Clinical Neuropsychology Flashcards
How many adults in Australians are 65 and over?
One in every six Australians
What percentage of older Australians were living in households?
95%
The likelihood of living in cared accomodation increased with age from ___ of people aged 65-79 to ___ of people aged >80 years.
1.4%
14.3%
How many older Australians lived in a low income household?
Two-thirds
What percentage of older adults reported having one or more long term health condition - with the most common being arthritis, hypertension and back problems?
86.5%
How many older Australians had a disability?
Half
What are some specific assessment issues with older adults that the APS ethical guidelines emphasises?
-Understanding the ageing process
-Being aware of own attitudes and values towards older adults
-Not assuming older adults presenting problems are attributable to old age
-Being aware of potential cognitive, sensory and physical deficits faced by older adults
Up to what percentage of older adults report cognitive changes (particularly memory)?
up to 95% of people report this
What is often the most significant reported symptoms of anxiety and depression in older age?
Cognitive changes
What are the two scales which are designed for older adults to measure anxiety and depression?
GDS (geriatric depression scale) and GAI (geriatric anxiety inventory)
Why are there different scales for older adults measuring anxiety and depression?
Somatic symptoms (trembling) more common in older adults.
Less cognitively demanding.
Cognition typically ___ from 20 over lifetime.
declines
We lose about what percentage of brain weight and volume each decade of life?
2%
As we age, we experience ___ in myelination and ___ in connections among neurons, ____ in certain neurotransmitters like dopamine and ____ blood flow.
Losses
reduction
decrease
reduced
Where in the brain experiences the most reduction over lifetime?
Prefrontal region of cortex-attention and working memory
Sensory changes are common as we age - what percentage of adults experience these?
93%
What are some social cognitive explanations of age related memory decline? (4)
-Negative age stereotypes
-Worry about underlying cause of memory slips
-Reduced routine and habit
-Increased overload of old memories
What did one study say about the power of positive reinforcement on memory performance in older age?
Given task they knew they could/couldn’t get.
Memory recall significantly higher for prior task success group.
____ appear to affect memory
Stereotypes
What percentage of older adults DON’T have dememtia?
Over 85% (most of them)
How many people have dementia worldwide?
46 million
What is the expected increase prevalence in dementia rates by 2050?
Triple
What is the economic impact of dementia worldwide?
US $18 billion
What is the greatest cause of disability in people >65?
Dementia
What is the second leading cause of death, which is also the leading cause of death for women in Australia?
Dementia
What is the only disease in the top 10 most common diseases with no reliable method of prevention, slowing, or cure?
Dementia
What is the difference between Alzheimer’s and dementia?
Dementia is a syndrome, not a disease. A pattern of symptoms that can be caused by many different illnesses.
Dementia refers to a syndrome involving progressive decline in
memory and other intellectual abilities.
What are some of the most common causes of dementia?
-Alzheimer’s
-Parkinson’s
-Huntingtons disease
-Fronto-temporal dementia
What is the criteria for all dementia?
Cognitive or behavioural symptoms that:
-Interfere with function at work or usual activities
-Decline from previous levels
-Are not due to delirium or psychiatric disorder
Alois Alzheimer described the first case of alzheimer’s in a 51 year old woman. The autopsy identified the hallmark pathology of AD which was what?
Amyloid plaques and neurofibrillary tangles.
Alzheimer’s disease is a pathological disease, meaning what?
Can only be officially diagnosed after death.
What does insidious onset mean, in regard to dementia patients?
Steady worsening over time
If the first presenting features are impairment in work finding, what type of dementia might be present?
Logopenic primary progressive aphasia
If the first presenting features are visual and other posterior cognitive impairments, what type of dementia might be present?
Posterior cortical atrophy
If there are predominant behavioural features (loss of empathy) and cognitive, what kind of dementia might be present?
Behavioural and dysexecutive variance
What are some pharmacological recommendations for dementia?
-Acetylcholinesterase inhibitors
-NMDA antagonist
-Others to control neuropsychiatric symptoms
-Dopamine agonists
What are some non-pharmacological ways to manage dementia?
-Psychoeducation
-Support services (family and client)
-Management of health conditions
-Cog strategies
-Speech therapy
What are some key elements to consider in an assessment for possible dementia?
-History (referral question, client interview, other info)
-Presentation (behavioural observations)
-Formal Tasks
-Formulation
-Ideas re management/recommendations
What are some important differentials to note when it comes to cognition?
