Manifestation of Novel Social Challenges of the European Union

in the Teaching Material of

Medical Biotechnology Master's Programmes

at the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011

COGNITIVE AND

AFFECTIVE DISORDERS

IN THE ELDERLY

Márta Balaskó and Gyula Bakó

Molecular and Clinical Basics of Gerontology – Lecture 18

Manifestation of Novel Social Challenges of the European Union

in the Teaching Material of

Medical Biotechnology Master's Programmes

at the University of Pécs and at the University of Debrecen Identification number: TÁMOP-4.1.2-08/1/A-2009-0011

TÁMOP-4.1.2-08/1/A-2009-0011

Aging-associated cognitive, affective

changes

In healthy aging overall intellectual performance does not

necessarily deteriorate.

Various cognitive functions decline, while others improve:

• Activity requiring quick reactions and or high degree precision

grow weaker.

• Decrease in speed of processing, working memory, inhibitory

function and long-term memory are seen.

• Wise consideration based on experience, the ability to

understand and learn from new experience is maintained.

TÁMOP-4.1.2-08/1/A-2009-0011

Aging-associated cognitive, affective

and psychiatric disorders (outline)

• Dementia

- Neurodegenerative disorders leading to dementia

(Alzheimer’s disease)

- Non-Alzheimer dementias (vascular dementia, organic

brain disorders)

- Delirium

- Amnestic syndromes

• Alcohol abuse and consequences

• Affective disorders: depression

TÁMOP-4.1.2-08/1/A-2009-0011

Dementia: definition and prevalence

Definition

A serious loss of cognitive ability with maintained vigilance.

Dementia is a clinical diagnosis.

Impairments affect:

• memory (disturbed recognition: agnosia),

• speech (aphasia), language,

• judgement,

• emotional control,

• behavior,

• attention ,

• abstract thinking,

• executive functions (apraxia),

that causes disruption in relationships and social functions.

TÁMOP-4.1.2-08/1/A-2009-0011

Dementia: prevalence and most

frequent forms

Prevalence

It affects 1% of population at the age of 60, prevalence doubles

every year.

It reaches 10 % at 65 years, and 35% above 90 years.

Most prevalent dementias

• Senile dementia of the Alzheimer type

(Alzheimer’s disease) 60%

• Non-Alzheimer dementias (organic brain disorders)

• Delirium

• Amnestic syndromes

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Senile dementia of the Alzheimer type

(SDAT, Alzheimer’s disease) 1

Definition

A (premature) progressive age-associated loss of cognitive

functions (in middle-aged and older) also involving affective and

behavioral disturbances.

Risk factors

• age 65 years

• female gender

• low education level (primary school drop-outs: 2× risk)

• positive family anamnesis: 4× risk

• head trauma: 2× risk

• smoking, metabolic syndrome X, atrial fibrillation, stroke,

alcohol consumption, genetic predisposition

TÁMOP-4.1.2-08/1/A-2009-0011

Prevalence of Alzheimer’s disease

0

10

20

30

40

50

60

60-64 65-69 70-74 75-79 80-84 85+ 95+

Pre

vale

nce (

%)

Age (years)

1% 2% 4%

8%

16%

30%

50%

TÁMOP-4.1.2-08/1/A-2009-0011

Senile dementia of the Alzheimer type

(SDAT, Alzheimer’s disease) 2

Characteristics

Loss of neurons, synapses and atrophy in the cerebral cortex

and certain subcortical regions (temporal and parietal lobes,

parts of the frontal cortex)

Pathogenesis

cholinergic theory: reduced synthesis of the acetylcholine

beta-amyloid: dense and insoluble deposits of amyloid beta

precursor protein (APP) fragments form senile plaques around

neurons initiating damage

tau protein misfolding : intracellular neurofibrillary tangles cause

microtubules to disintegrate, damaging the neuron’s transport

system

Inflammation, oxidative stress, accumulation of aluminium in

brain, etc.

