2. Identify manifestations of
abnormalities in brain function
associated with aging.
Explore interventions and
treatments to maximize functioning
when pathology is present.
4. Delirium is often unrecognized
Delirium might be the only indication of
a life threatening condition
Extremely important to identify
5. Approximately 14-80% of hospitalized elderly
patients experience an episode of delirium
Can represent a medical emergency and is a
potentially reversible condition
Requires immediate interventions to prevent
permanent disability and health risks including
death
6. increased length of hospitalization and
increased hospital mortality rates of
approximately 25-33%
greater intensity of nursing care
more frequent use of physical restraints
greater in-hospital functional decline
greater health care costs
worse outcomes in severe delirium especially at
6 months (e.g., ADL and ambulatory decline,
nursing home placement and death)
7. Disturbance in attention (reduced ability
to direct, focus, sustain, and shift attention)
and awareness (reduced orientation to
environment)
Develops over a short period of time,
a change from baseline, fluctuates
during the course of a day
8. An additional disturbance in cognition
(memory deficit, disorientation, language,
visuospatial ability, or perception)
The disturbances are not better
explained by another preexisting,
established, or evolving neurocognitive
disorder
9. Evidence from history, physical exam,
or lab findings that the disturbance is a
direct physiological consequence of
another medical condition, substance
intoxication or withdrawal, or exposure
to a toxin, or is due to multiple
etiologies
10. 1) Acute onset and fluctuating course
2) Inattention
3) Disorganized thinking
4) Altered level of consciousness
Delirium requires the presence of 1 and
2 plus either 3 or 4
12. Hardest to recognize
May look like depression
Subdued, quiet
Extremely important to recognize and
look for medical cause
13. Chronological age – very young and very old
Sensory deficits
Dehydration
Sleep disturbances
Pre-existing dementia
Cognitive impairment
Immobility or use of restraints
Medications–anticholinergic meds
Metabolic abnormalities
Comorbidities
Presence of urinary catheter
Under and over treatment of pain
Withdrawal
14. First have to recognize it
Search for underlying cause
Environment conducive for orientation
Maintain safety and comfort
Encourage mobility – avoid bedrest
Environment conducive for sleep
Optimize hearing and vision
Avoid dehydration
Avoid catheters
Avoid deliriogenic medications
Maximize the familiar and avoid distractions
15. Most common psychiatric condition
affecting older adults
“Common cold” of psychiatry
Leading cause of disability in the US and
the world (NIMH)
Often under-diagnosed and under-treated
16. Robs elderly of late life satisfaction
Causes impairment in cognitive, social
and personal functioning
Involves undue suffering for patient
and often their family
Causes excess morbidity and mortality
Could be a symptom of an underlying
medical condition
17. Increased risk of suicide
Increased economic burden
Could lead to substance abuse or
misuse
Treatment is often very effective
18. In older adults, depression may mask, or
be masked by, other physical disorders.
Is difficult to disentangle depression from
the many other disorders affecting older
people
19. Of the 35 million over age 65 in US, 2
million meet criteria for major depression
and another 5 million have depressive
symptoms
One primary care study found that 11% of
depressed patients were adequately
treated, 34% were inadequately treated,
and 55% received no treatment.
20. At least 5 symptoms must be present in
the same 2-week period and must include
either
◦ 1) Depressed mood
◦ 2) Loss of interest or pleasure
21. 3) Change in appetite or weight
4) Insomnia or hypersomnia
5) Psychomotor agitation or retardation
6) Fatigue or loss of energy
7) Feelings of worthlessness or guilt
8) Difficulty with thinking or
concentration
9) Thoughts of death or suicide
22. Elderly may not admit or report sadness
In general, elderly are less verbal about
feelings
May be masked by somatic complaints
◦ Common are headache, nausea,
constipation, anorexia, “Just don’t feel well,”
GI upset, pain
◦ Preoccupation with physical health
23. Less interest in hobbies or recreational
activities
Daily chores left undone
Social withdrawal
Less interest in sex
May neglect personal hygiene or
appearance
Less able to experience pleasure
24. Most often, decreased appetite but may
be increased
Monitor weight
May complain that food has no taste
At risk for dehydration, electrolyte
imbalance, and malnutrition
25. Insomnia or hypersomnia
Early morning awakening
Middle insomnia
Waking too early
26. Agitation – restlessness, irritable,
appear anxious and distressed, hand
wringing
Slowness in movement, slowed
speech, latency of response
27. Tired and worn out
Everything is just too much effort
Poor time management
Apathetic
“It’s too much work.”
28. Blames self for things done and undone
Feelings of being of “no value”
Hopelessness, worry
Future is bleak
Self-reproach, critical of self and others
“Don’t spend time with me; I’m not worth it.”
