CognitionCognition Aphasia- a disturbance of language use. Because of brain pathology, the

patient becomes unable to use words as symbols. Amnesia- a loss of memory, It can be retrograde (loss of memory for events

that occurred before a certain time) or anterograde (loss of ability to form new memories)

Apraxia- the inability to perform a motor behavior, even though the muscles and nerves required for the motion are themselves intact.

Agnosia- the inability to recognize familiar objects, even though the senses required for this recognition are intact

Loss of executive functioning- difficulty planning , organizing, sequencing, or abstracting information

Prosody- Confusion- inexact term used to describe slowed thinking, loss of memory, or

disorientation. Functional- term used to describe d/o’s for which they can no find no basis in

brain anatomy, chemistry, or physiology.

Case ExampleCase Example

42 school principal with recent history of having sexual relationships with several of her students

No previous history of sexual assault, but was sexually abused as a child

Possible diagnoses?

DeliriumDelirium

Rapidly developing, fluctuating state of reduced awareness in which the following are true:

– trouble shifting/focusing attention, and

– at least one defect of memory, orientation, perception, or language and

– symptoms are not better explained by a dementia Causes- GMC, Substance-Induced, Multiple Etiologies*,

and NOS

DementiasDementias(how differs from Delirium)(how differs from Delirium)

Memory loss as well as other cognitive deficits (e.g... amnesia, aphasia, apraxia, agnosia, and loss of executive functioning)

No prominent impairment in the ability to focus or shift attention

Cause can usually be found within the CNS instead of elsewhere in the body.

Dementia is relatively fixed and unchanging Recovery is not common Types- DAT, Vascular, GMC, Substance-Induced,

Multiple Etiologies, NOS

Assessment IssuesAssessment Issues

MMSE (page 71 Spreen & Strauss)– Most dementia studies have < 21 as a cuttoff

Imaging– http://www.med.harvard.edu/AANLIB/home.ht

ml

DAT FactsDAT Facts

Cost is over 100 billion dollars annually in the United States

Average age at diagnosis is 80– 1-2% @ age 65– 1-5% @ age 80– 50% “have Sx” @ 90

Heritibility rate is 40% in those with early onset dementia in sibs and parents

Lewy Body Disease/DementiaLewy Body Disease/Dementia Protein deposits found on deteriorated nerve cells

throughout the brain Fluctuations in cognition, with confusion and

hallucinations in early stages Autopsies show Lewy bodies in cortex without tangles

seen in DAT Genetic changes seem to trigger neurodegenerative

process Worse visuospatial functioning and better memory

functioning compared to DAT

Beh. Problems of DementiaBeh. Problems of Dementia

Agitation/Aggression Sundowning ADL decrements Combativeness Psychosis Disinhibition Incontinence

Agitation/Aggression Agitation/Aggression in Dementiain Dementia

Most common psychiatric referral (40-80%) Negative correlation with cortical

serotonin levels More common in mid to late stages Responds to a variety of pharmacotherapy

Afternoon Sundowning Afternoon Sundowning in Dementiain Dementia

Possibly due to fatiguability Increase cognitive cues and structure

late in day Nap after lunch Dose of psychotropics around 3PM

Nocturnal Sundowning Nocturnal Sundowning in Dementiain Dementia

Few orienting cues at night coupled with tendency toward nocturnal awakening

Increase phototherapy or daylight Sleep hygiene (no naps or caffeine) Hypnotics (e.g. Chloral hydrate, Trazadone) Don’t forget the nightlight

Combativeness in DementiaCombativeness in Dementia

Common in pts. with executive dysfunction Intervention: limit goals; negotiate, don’t

drill!; pre-medication with lorazepam Visual agnosia may lead to fearfulness in

severely demented patients. (go slow/easy) Usually able to read emotional prosody

better than comprehend words

Psychosis in DementiaPsychosis in Dementia

50% Prevalence Usually doesn’t cause problems May predict more rapid progression Treatments include reality therapy (drive

around the house/block) and a host of neuroleptics

Disinhibition in DementiaDisinhibition in Dementia No goal oriented behavior, therefore very

responsive to impulses Consider beta-blockers and Progesterone Wandering (Rx.: activity for stimulation

seekers or decrease neuroleptics) Screaming

– in late stages– rule out pain– increase stimulation

Incontinence and DementiaIncontinence and Dementia

Common in strokes and late stage DAT Depends Often the most difficult symptom for

caregivers to cope with

Depression and DementiaDepression and Dementia

20 to 30% prevalence, mostly early Most important treatable cause of diminished

quality of life Predictors include past history or family history of

depression Differential: Depressed patients demonstrate

cognitive response to antideps. Depression secondary to Dementia

– Client and Cargiver

Management Issues Management Issues in Dementiain Dementia

Feedback Family meeting and long-term planning When is it time? (driving, tell dx, safety-

proof house, support group, ALF/ECF) Education (e.g. groups, bibliotherapy) Interacting with patient Caregiver burden*

Implications of dementiaImplications of dementia

Driving POA Competency to make decisions Need for re-evaluation

Case Example (10/26/04 ET)Case Example (10/26/04 ET)

Competency to Stand TrialCompetency to Stand Trial 1. Capacity to appreciate charges or allegations 2. Capacity to appreciate the range and nature of

possible penalties which may be imposed 3. Capacity to understand the adversary nature of

the legal process 4. Capacity to disclose to attorney facts pertinent to

the proceedings 5. Capacity to manifest appropriate courtroom

behavior 6.  Capacity to testify relevantly

Amnestic DisordersAmnestic Disorders

No requirement for reduced ability to focus or shift attention

Memory is affected far more than any other function, sometimes to the extent that pts. will forget conversations that took place only a few minutes earlier.