-Normal cognition
-Mild cognitive impairment/mild neuro-cognitive disorder
-Psychiatric causes (particularly depression)
If someone had mild cognitive impairment, what would we be looking out for to see that it hasn’t turned into dementia?
Lack of functional impairment.
What is mild cognitive impairment characterised by?
Subjective cognitive concerns and objective impairment on tests.
MCI increases the risk for
dementia
Depression and anxiety and ___ in older age.
Less common
What are some factors when comparing AD dementia to depression in older people?
-More acute onset
-Cog concerns out of proportion to performance
-Dysphoric mood and loss of self esteem
-Effortful processing, diminished effort, reduced processing speed, attention
If you can’t identify functional impairment that is affecting daily life, what can not be diagnosed and why?
Dementia, cause it’s not influencing his daily life.
If adults are independent in activities of daily living, what does this most likely mean?
At this stage, they most likely do not meet the criteria for dementia.
Vascular dementia are a common cause of dementia. What are some of the risk factors of this?
Hypertension, atrial fibrillation, smoking, diabetes, etc.
Vascular dementia is more common in ____, however Alzheimer’s disease is more common in ___.
men
women
What are some of the criteria for vascular dementa?
-Dementia, BUT more recently vascular cognitive impairment
-Cerebrovascular disease
-Relationship between dementia and cerebrovascular disease evidence by at least one of :
1. Dementia onset within 3 months post recognised stroke
2. Abrupt deterioration in cognition
3. Fluctuating, stepwise progression of cognitive deficits
What are some consistent features of vascular dementia diagnoses, and what indicates that it is unlikely to be this?
Gait disturbance, frequent falls, mood changes.
Unlikely to be vascular dementia if there is early onset memory deficit and progressive worsening of memory and other cognitive functions in the absence of corresponding focal lesions, absence of neurological signs other than cognition
What is the updated criteria for vascular cognitive disorders?
- Establishment of a cognitive disorder (not necessarily dementia)
- Determination that vascular disease is the dominant if not exclusive pathology accounting for cognitive deficits.
Outline dementia with lewy bodies:
-Common form of dementia
-Occurs in older age, more common in men
-Pathology: lewy bodies (note also present in AD)
What are some of the clinical features of DLB diagnostic criteria?
Dementia with (core clinical features, first 3 typically early):
1. Fluctuating cognition
2. Recurrent visual hallucinations (typically well formed and detailed, around 80% clients)
3. REM sleep behaviour disorder (thrashing out in bed etc)
4. Parkinsonism
What are some supportive clinical features of DLB diagnostic criteria?
Severe sensitivity to antipsychotics, repeated falls, non visual hallucinations etc.
(DLB vs. PDD), DLB diagnosed when dementia occurs _____ with parkinsonism.
Before or concurrently
Parkinson disease dementia (PDD) used to describe dementia occurring in the context of well established Parkinson’s disease. Usually there is a significant cognitive symptoms on average ____ later.
Approx 10 years
In DLB, memory is usually what?
Less severely affected than AD.
What happens to language (naming) typically with DLB?
Typically intact early
During a session with someone with DLB, what do we typically see?
Evidence of fluctuation.
What should we ask about dreams when it comes to suspected DLB?
Hallucinations and acting out dreams - injuries to bed partner.
If there are behavioural observations when someone comes in for DLB diagnosis, what should we be aware of?
That there’s evidence of Parkinsonism.
What is the most common type of dementia?
Alzheimer’s
What’s a question you could ask to assess functional behaviour?
If you take away help, could they live independently
Around 1 in __ Australians had an acquired brain injury with activity limitations or participation restrictions due to disability?
45
Approximately what percentage of people with ABI were are aged <65 years?
75%
If hallucinations, most likely what kind of dementia?
Lewy bodies
If memory impairment, most likely what kind of dementia?
Alzheimer’s disease
At all ages, do males or females more likely to have an ABI?
Males
What was the main cause for more than half of people with an ABI?
Traffic injury
What are some of the most common causes of traumatic brain injuries?
-motor and other traffic accidents
-Falls
-hit by an object
-sports related
-work related
When are the two peaks of incidents occurring for TBI?
One around later late 20’s early 30’s, and one in older age
What percentage of TBI are open head and what percentage are closed?
Around 30% are open head, around 70% are closed head.
What is the difference between a coup and a contrecoup?