May be delusional
29. Slowed thinking
Inability to focus or concentrate
Indecisive
Feels confused and bewildered
Ruminations about insignificant problems
Negativity
30. Weary of life
Life isn’t worth living
“I’d be better off dead.”
“You’d be better off if I weren’t here.”
Passive suicide
◦Refuse to eat
◦Refuse medications
31. Interaction of biological and psychosocial
factors
Possible genetic contribution
Reaction in response to losses
Unresolved grief
Physical illnesses may lead to depression
Medications may cause symptoms of
depression
32. Involve the person’s family
Obtain an evaluation by a professional
Every interaction has the potential to help
Communicate a caring attitude
Support and encourage
Provide opportunity for social interactions
Involve in scheduled or structured activities
Spend time with the person and listen
33. Encourage physical activity
Mobilize support systems
Monitor physical health
◦Medication monitoring
◦Nutrition and weight
◦Sleep
◦Comfort and relaxation
◦Management of pain
Beware of being “too cheerful”
34. Antidepressant medications take time to
exert a therapeutic effect
Monitor for suicidal thoughts, especially as
depression starts to improve
Promote a positive attitude toward the future
– “I know that you feel this way now, but you
won’t always.”
Remember that depression is usually very
treatable over time
35. A subjective state of dysphoric
apprehension or expectation
accompanied by physiological
responses
Symptom of many disorders including
depression, dementia, delirium
Primary symptom of anxiety disorders
36. Excessive worry that person finds difficult to
control
Complaints of shakiness, restlessness,
jitteriness, jumpiness, trembling, tension,
irritability, impatience, poor concentration,
memory problems, unrealistic fears
Feeling of impending doom
Anticipation of the worst that could happen
37. Physical symptoms including:
◦palpitations, chest pain
◦dizziness, lightheadedness
◦tingling, numbness
◦stomach upset, diarrhea
◦too hot or too cold, sweating
◦shortness of breath, sensation of lump
in throat or choking
◦sleep disturbance
38. Medical illnesses
◦ hypoglycemia, hyperthyroidism
Medications
◦ caffeine, stimulants, sympathomimetics
Withdrawal states
◦ alcohol, benzodiazepines
Situational anxiety
◦ going to a dentist, flying
40. Minimize caffeine
Social interaction
Relaxation techniques
Diversion and recreational activities
Physical exercise
Counseling or psychotherapy
Medication, if use is justified
42. Complex attention (Sustained and divided
attention, processing speed)
Executive ability (Planning and decision
making)
Learning and memory (Recall and recognition)
Language (Expressive and receptive)
Visuoconstructional-perceptual activity
(Construction and visual perception)
Social cognition (Emotions and behavioral
regulation)
43. Evidence of minor cognitive decline
from a previous level of performance
Deficits not sufficient to interfere with
independence
Deficits do not occur exclusively in
context of delirium
44. Greater cognitive deficits in at least one
(typically 2 or more) cognitive domains
Evidences of significant cognitive decline
from previous level of performance
Deficits sufficient to interfere with
independence
Deficits do not occur exclusively in context
of delirium
46. Preclinical – pathophysiological
changes in the brain, but cognitively
normal
Mild cognitive impairment due to AD –
clinical and research criteria
Dementia due to Alzheimer’s Disease –
Possible, Probable, Probable with
evidence of AD pathophysiology
47. Cerebral spinal fluid
◦ Phospho-tau concentration elevated
◦ Amyloid beta (1-42) peptide reduced
◦ AT Index <1 consistent with Alzheimer’s
PET scan with special imaging agent
◦ Demonstrates amyloid burden
Blood or urine tests – not available yet
48. Alzheimer’s is the most common
form of dementia
5.4 million people in US have DAT
1 in 8 elderly has DAT
About 500,000 Americans <65 years
old have a dementia; 40% of those
have DAT
Alzheimer’s is the 6th leading cause
of death in the US
50. Short-term memory
- Hippocampus involved
◦ Can’t make deposits into “memory bank”
◦ Like a computer with a faulty save
function
◦ “Floating” reference point for time
51. Memory
Judgment and decision making
Abstract thinking
Inhibition control
Organizational skills
Motivation and attention
53. ◦ Sudden onset
◦ Step-wise progression
◦ Focal neurological signs and symptoms
◦ Evidence of cerebrovascular disease on
brain imaging
◦ History of hypertension, diabetes,
dyslipidemia, atrial fib, smoking, prior
TIAs or stroke
54. Likely accounts for 75% of vascular dementia cases
Affects small arterioles, venules and capillaries in
the brain
Hypertension is a major risk factor
Seen on MRI as small focal areas of infarction,
hyperintensities, microbleeds, or enlarged
perivascular spaces
Subacute symptoms include cognitive impairment
