assessment
  • Neurochemical Assessment
  • Amount of neurotransmitter, quantity of
    neurotransmitter receptors,
  • PET scanning
  • Post-mortem
  • Metabolites
  • Urine, blood, CSF

20
1. Biological Assessment
  • Neuropsychological Assessment
  • Neuropsychologist
  • Psychological testing
  • Psychophysiology
  • Bodily changes
  • Autonomic nervous system (ANS)

21
2. 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

22
2. 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

23
Pathological causes of dementia
  • Alzheimers Disease (AD)
  • Parkinsons Disease (PD)
  • Huntingtons Chorea (HC)
  • Reversible dementia

24
Alzheimers Disease (AD)
  • Alois Alzheimer
  • Cortical dementia, irreversible
  • Most devastating and prevalent of dementias
  • 50 of all diagnosed dementias

25
Alzheimers 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

26
Alzheimers Disease (AD)
  • Occurrence
  • 7 of population over age of 65
  • 40 population over age of 80
  • 18 million people worldwide
  • 1 million people UK

27
Alzheimers 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

28
Alzheimers 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

29
Alzheimers Disease (AD)
  • Pathology
  • 1. Atrophy
  • 2. Histopathological features
  • 3. Neurotransmitters systems

30
Alzheimers Disease (AD)
  • 1. Atrophy

AD severe degeneration of the hippocampus,
cerebral cortex and ventricular enlargement
31
AD brain regions
32
Alzheimers Disease (AD)
  • 2. Histopathological features
  • A. Plaques

33
Alzheimers Disease (AD)
  • 2. Histopathological features
  • B. Neurofibrillary Tangles

34
Alzheimers 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

35
Causes 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

36
Subcortical Dementias
  • Do affect cortical functioning
  • However, structures predominantly damaged
    subcortical
  • Examples
  • Parkinsons Disease (PD)
  • Huntingtons Disease (HD)

37
Parkinsons 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?

38
Parkinsons Disease
  • Loss of dopaminergic cells in substantia nigra
  • Presence of Lewy bodies

39
Parkinsons 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?

40
Huntingtons Chorea (HC)
  • Rare
  • Progressive, subcortical dementia
  • Hereditary

41
Huntingtons Chorea (HC)
42
Huntingtons 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

43
Reversible Dementia
  • Benign Tumors
  • Chronic subdural haemotoma
  • Metabolic and endocrine disorders
  • Wilsons disease
  • Infections
  • HIV

44
Dementia - 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)

45
Mental 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

46
Reminiscence Therapy
  • Remembering the past positive experiences
  • Individual/group sessions
  • Increase well-being/provide pleasure
  • Impact?
  • Other benefits
  • Pre-morbid aspects of personality

47
Dementia and depression
  • Similar symptoms?
  • Frequently co-exist
  • Depression or dementia?
  • Accurate diagnosis
  • Uncertainty
  • Depression may exacerbate dementia
  • Behavioural changes

48
Carers
  • 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

49
References(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
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