Coup - Damage at the site of impact
Contrecoup - Pressure resulting from a coup
What does the Glasgow Coma Score assess regarding TBI severity?
The presence and depth of coma.
What does the post traumatic amnesia scale measure regarding TBI serverity?
The period of time prior to return of ongoing memory.
What are some other things we need to consider to measure the severity of a traumatic brain injury other than the Glasgow coma score and the post traumatic amnesia scale?
Neuroimaging findings -
-CT; quicker, easier to monitor patient
-MRI; more sensitive, greater resolution, takes longer, conimpatibilities
How long is loss of consciousness for with mild TBI/concussion
Less than 30 minutes
What are the symptoms of mild TBI?
confusion, disorientation, dizziness, nausea
With Mild TBI, there are typically no what? And how long does it take for symptoms to resolve?
Typically no neurological deficits
Within days - weeks
What percentage of cases with mild TBI have ongoing symptoms?
15-25%
Although you might only have mild TBI, what can lead to chronic traumatic encephalopathy?
Repeated head injury
Chronic traumatic encephalopathy (developed after repeated head injury) can only be diagnosed when?
Post mortum
There is a link between chronic traumatic encephalopathy and what?
Mental health problems
How long does the coma and amnesia last for in moderate and severe TBI?
Coma >1 hour
PTA >24 hours
With moderate and severe TBI, we typically see more:
extensive cognitive and behavioural changes.
Moderate and severe TBI varies according to the:
site and extent of injury .
What are some sensorimotor deficits we might see with a moderate or severe TBI?
-Motor weakness or paralysis
-Speech issues - producing speech
-Swallowing issues
-Impacts on smell, sight, hearing, taste, pain, temperature, texture, proprioception
What are some of the psychological ongoing symptoms of TBI and why?
Self esteem, depression and anxiety.
What are some negative psychosocial outcomes following moderate to severe TBI?
-unemployment/changed duties
-Reduced participation in education
-reduced leisure activities
-social isolation
-difficulty with new/existing personal relationships
-depression, anxiety, loss of self worth
-sexuality issues
What are the 3 main mechanisms that are the causes of psychological problems after acquired brain injury?
- Directly related to brain injury
- Secondary factors association with brain injury (social isolation, reduced independence)
- Premorbid factors (substance abuse, lack of social support)
What are some family issues associated with TBI?
-frequent initial denial
-difficult burden
-significant long term effects upon siblings/children
-behaviour changes causes greatest stress
What is the role of psychology in TBI?
-history of concussion or mild TBI that was not investigated
-assess persisting symptoms
-educate client and families
-design and implement strategies to manage deficits
What does cerebrovascular referring to?
Blood flowing to the brain
What are the two types of stroke?
- Cerebral Ischaemia
- Haemorrhage
Outline a Cerebral Ischaemia stroke (3)
- Deprivation of blood supply due to blockage
- Caused by thrombosis, embolism, anterior schlerosis
- Transient ischaemic attack or infarction
Outline a Haemorrhage stroke:
-Intracranial bleeding due to ruptured blood vessel
-Caused by high blood pressure, aneurysm
-Pressure effects, disruption of cell functioning, and may cause hypo perfusion to some brain areas
Difference between cerebral ischaemia and haemorrhage:
First is reduced supply of blood, second is due to blood being where it shouldn’t be
What is Australia’s third most common cause of death?
Stroke
How many people will have a stroke in their lifetime?
1 in 4
In 2020, what percentage of first strokes occurred in people under 55 years old?
24 percent
Stroke causes a greater range of _____ than other conditions
disability
how many strokes out of 8 are fatal?
approx 1 in 8
Patients in dedicated stroke units have better outcomes, yet ____ of patients are admitted into one.
<50%
Strokes have a huge financial coast; around ____ billion in direct financial impact and around ___ billion in mortality and lost wellbeing.
$6.2
$26
What does the FAST acronym stand for with stoke?
Face
Arms?
Speech
Time
What are some things we can do for early management with a stroke?
-endarterectomy
-stenting
-thrombolysis
-endovascular clot retrieval
-medications
What are some examples of early management for a hemorrhagic stroke?
-lowering blood pressure
-trying to clot the blood so it doesn’t go around the brain where it’s not supposed to
What are some things that happen in acute rehabilitation after a stroke?
-standardised and evidence based stroke unit care
-multidisciplinary team
-education and support
-goal setting and monitoring using smart goals
-discharge planning
After a stroke, you should set SMART goals. What does this acronym stand for?