(executive dysfunction, slowing of psychomotor
speed, memory problems), mood disorders, gait
disturbances
55. Progression less predictable
Focus on stroke prevention
◦ Manage hypertension
◦ Treat diabetes
◦ Lipid lowering agents
Alzheimer’s drugs generally not beneficial
56. Memory impairment evident with
progression, but not always early
Abnormal proteinaceous (alpha-synuclein)
cytoplasmic inclusions called Lewy bodies
develop in cells throughout the brain
57. Progressive dementia – deficits in attention,
executive function, memory, language and
visual spatial abilities
Two of three core features
◦ Parkinsonism
◦ Recurrent visual hallucinations
◦ Fluctuating attention and concentration
Dementia onset before or within one year of
parkinsonism onset
60. Multiple System Atrophy
Corticobasal Degeneration
Progressive Supranuclear Palsy
FTD with Parkinsonism
61. A neurodegenerative disorder affecting the
frontal and/or temporal lobes of the brain
that presents predominantly with
behavioral or language disturbance, with
relative preservation of memory and
spatial skills early in the illness
62. -Earlier age of onset - 50% before age 65
-Survival 6.6 – 10 years after symptoms onset
-Personality changes and decline in social
skills
-Impaired executive functions
-Emotional blunting; apathy
-Behavioral disinhibition; bizarre behavior
-Language changes
-Prominent temporal and/or frontal atrophy
63. Behavioral variant – prominent
changes in behavior and personality
Progressive nonfluent aphasia –
expressive language changes
Semantic dementia – can’t
understand words or recognize
familiar people and objects
64. Insidious onset and gradual progression
Early decline in social interpersonal conduct
Early impairment in regulation of personal
conduct
Early emotional blunting
Early loss of insight
65. Decline in personal hygiene and grooming
Mental rigidity and inflexibility
Distractibility and impersistance
Hyperorality and dietary changes
Perseverative and stereotyped behavior
Utilization Behavior
Speech and language changes
66. ◦ Rapidly progressive, fatal
◦ Cognitive and behavioral changes
◦ Loss of coordination
◦ Myoclonus
◦ Spongiform changes in frontal cortex
◦ A type of prion disease misfolded proteins
67. ◦ Autosomal dominant pattern of inheritance
◦ Defect of chromosome 4
◦ Basal ganglia affected
◦ Movement and coordination affected
◦ Loss of intellectual abilities and emotional
and behavioral disturbances
72. It is important to know
what PERSON the disease
has, not what disease the
person has.
-Sir William Osler 1849-1919
73. Difficulty learning new things
Misplaces items
Forgets to tend to appliances
Trouble following recipes/directions
Can’t remember the date/time
Trouble recalling recent events or
conversations
Forgets to pay bills or repays
Trouble following plot in stories or on TV
74. Use calendars, notes, reminders
Write important information
Repeat explanations or directions
Try to limit distractions and simplify
One specific location for keys,
glasses, important items
Supervise medications, finances, and
for safety needs
75. Provide reminder cues in conversations
or in the environment
Try to endure repetitiveness
Help locate missing items
Monitor appetite and weight
Don’t force reality orientation
Discuss positive memories from the past
76. Judgment and decision making
Abstract thinking
Inhibition control
Organizational skills
Motivation and attention
77. Loss of sense of risk and danger
Financial vulnerability
Difficulty problem-solving
May appear more dependent and
indecisive
May trust strangers or be
“inappropriately familiar”
Unable to prioritize activities
78. Identify surrogate decision maker/s
Avoid extended logical explanations
Set limits on unrealistic demands
Anticipate safety needs and safety proof
surroundings
Avoid situations where failure is likely
Use distraction rather than confrontation
Maintain the person’s integrity
79. Takes more time to understand
Difficulty with time relationships
Trouble with calculations and money
Unable to “figure out” complex problems
Poor interpretation of social cues
Change in sense of humor
80. Allow time to process verbal
communication
Be alert for misunderstandings
Interpret what is occurring in the
environment
Help identify the function of objects
Use discretion with humor
81. More impulsive – desires immediate
gratification
Frustrated easily – quick to react
May make hurtful/insensitive comments
May have inappropriate social behavior
Possibility for sexual disinhibition
82. Anticipate needs and possible
overreaction
Maintain a calm environment
Don’t take insensitive comments
personally
Use a matter of fact approach for socially
inappropriate behavior
Assist in covering social “mistakes”
83. Unable to plan, organize, sequence
activities
Don’t remember “how” to get started
on tasks
May appear apathetic or disinterested
