Lecture 9: Dementia 1: Chapter 19 Flashcards
What is the name of the pre stage of dementia?
Mild cognitive impairment (MCI)
What are the 2 differences between crystallized and fluid intelligence?
Crystallized:
- Well-practiced skills, vocabulary, general knowledge
- Remains stable/improves with normal aging
Fluid:
- Processing speed, executive functions, problem-solving
- Declines with normal aging
What are the 6 cognitive domains that change with aging? What type of intelligence fits with it and how does it develop with aging?
- Processing speed
–> Fluid
–> Declines with age - Attention
–> Fluid
–> Simple no decline, complex yes decline - Memory
–> Fluid
–> Mixed - Language
–> More crystallized than fluid
–> In general no, but more issues in naming and verbal fluency - Visuospatial
–> Mixed
–> Simple no decline, complex yes decline - Executive function
–> Fluid
–> Mixed
When does the decline of fluid intelligence usually start?
After adolescence
What does it mean that someone has delayed recall?
Difficulties in spontaneous retrieval of information from memory without a cue
E.g. recalling list of items to purchase at the grocery store without cue
What are 3 types of memory that decline with aging and what are 3 types of memory that remain stable with aging?
Decline:
1. Delayed free recall
2. Source memory
3. Prospective memory
Stable:
1. Recognition memory
2. Temporal order memory
3. Procedural memory
What is source memory? Give an example
Knowing the source of the learned information
E.g. know where you learned a fact (newspaper, tv, friend etc.)
What is prospective memory? Give an example
Remembering to perform intended actions in the future
E.g. Remembering to take medicine before going to bed
What is recognition memory? Give an example
Ability to retrieve information when given a cue
E.g. correctly giving details of a story when given yes/no questions
What is temporal order memory? Give an example
Memory for the correct time or sequence of past events
E.g. Remembering that last saturday you went to the grocery store after you ate lunch with your friends
What is procedural memory? Give an example
Memory of how to do things
E.g. knowing how to ride a bike
What are 3 structural and functional changes in normal cognitive aging?
- Cortical thinning, shrinkage gray matter volume
- Decreased white matter density
- Loss of dopaminergic receptors
What are 3 consequences of loss of dopaminergic receptors?
- Attention dysregulation
- Executive dysfunction
- Difficulty with contextual processing
In which 2 brain regions is decreased white matter density common with normal aging? What does it mean when it’s not in these regions?
Normal in frontal and occipital regions
Not normal in temporal/parietal regions –> indication that something is wrong
What are 3 types of activities associated with high cognitive function in elderly?
- Intellectually engaging activities (puzzles, high education attainment)
- Physical activities (dancing, exercise)
- Social engagement (travel, socializing)
What are 3 protective factors for successful cognitive aging?
- Lifestyle
- Cognitive reserve
- Cognitive retraining
What is cognitive reserve? Which 2 factors influence it?
The flexibility and adaptability of the brain(networks) to cope with brain damage
Factors:
1. Education level (high education –> high reserve)
2. Lifestyle
Describe the graph of the relationship between the course of dementia and the level of cognitive reserve
Low level reserve: early onset dementia, slow decline
High level reserve: late onset dementia, fast decline
What are 3 factors that influence lifestyle as a protective factor for cognitive aging?
- Active/healthy lifestyle
- Cognitive and social stimulation
- Limit cardiovascular risk
What is cognitive retraining?
Teaching strategies to improve memory, reasoning and speed of processing
What is the difference between minor and major neurocognitive disorders in DSM5?
Minor = mild cognitive impairment MCI
Major = dementia
What is dementia?
Umbrella term for a number of neurological conditions, of which the major symptom is the decline in cognitive function due to physical changes in the brain
It’s distinct from mental illness
What are the 4 criteria of dementia in the DSM5?
- Substantial cognitive decline in one or more cognitive domains
- Deficits interfere with independence (require assistance)
- Not due to delirium
- Not due to other mental disorder
What are the 6 cognitive domains?
- Executive function
- Complex attention
- Social cognition
- Language
- Learning and memory
- Perceptual-motor function
What are 5 parts of language as a cognitive domain?
- Object naming
- Word finding
- Fluency
- Grammar and syntax
- Receptive language
What are 6 aspects of executive functions?
- Planning
- Decision making
- Working memory
- Responding
- Inhibition
- Flexibility
What are 4 types of complex attention?
- Sustained attention
- Divided attention
- Selective attention
- Processing speed
What are 3 aspects of social cognition?
- Recognition of emotions
- Theory of mind
- Insight
What are 5 aspects of learning and memory as a cognitive domain?
- Free recall
- Cued recall
- Recognition memory
- Semantic and autobiographical longterm memory
- Implicit learning
What are 3 aspects of perceptual-motor functioning as a cognitive domain?
- Visual perception
- Visuoconstructional reasoning
- Perceptual-motor coordination
What are some possible causes of major/minor NCD (DSM5)?
Alzheimer’s, Vascular disease, Frontolobar degeneration, Lewy bodies, Huntington’s, Parkinson’s, HIV, TBI, Substance use, Multiple etiologies
What is the difference in distribution of the different types of dementia between people under and people over the age of 65?