Confabulation (trying to hide a loss of memory by making up experiences to fill information void) is common early in the course of illness. Most common in early phases.

Types- GMC, Substance-Induced, or NOS

Normal Aging?Normal Aging?

Other Causes of Cognitive Other Causes of Cognitive SymptomsSymptoms

Age-Related Cognitive Decline Dissociative Disorders Pseudodementia Malingering Factiscious Disorder with Predominantly

Psychological Signs and Symptoms

The Neuropsychological Impact of The Neuropsychological Impact of Concussion in College Football:Concussion in College Football:

A Multi-center Analysis of Mild Traumatic Brain A Multi-center Analysis of Mild Traumatic Brain InjuryInjury

(JAMA, 1999)(JAMA, 1999)Michael W. Collins, Ph.D.Michael W. Collins, Ph.D.

Duane E. Dede, Ph.D., et al.Duane E. Dede, Ph.D., et al.• Participating Universities:

• Michigan State University• University of Florida• University of Pittsburgh • University of Utah

• Sources of Funding:• Arthur J. Rooney Foundation• Blue Cross/Blue Shield of MI• Michigan State U. Foundation• U. of Florida Golden Opportunity

Fund

Co-Investigators and CollaboratorsCo-Investigators and Collaborators

Sam Sears, Ph.D.; Benjamin Phalin, B.S.; Dave Moser, PhD.; Guido Urizar, B.A., Chris Houck, B.A., Arthur Day, M.D.; Peter Indelicato, M.D.; Guy Nicholette, M.D.; Mike Wasik, A.T.C., M..Ed; Matt Walser, A.T.C.; Chris Patrick, A.T.C., M.A.; Tom Kaminski, Ph. D. Mary-Beth Horodyski, Ed.D.

David Cordry, M.A.; Michelle Klotz Daughtery, M.A.; Mark Lovell, Ph.D.; Jeffrey Covan, D.O.; Randy Pearson, M.D.; Sally Nogle, A.T.C., M.A.; Jeff Monroe, A.T.C., M.S.

Scott Grindel, M.D.; Douglas McKeag, M.D.; Kevin Connelly, A.T.C., M.A.; Rob Blanc, A.T.C., M.A.

Baseline: Preseason testing

Post season testing

Project TimelineProject Timeline

24 hours

Day 3

Day 5

Day 7

Concussion

DemographicsDemographics

Variable Mean ScoreAGE 19.8Year in College 2.6

Years of Football 8.7

Years of B-ball 3.5

Years of Soccer .87

ACT Scores 20.2 (3.6)

SAT Scores 956.2 (148.5)

Race AA=53%EA=46%HA=1%

Hx. Of LD* Yes=16.5%No=85.5%

Grade 1 ConcussionGrade 1 ConcussionHopkins Delay Total Score (Standard Score)Hopkins Delay Total Score (Standard Score)

(Mean =100; SD =15) (Mean =100; SD =15)))))

84

4046 43

97

0

10

20

30

40

50

60

70

80

90

100Delay Base.

Delay 24

Delay 3

Delay 5

Delay 7

Recovery Curve?Recovery Curve?

-0.4-0.2

00.20.40.60.8

11.21.41.6

24 hour Day 3 Day 5 Day 7

Memory

Exec. Fxn.

Psych-Mtr

SR Sx.

Key FindingsKey Findings LD & previous concussion history were

more significant than concussion grade More prevalent than previously reported Demonstrate “recovery curve” Empirical findings will offer a more

informed basis for guidelines Memory testing is particularly sensitive

Retired athletesRetired athletes Cognitive and

emotional impairments reported in FB, soccer & boxing

Significant orthopedic comorbitiy

Players Association UNC-CH Center for

Professional Athlete Rehabilitation

Second Impact SyndromeSecond Impact Syndrome(SIS)(SIS)

Individuals with two blows to the head within a short time frame are at sudden risk of sudden, irreversible and fatal diffuse cerebral swelling with delayed catastrophic deterioration

From 1992-1995, there have been 17 documented fatalities in males involved in sports (boxing, skiing, ice hockey and football).

All football SIS deaths were in HS students Fatal in 50% of cases

Case StudyCase Study20 yo EA defenseperson4 Grade 2 concussions

1995-Head to head (2 days of Sx.)

1996-Head to head (2 days of Sx.)1998-Ball to RTL (30 days of Sx.)

1999-Ball to RTL (40 days of Sx.)

All EEGs and MRIs negative1999 testing

c/o mild headache and irritabilitySDMT Memory (-1.9 SD)Pegsdom (+1.5 SD)

Children and SRCChildren and SRC

Limit heading Proper technique Protective devices Follow return to play

guidelines after initial concussion

Serial NP testing Repeat CT scan

Protective Headgear?Protective Headgear?

Ziejewski (2002) reported decreased incidence and severity

Face masks were associated with less severe symptoms

Compliance poor in male athletes, especially rugby

MouthguardsMouthguards

Other impact of SRCOther impact of SRC

Emotional regulation Controversies in testing

– Definition of SRC– IMPACT vs. other modes– Frequency of testing– Return to play issues– Individual differences