Trouble following directions
84. Simplify the environment
Continue with familiar routine
Provide structured activities, but be
flexible
Break tasks into individual steps
Give one-step directions
Inconspicuously give cues
Avoid sounding controlling or bossy
If resistive, stop and try again later
85. Problems with initiation
Can’t switch mental gears easily
Trouble completing tasks or “gets stuck”
Loss of mental flexibility
Difficulty maintaining effortful activities
Distractibility
86. Eliminate competing stimuli in the
environment
Provide cues and prompts
Plan activities that do not require sustained
periods of concentration
Attempt distraction if the person is “stuck”
Plan frequent rest periods
88. Disinhibited/impulsive
Blurt out socially inappropriate remarks
Frontal release signs (grasp reflex,
palmomental reflex)
Compulsive eating
Unable to resist impulse to use or touch
objects
89. Lack of motivation
Unable to initiate
Inability to maintain effortful behavior
Apathy
90. Perseveration
Lack of mental flexibility
Self management difficulty to make
any change
Improper emotional responses
91. Poor interpretation of social cues
Difficulties secondary to lack of
motivation, personality changes,
and uninhibited behavior
Insensitive to others
Unable to “read” social signals
from others
92. Inability of volition
Cannot multitask
Non compliance because can’t plan
“Stubborn” – “Uncooperative”
93. Unable to anticipate consequences
Can’t prioritize
Lack empathy
Little or no insight
95. Apathy vs irritability
Paranoia
Abnormal beliefs
Delusions or hallucinations
Fearfulness
Clinging/shadowing
Anger/frustration
96. Try to exhibit the desired demeanor
Be aware of your limits and stress level
Clearly identify the purpose of cares
Avoid arguments about abnormal beliefs
98. Address depression if it is suspected
Provide environmental and
interpersonal supports to minimize
fears and anxiety
Distract rather than confront
Maintain a calm, routine, predictable
environment
Encourage social activities
99. Word-finding problems
Trouble with names – talks “around”
names
Loses train of thought in mid-sentence
Can’t filter out distractions during
conversations
Less use of nouns
May not recognize objects
100. Approach slowly from the front or side
and gain the person’s attention before
talking
Speak slowly and clearly
Maintain relaxed body language
Face the person, establish eye
contact, and smile
Introduce yourself and call the person
by name
101. Eliminate distracting background noises
Speak in low pitched tones
Begin with social conversation or “small
talk”
Keep sentences short
Keep to one clearly defined subject at a
time
102. Use nouns or names rather than pronouns
Use the same word every time to refer to
common tasks/objects
Avoid open ended questions
Limit the number of decisions the person
has to make
Accompany verbal communication with
appropriate non-verbal cues
103. Exaggerate gestures or facial expressions if
hearing or vision impaired
Use gentle touch that is not task oriented
Break down tasks into individual steps and
ask the person to do one at a time
Repeat explanations or directions as
needed
Try to match requests to the person’s
current level of functioning
104. Allow sufficient time for the person to
process information
Focus on the feeling tone of the
conversation rather than content of words
State positive directions; limit the use of
“don’ts”
Talk about pleasant memories from the past
105. Try supplying a word if it is appreciated
Repeat the last few words to help regain
train of thought if blocking is a problem
Allow word mistakes to go by “unnoticed” if
the general meaning is understood
Inconspicuously give prompts during
interactions
106. Avoid “quizzing” or forcing a response
Make “educated guesses” of what intent
could be if verbal statements are unclear
Give reassurance by making general
statements if that provides comfort
Use humor appropriately
107. -Loss of “motor memory”
-Need more time to complete tasks
-Need assistance with daily tasks
-Don’t rush well
108. Allow more time to complete tasks
Provide prompts and step-by-step
directions
Demonstrate the desired action
Do not rush the person
109. Unaware of relationship to environment
◦ Might fall
◦ Unable to find way or gets lost
◦ May wander
Geographic disorientation
110. Evaluate fall risk
Use way finding cues
Use personal items to help recognize room
Be aware of social distance in conversations
Avoid abrupt movements toward the person
112. Current Alzheimer’s Trials at UNMC
-Prevention Trial
-Asymptomatic AD
-≥65 years
-Monthly IV x 3yr
-Solanezumab
-a4study.org
Interested? Call 402-552-6241
-Mild AD study
-MMSE 20-26
-ages 55-90
-Monthly IV x 18m
-Solanezumab
-expedition3study.com
-Moderate AD study
-MMSE 12-22
-ages 55-85
-oral med x 1yr
-T-817MA
-adcs.org (studies)
University of Nebraska Medical Center