TÁMOP-4.1.2-08/1/A-2009-0011

Senile dementia of the Alzheimer type

(SDAT, Alzheimer’s disease) 3

Phases

1 Mild cognitive impairment, preclinical stage

a gradual, hidden, progressive onset may last for 7-8 years

symptoms (memory loss) are mistaken for stress and aging

2 Early stage

increasing forgetfulness, difficulties with language, executive

functions, agnosia, apraxia, personality changes

3 Moderate stage

dependency increases

difficulty with speech, pathological behavior (agression) and

confusion, delusions

4 Advanced stage

complete dependency, verbal output decreases, pronounced

memory decline, patients get bed-ridden, death

TÁMOP-4.1.2-08/1/A-2009-0011

Senile dementia of the Alzheimer type

(SDAT, Alzheimer’s disease) 4

Prognosis

Average survival is 7 years. Most common causes of death:

pressure ulcers, pneumonia

Treatment

No drug has been shown to cure the disease or delay

progression.

Some drugs alleviate symptoms:

• acetylcholinesterase inhibitors

• glutamate NMDA receptor antagonist

A safe, emotionally supportive environment, physical exercise,

optimal diet may improve quality of life of the patient.

TÁMOP-4.1.2-08/1/A-2009-0011

Non-Alzheimer dementias (organic

brain disorders)

Characteristics

• Symptoms may resemble those of Alzheimer’s disease

• Onset is usually different, changes may occur suddenly or

they may not be progressive over time

• In case of metabolic or infectious causes progression may be

stopped, even some alleviation of the symptoms is possible.

TÁMOP-4.1.2-08/1/A-2009-0011

Causes of non-Alzheimer dementias

Intracranial:

Degenerative disorders

Parkinson’s, Pick, Lewy

Huntington

Vascular, post-stroke states

Space occupying lesions

Post-trauma states

polytrauma (boxing, liver)

subdural hematoma,

hemodialysis

Infectious agents

AIDS, prion (Creutzfeldt-Jakob),

neurosyphilis, Lyme disease

meningitis

Extracranial:

Poisons

alcohol, drugs, medications

CO poisoning

Genetic, metabolic causes

Wilson’s, hypoglycemias

Organ failures

Tumor, metastases failure,

renal failure, hydrocephalus

heart failure,

thyroid disorders

Deficiencies

vitamin B12-, folic acid-, niacin

deficiency

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Delirium: definition

Characteristics

• It is a clinical syndrome characterized by inattention and

acute severe (reversible) cognitive dysfunctions

• In the young, high fever, severe alcohol intoxication, severe

metabolic disturbances, etc. may cause delirium

• In the elderly, functional reserve capacity of the brain

declines , therefore many milder disorders may lead to

delirium

• Delirium affects 14–56% of all hospitalized elderly patients.

Postoperative delirium occurs in 15–53% of surgical

patients over 65 years, and 70–87% among elderly

patients admitted to intensive care units.

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Delirium in the elderly: risk factors 1

Risk factors

• Dementia or cognitive impairment

• History of delirium, stroke, neurological disease, falls

• Multiple comorbidities

• Male gender

• Chronic renal or hepatic disease

• Sensory impairment (hearing or vision)

• Immobilization (restraint, catheters)

• Medications (sedative hypnotics, narcotics, anticholinergic,

drugs, corticosteroids, polypharmacy, alcohol or drug

withdrawal)

• Acute neurological diseases [acute stroke (usually right

parietal), meningitis, encephalitis]

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Delirium in the elderly: risk factors 2

Risk factors

• Intercurrent illness

(minor infections, iatrogenic complications, anemia, ordinary

volume loss, poor nutrition, fracture, trauma)

• Metabolic derangement

severe hypoglycemia, hyper- or hypotonicity

• Surgery

• Alarming environment

(e.g. admission to an intensive care unit)

• Pain

• Emotional distress

• Sustained sleep deprivation

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Amnestic syndromes

Definition

Memory functions are disproportionately impaired compared to

other cognitive functions in an otherwise alert patient.

The patient can not remember recent events or learn simple tasks,

while performing complex tasks learned previously.

Most common forms

• Wernicke-Korsakoff Syndrome

chronic alcoholism, chronic thiamine deficiency

• Transient Amnestic Syndromes

transient cerebral ischemia, migraine, alcohol intoxication

(“blackouts”), drugs (e.g. benzodiazepines, barbiturates,

ketamine), head injury (concussion)

• Psychogenic amnesia

posttraumatic stress disorder

TÁMOP-4.1.2-08/1/A-2009-0011

Alcohol abuse and consequences

in the elderly

Prevalence

Alcohol abuse and alcoholism are prevalent and under-recognized

problems in the elderly. About 6 percent of older adults are

considered heavy users of alcohol (13% of men, 2% of women).

