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 Omar is a 72-year-old male  Asked to retire due to erratic performance at work  No appetite or energy since wife’s death  Recently lost his car downtown  Unable to recognize surroundings  Unshaven with oversized slacks and worn shirt Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Dementia?  Delirium?  Depression? Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Three most common in adults  Dementia  Delirium—acute confusion  Depression ▪ Often associated with dementia and delirium Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Syndrome characterized by dysfunction or loss of  Memory  Orientation  Attention  Language  Judgment  Reasoning Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Other characteristics that can manifest  Personality changes  Behavioral problems such as ▪ Agitation ▪ Delusions ▪ Hallucinations Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Problems disrupt individual’s  Work  Social responsibilities  Family responsibilities  Physicians usually diagnose when 2 or more brain functions are significantly impaired Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Not a normal part of aging  Affects 15% of older Americans  Half of the patients in long-term care facilities have dementia  ~100 causes of dementia Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Due to treatable and nontreatable conditions  Two most common causes  Neurodegenerative conditions  Vascular disorders Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

Alzheimer’s Disease 60% Vascular Dementia 20% Lewy Body Disease 10% Other Types Pick’s disease Normal pressure hydrocephalus Creutzfeldt-Jakob disease Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Important risk factors  Advanced age  Family history Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Infectious diseases can result in vascular and neurodegenerative changes that can lead to dementia  Bacterial meningitis  Viral encephalitis Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Dementia sometimes caused by treatable conditions can be reversed  But prolonged exposure may make dementia irreversible Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Vascular dementia  Loss of cognitive function due to brain lesions caused by cardiovascular disease  Result of decreased blood supply from narrowing and blocking of arteries that supply brain Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Vascular dementia (cont’d)  Predisposed risks of vascular dementia ▪ Smoking ▪ Cardiac dysrhythmias ▪ Hypertension ▪ Hypercholesterolemia ▪ Diabetes mellitus ▪ Coronary artery disease Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Onset of dementia depends on cause  Insidious and gradual ▪ Neurologic degeneration dementia is usually gradual and progressive over time  Abrupt ▪ Vascular dementia tends to be abrupt or progress in a stepwise pattern Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Classifications  Mild  Moderate  Severe Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Early Stage (Mild)  Forgetfulness beyond what is seen in a normal person  Short-term memory impairment  Geographic disorientation Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Initial symptoms are related to changes in cognitive function  Family members often report to doctor  Memory loss  Mild disorientation  Trouble with words and/or numbers Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Middle Stage (Moderate)  Impaired ability to recognize close friends and family  Wandering, getting lost  Forgets how to do simple tasks  Delusions, hallucinations Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Late Stage (Severe)  Little memory, unable to process information  Difficulty eating, swallowing  Cannot understand words  Incontinence Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Depression often mistaken for dementia and vice versa  Manifestations of depression, especially in older adults  Sadness  Difficulty thinking and concentrating Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Manifestations of Depression (cont’d)  Fatigue  Apathy  Feelings of despair  Inactivity Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Dementia and depression occurring together can cause extreme intellectual deterioration  Depression alone or with dementia is treatable Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 First focused on determining cause  Reversible or nonreversible  Thoroughly evaluate patient history  Medical  Neurologic  Psychologic Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Physical examination to rule out other medical conditions  Screen for  Cobalamin (vitamin B 12 ) deficiencies  Hypothyroidism  Possibly neurosyphilis Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Mental status testing is important  Those with mild dementia may be able to compensate, making diagnosis difficult through just conversation  The Mini-Mental State Examination is most commonly used tool for assessing cognitive function Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Computed tomography (CT)  Magnetic resonance imaging (MRI)  To monitor changes:  Single-photon emission computed tomography (SPECT)  Positron emission tomography (PET) Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 What is Omar’s diagnosis?  Dementia  Depression  Delirium Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Chronic, progressive, degenerative disease of the brain  ~5.3 million Americans suffer from AD  Most live 8-10 years after being diagnosed Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Incidence slightly higher is African and Hispanic Americans  May be related to socioeconomic status or access to health care, not ethnicity  Women more likely to develop AD  Have longer life expectancy than men Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Exact etiology is unknown  Age of onset determines type:  Early onset  Late onset  Familial Alzheimer’s disease  Earlier onset  More rapid disease course Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Changes in brain structure and function  Amyloid plaques  Neurofibrillary tangles  Loss of connections between cells and cell death Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Pathologic changes precede clinical manifestations by 5 to 20 years  Alzheimer’s Association has developed a list of 10 warning signs Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

1.Memory loss that affects job skills  Frequent forgetfulness or confusion that goes beyond forgetting names or phone numbers 2.Difficulty performing familiar tasks  Such as cooking a meal then forgetting that they made it Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

3.Problems with language  Forget simple words or substitute inappropriate words, making speech hard to understand 4.Disorientation to time and place  Become lost on their own street: not know where they are, how they got there, or how to get back home Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

5.Poor or decreased judgment  May dress inappropriately in noticeable ways, such as wearing a bathrobe to the store or sweater on a hot day 6.Problems with abstract thinking  Difficulty recognizing numbers or doing basic calculations Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

7.Misplacing things  May put items in inappropriate place (such as eating utensils in a clothing drawer) and have no memory of how they got there 8.Changes in mood or behavior  Exhibit rapid mood swings for no apparent reason Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

9.Changes in personality  Such as an easygoing person becoming angry, suspicious, or fearful  Can change dramatically, either suddenly or over time 10.Loss of initiative  May become and remain uninterested in many of their usual pursuits Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Progression is variable from person to person and ranges from 3 to 20 years  Initial sign is subtle deterioration in memory  Inevitably progresses to more profound memory loss Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Recent events and new information cannot be recalled  Behavioral manifestations are not intentional or controllable because of ongoing loss of neurons  Some develop psychotic manifestations Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 In AD that has progressed  Dysphasia  Apraxia  Visual agnosia  Dysgraphia  Some long-term memory loss  Wandering  Aggression Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Late stages  Unable to communicate  Cannot perform activities of daily living  Patient may be unresponsive and incontinent, requiring total care Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.

 Early findings show people who engage in activities that involve information processing have a decreased risk of developing AD  Reading  Crossword puzzles  Learning a new language Mosby items and derived items © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier, Inc.