Specific
Measurable
Achievable
Relevant
Timely
The symptoms of a stroke depend on the:
Cause, location and severity of blockage
What are typical symptoms of a left sided stroke?
Right sided weakness, language deficits
What are typical symptoms of right sided strokes?
Left sided weakness, visuo perceptual deficits
What is common post stroke but often missed?
Cognition and mood impairment
What are strong predictors of long term outcome when it comes to stroke?
Cognitive and mood disorders
What is associated with improved longer term outcome when it comes to strokes?
Early intervention
Common post stroke (that has affected the occipital lobe) cognitive impairments are:
Visual fields
Common post stroke (that has affected the temporal lobe) cognitive impairments are:
Visual agnosia (difficulty recognising objects)
Prosopagnosia (difficulty recognising faces)
Common post stroke (that has affected the right parietal lobe) cognitive impairments are:
Loss of sensation, issues with the somatosensory cortex, problems with tension
Common post stroke (that has affected the left/bilateral parietal lobe) cognitive impairments are:
Difficulty integrating modes, can impact:
Reading, writing, maths and skilled movement
Common post stroke (that has affected the left temporal lobe) cognitive impairments are:
Auditory processing and comprehension (difficulty processing and understanding things you hear)
Common post stroke (that has affected the right temporal lobe) cognitive impairments are:
Agnosia for sound and music
Common post stroke (that has affected the left frontal lobe) cognitive impairments are:
Speech production (Broca’s aphasia) and expressive language
Common post stroke (that has affected the frontal motor area) cognitive impairments are:
Apraxia
To manage cognitive issues post stroke, there is evidence for _____, including memory skills group
Memory rehibilitation
To manage cognitive issues post stroke, there is evidence for
Face to face or telehealth interventions
Emotional issues after stroke are:
very common
What significantly affects functional outcomes after stroke?
Emotional issues
What kind of mental health disorders are experiences by people post stroke?
Depression, anxiety, and PTSD like problems
___ fatigue and _____ disturbance are also common after stroke.
Mental
sleep
Post stroke shows difficulty with ___ and ____.
coping
adjustment
What kind of assessment do we generally do post stroke to assess mood?
A non-verbal assessment
What has been shown to be effectively adapted to treat depression, anxiety, fatigue and sleep disturbance post acquired brain injury?
Psychological therapies (e.g., CBT)
What are some challenges in applying psychological interventions to a post-stroke population?
-Pleasant activity scheduling/behavioural activation for someone with major physical disability
-Challenging automatic thoughts/core beliefs in someone with impaired reasoning/rigidity of thought
-Exposure therapy in someone with significant memory problems
-Mindfulness in someone with attentional disturbance
No matter the condition, neuropsychologists always start with what?
A neuropsychological assessment, using a hypothesis testing approach.
A neuropsychological assessment has a number of steps, including:
Gathering info about a clients history and current symptoms from a variety of sources.
Formal assessment tools will be administered based on:
The referral question and reported symptoms.
What also plays a crucial role in the information gathering process?
Behavioural observations
What is the most common symptoms of schizophrenia?
Psychosis: hearing or seeing things that aren’t there.
What are positive symptoms in schizophrenia?
-Delusions
-Hallucinations
-Disorganised thinking
-Disorganised agitated behaviour
What are negative symptoms of schizophrenia?
-Diminished emotional expression
-Avolition
-Alogia
-Anhedonia (decreased ability to experience pleasure)
-Asociality
What are some neurobiological changes when it comes to schizophrenia?
-Enlarged ventricles
-Overall decrease in brain volume
-Decreased grey matter -frontal and temporal lobes
-Reduced white matter
-Disorganised neurons
-Changes involving dopamine, glutamate, GABA
What are some cognitive symptoms of schizophrenia?
-Broad deficits across most cognitive distortions
-Commonly impaired: processing speed, attention, memory, reasoning, executive functioning, social cognition
-Occur early and persist through the course of the illness
-Strongest predictor of functional outcomes
What is not improved by pharmacological treatment for psychosis?
Cognitive impairment
Cognitive remediation improves global ___ and global ____ in psychosis.
cognition
functioning
What does cognitive remediation need to address when being used as an intervention for psychosis?
Motivation, engagement, self efficacy and self concept.
What are the 3 focuses used in cognitive interventions for psychosis?
-Repeated practice of cognitive exercises
-Development of cognitive strategies
-Facilitate transfer to everyday function