> 65: more than half caused by Alzheimer’s
<65: most AD, more frontotemporal dementia and alcoholrelated dementia
What are 3 diagnostic criteria for mild cognitive impairment (MCI)?
- Concern regarding cognitive change by the patient or informant
- Impairment in one or more cognitive domains based on neuropsychological examining
- Impairment doesn’t interfere with activities in daily life
What is delirium? What is it’s connection to NCD?
Transient stage of confusion in time, sometimes with mild hallucinations
If this is going on, you can’t classify a neurocognitive disorder!
Why is MCI often not diagnosed?
Most people don’t go to the doctor for it
Which type of dementia always has a phase of MCI?
Alzheimer’s
How can you treat MCI? (3)
No intervention has proven to be effective in decreasing symptoms or delaying/preventing progression of MCI to dementia yet
Reassessment is needed to monitor progression of MCI
Psychoeducation and cognitive training
What is the most distinctive impairment in Alzheimer’s disease (AD)?
Memory impairment
What percentage of dementia cases has Alzheimer’s? And what is the clinical duration?
80% of dementia cases (varies among countries)
8-10 years (duration depends on time of diagnosis)
What are 2 causes of cortical atrophy in AD?
- Neuronal death from accumulation of beta amyloid protein fragments outside neurons
- Twisted strands of tau protein (tangles) inside neurons
What are 3 things that indicate brain atrophy in AD on an MRI scan?
- Extreme shrinkage cerebral cortex
- Severely enlarged ventricles
- Extreme shrinkage of hippocampus (unique for AD)
What are 3 issues with the amyloid cascade hypothesis of AD?
Scientists think that amyloids are the cause of AD
- Lack of coherent evidence
- Unclear if plaques/tangles are cause of Alzheimer’s disease or just a consequence
- Failure to provide effective treatment
When is AD considered to be EOAD?
Onset before age 65 –> EOAD
EOAD = early onset AD
LOAD = late onset AD (95% cases)
How does risk for AD develop with age?
Risk increases with age
65-74: 5%
75-84: 13%
>84: 35%
What are 7 general risk factors for AD?
- Age
- Female gender
- Brain injury
- Cardiovascular risk factors
- Genetics
- Inactive lifestyle
- (lower education level)
With what type of condition is AD often observed together? Give an explanation
Cerebrovascular damage –> inadequate blood flow to the brain (brain hypoperfusion) is likely involved in pathogenesis of AD
What is hypoperfusion?
Inadequate blood flow to the brain
What are 2 issues with the vascular hypothesis of AD?
Hypothesis = inadequate blood flow to the brain is involved in pathogenesis of AD
Issues:
1. Unclear if vascular component constitutes the cause or rather the effect of the disease
2. Unclear if typical AD pathology and vascular pathology are 2 simultaneously unrelated processes or 2 processes that affect and amplify each other
What are the 4 stages of the diagnostic cycle?
- Complaints analysis
- Problem analysis
- Diagnosis
- Indication for treatment
What are 4 aspects of the clinical diagnosis (specific diagnosis) of NCD?
- (Medical) history of patient
- Clinical examination
- Neuroimaging
- Neuropsychological testing
What is part of the complaints analysis in diagnosing AD? Give examples of questions
Clinical interview with patient and close relative
E.g. complaints cognitive dysfunction, onset and progression of problems, medication use, family history, psychiatric symptoms
What are examples of psychiatric symptoms in dementia?
Mood and anxiety issues
What is meant with the level of independence of someone?
Activities of daily functioning (without help)
How can a screening test help you in the complaints analysis?
It’s an assessment of global cognitive functioning and gives you an idea of a direction you can look in
What is part of the problem analysis in diagnosing AD? (2)
- Neuropsychological assessment (memory, EF/problem solving, attention, other cognitive problems)
- Assessment neuropsychiatric symptoms
What type of memory impairment is associated with early stages of AD? And late stages?
Early = anterograde long-term memory impairment (make new memories)
Late = anterograde + retrograde memory impairment and semantic memory problems
Give a few examples of neuropsychological tests in the problem analysis stage
Visual association task, word recall, trail making test, stroop task, digit span, clock drawing
What are 8 neuropsychiatric symptoms in AD?
- Depression
- Anxiety
- Apathy
- Psychosis (hallucinations/delusions)
- Agitation, aggression, wandering
- Motor unrest
- Sleeping problems
- Eating problems
What are 3 other symptoms that can occur in AD?
- Olfactory dysfunction
- Seizures (10-20% of cases, usually later stage)
- Motor signs (usually later stages)
Why is it important to understand normal cognitive aging? (2)
- May affect older adult’s day-to-day functioning
- Help distinguish normal from disease states
What are 4 methodological challenges that plague the study of normal brain aging?
- Selection bias: people with limited social or financial support are less likely to enroll (too busy, too ill etc.)
- Cohort differences in cross-sectional designs: different age cohorts may have had different lives (overestimate effect of aging)
- Practice effects in longitudinal studies
- Complicated when subjects are misdiagnosed (early symptoms of dementia are easily missed)
How can you measure simple auditory attention span?