The majority of older alcoholic persons (around 66%) grow older

with early-onset alcoholism, about 34% develop a problem with

alcohol in later life.

Age-related alterations in pharmacokinetics of alcohol

• Gastrointestinal absorption is comparable, distribution is

diminished due to decrease in fat free mass.

• Liver perfusion and metabolism in the liver declines slightly.

higher peak serum alcohol

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Consequences of alcohol abuse

in the elderly 1

Consequences

Alcohol-induced alterations in drug metabolism:

• acute competitive inhibition of drug metabolism involving the

cytochrome P450 system (microsomal ethanol oxidizing

system=MEOS), e.g. narcotics, tranquillizers leading to

suppression of respiratory center

• chronic upregulation of the cytochrome P450 system enhancing

clearance of drugs, e.g. coumarins

Falls may be precipitated by alcohol due to acute ataxia, acute

hypotension (vasodilatory and diuretic effect), chronic myopathy,

cerebellar atrophy and peripheral neuropathy. These falls may lead

to hip fractures!

Moderate drinking may exacerbate hypertension, and heavy

drinking increases the risk of stroke. Arrhythmia may develop after

an alcohol binge.

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Consequences of alcohol abuse

in the elderly 2

Consequences

Ischemic heart disease is responsible for more cardiac deaths

among older alcoholics than alcohol-induced cardiomyopathy.

Gastrointestinal bleeding are common among older alcoholics.

The liver is more susceptible for alcoholic hepatitis, fatty liver or

cirrhosis in old individuals. About 50% of elderly patients with

cirrhosis die within one year of diagnosis.

Elderly patients are more prone to alcohol or its withdrawal-induced

delirium .

Chronic alcoholism lead to Wernicke encephalopathy (an acute state

of confusion, ataxia and abnormal eye movements) and Korsakoff’s

syndrome (an isolated memory deficit manifesting in

confabulation). Global cognitive impairment and alcohol-related

dementia based on profound cerebral atrophy is more common in

elderly alcoholics.

Depression in the elderly:

definition and characteristics

Definition

Depression is a state of low mood and aversion to activity. It

may can affect the thoughts, feelings, behavior, and physical

well-being of the patient. It usually involves feelings of

sadness, anxiety, emptiness, hopelessness, worthlessness,

guilt, irritability or restlessness.

The prevalence of depression among the elderly is increasing.

Their treatment presents a big strain on society.

Depression in the elderly is seldom properly diagnosed. It does

not receive proper attention.

TÁMOP-4.1.2-08/1/A-2009-0011

Depression in the elderly:

risk factors

It is strongly influenced by such risk factors that become more

common with aging:

• genetic factors determine susceptibility for depression

• neurological changes,

• multimorbidity, pain,

• impaired function of sensory organs

• loneliness, isolation

• personal crises, bereavement, anxiety

• reduced adaptability

• lack of perspectives in life, lack of motivation,

• decreased ability to work,

• loss of family background, deficiencies of education, poor

social network, negative effects of retirement.

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Factors that make the diagnosis of

depression especially difficult

Diagnostic factors: • There is an overlap between the normal phenomena of aging and

signs of depression.

• Clinical characteristics may be misleading. Symptoms may be

suppressed, non-characteristic or associated with somatization

(complaining about unreal somatic symptoms) and agitation/anxiety.

• It may occur (in a hardly discernible way) in association with chronic

diseases and organic cerebral disorders.

Characteristics associated with the patient: • Losses, bereavement, isolation, shame, refusal of treatment.

• Neither the patient nor the relatives hope for any improvement with

the treatment.

Characteristics of health professionals: • Misconceptions related to old age, lack of empathy and attention.

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Depression: prognosis

Poor prognosis, danger signs of suicide:

• advanced age at the onset of depression,

• presence of anxiety in past medical history,

• personality disorders,

• alcohol abuse,

• psychotic signs,

• cognitive impairment,

• organic cerebral disorders, loneliness, poor social

circumstances,

• delayed treatment, inadequate management

TÁMOP-4.1.2-08/1/A-2009-0011

Differential diagnosis of depression

(pseudodementia) and dementia

PSEUDO-DEMENTIA

• keeps complaining

• communicates in detail

• “I don’t know”

• does not want to do

DEMENTIA

• does not complain

• poor communication

• replies with mistakes

• eager to cooperate