Repetition of a string of digits
What is the difference between selective and divided attention?
Selective = ability to focus on specific information and ignore the rest
Divided = ability to focus on multiple things at once
Age related memory changes may be related to… (3)
- Slowed processing speed
- Reduced ability to ignore irrelevant information
- Decreased use of strategies for learning
What are the subtypes of memory? (2)
- Declarative (explicit)
- Semantic
- Episodic/autobiographical - Nondeclarative (implicit)
What is the difference in decline of semantic and episodic memory in normal aging?
Semantic: decline late life
Episodic: decline through life
What are the 3 stages of memory?
- Acquisition
- Retention
- Retrieval
Language remains relatively intact with normal aging. What are 2 exceptions?
- Visual confrontation naming
- Verbal fluency
What is the difference between visual construction skills and visuospatial abilities?
Construction = put together parts to make a coherent whole
–> declines with age
Visuospatial = object perception/recognition + spatial perception/location perception
–> remain intact with age
What is the cause of loss of neurons in normal aging?
Death of neurons is a cause of loss of gray matter volume
What is the evidence that older people are worse at mentalizing?
fMRI BOLD: decreases in mPFC. This area may be important for mentalizing
At what age will a normal adult have a synaptic density of someone with AD?
130
Is there more decrease in volume of white or gray matter with normal aging?
More white, most in frontal and occipital lobes
What is a good predictor of motor vehicle crashes in older adults?
Low visual processing speed
(Measured with useful field of view test)
What is the best way to predict driving fitness?
Performance-based road test
What may be an effective option for older adults to be able to keep driving?
Driving retraining
What is the heritability of cognitive ability?
60%
What is passive cognitive reserve? What is active cognitive reserve?
Passive = Genetically determined characteristics such as brain volume and the number of neurons/synapses present
Active = Brain’s potential for plasticity and reorganization in neural processing, ability to compensate for neuropathology
What is the scaffolding theory of aging and cognition (STAC)? What is some evidence on this?
Alternative neural circuits are recruited to achieve a cognitive goal
fMRI evidence: aging is correlated with recruitment of more areas within a neural network to perform tasks (especially memory) compared to young controls
What is an issue with the DSM 5 classification of AD?
One of the criteria is that there is no evidence of mixed etiology. This is actually rare, because vascular etiology is often seen as well
What is the life expectancy after AD diagnosis and what is it related to?
8-10 years
It relates to the stage of disease at diagnosis and age of onset of symptoms
What does an older age of onset mean for the rate of decline?
Slower rate of decline
What do early neuropsychiatric symptoms mean for the rate of decline?
Faster rate of decline
What are 2 types of medication to inhibit cognitive symptoms of Alzheimer’s disease?
- Cholinesterase inhibitors (mild to moderate AD)
- N-methyl D-aspartate (NMDA) antagonist (moderate to severe AD)
What are 4 treatment options for AD?
- Medication to inhibit symptoms
- Psychoeducation
- Cognitive training (early stages)
- Manage behavioral symptoms
What is posterior cortical atrophy (PCA)? What type of atrophy fit with the onset and what is the neuropathology?
It’s a subtype of Alzheimer’s disease, characterized by motor
Onset = atrophy visual cortex, sometimes cerebellum
Pathology = tangles and plaques
What are 5 progressive visuoperceptual problems of posterior cortical atrophy (PCA)?
- Visual field deficits
- Not being able to recognize objects or faces
- Problems with letter recognition/reading
- Optic ataxia (lack of coordination between visual input and motor output)
- Visual and spatial orientation problems
Why is posterior cortical atrophy (PCA) difficult to diagnose?
Because of atypical, strange complaints in daily life
What are 6 atypical complaints that make it hard to diagnose PCA as a subtype of Alzheimer’s?
- Blind sight
- Objects suddenly seem to appear or disappear
- Objects seem distorted
- Not able to recognize objects up close, but no problems far away
- Letters are distorted/missing
- Sometimes not aware of their visual problems
How many cognitive domains should be affected in order to get the diagnosis of Alzheimer’s?
2 or more
What is double ageing? How does it relate to Alzheimer’s?
- Demographic structure of western society is changing, so the amount of elderly people in the population will increase over the next decades
- Average life expectancy has increased and is continuing to do so
So it means the number of people with Alzheimer’s will increase rapidly over the next few decades
In which 2 steps is a diagnosis of Alzheimer’s usually made?
- Determining severity of symptoms (syndrome diagnosis)
- See what type of dementia is present (etiological diagnosis)
What are the 2 main hypotheses of explaining Alzheimer’s disease?
- Amyloid cascade hypothesis
- Vascular hypothesis (mixed pathology)
In which type of patients is mixed etiology of Alzheimer’s seen more often?
Elderly patients.
Younger patients often have a pure form of Alzheimer’s disease
Atrophy of the hippocampus (medial temporal lobe) is often there in an early stage of Alzheimer’s. What is the consequence of this?
Difficulties in capturing and retention of new information
This is why memory is most pronounced symptom of Alzheimer’s disease
