Download Sid Williams - Dementia Concepts

Sid Williams 2016
Psychiatric Times May 10 2014
Konsul_777_999 9/7/13
Blind Men Appraising an Elephant by Ohara Donshu, Edo Period (early 19th century), Brooklyn
Museum
Dementia is a convenient shorthand often
mistakenly thought to describe a syndrome
Syndrome: A group of signs, symptoms and
illness course that occur together and often
characterise a disease or medical condition
In the past DSM treated dementia as if it were a
syndrome
Dementia is not an animal (or a coherent thing)
at all
‘But if thoughts corrupt language, language can
also corrupt thought’ George Orwell, Politics and the English
Language. Horizon, GB London, 1946
‘What is Dementia’
‘Dementia’ is a term used
medically to describe a
syndrome (set of symptoms)
that is caused by many
different diseases. …. An
analogy is the term ‘cancer’
that is used to describe any
malignant tumour but is not
a specific disease” WRONG
The reification of ‘dementia’
‘Dementia’ has become a ‘thing’ separate from
concepts of Alzheimer’s disease, and other
brain pathologies
‘I know he had a stroke causing difficulties
communicating and such but now does he have
dementia?’
‘A dementing process’
Démence (French)  dementia (English) about
1806 – concept close to ‘madness’
Late 19th century link to physical disease of the
brain became embedded in the term
1960-70s USA: ‘Organic Brain Syndrome’
Up to DSM-III-R (1987) general definition of
dementia as if it were a syndrome or disorder
DSM-IV (1994) moved away from general
definition, although Criteria A and B for all
forms of dementia were the same
DSM-5 (2013) jettisoned Dementia 
Neurocognitive disorders
DSM-5 introduces concept of Cognitive Domains
Neurocognitive disorders defined by evidence of
significant cognitive decline in one or more
cognitive domains + other criteria (significant
decline, not delirium, not other mental
disorder)
Williams, S. Your Brain in Sickness and in Health. In Press.
Chiu (1994 & 2005)
Sachdev (2000)
Williams (2006)
Chiu, E. 1994, "What's in a name - dementia or dysmentia?", International Journal of
Geriatric Psychiatry, vol. 9, pp. 1-4.
Sachdev, P. 2000, "Is it time to retire the term "dementia"?", Journal of Neuropsychiatry &
Clinical Neurosciences.12(2):276-9.
Chiu, E. 2005, "Limitations in the current classification systems for dementia.",
International Psychogeriatrics.17 Suppl 1:S17-26.
Problems Associated with the Term and Concept of Dementia, 6th International Congress
of Neuropsychiatry, Sydney, 13/9/06
14
‘stages’ of dementia deterioration
memory loss is a key feature
always progressive – ‘a dementing process’
cognitive impairment is the central feature and
changes in social and emotional function are
secondary
changes in social and emotional function,
delusions (confabulatory or otherwise),
hallucinations are separate (‘psychiatric’)
phenomena
changes in motor function are separate
phenomena
that impairment is ‘global’
Many conditions where the old concept of
dementia was not appropriate can now be
included under neurocognitive disorders e.g.:
Traumatic brain injury
Alcohol Related Brain Damage
Localised brain damage (e.g. infarcts)
Huntington’s disease
Not a return to reductionist localisationism e.g.
Phrenology
‘Domains of function’ refers to particular areas of
function (e.g. Learning and memory; Language) not
necessarily corresponding to particular brain areas
Complex attention
(sustained attention, divided attention,
selective attention, processing speed)
Executive function
(planning, decision making, working
memory, responding to feedback/error
correction, overriding habits/inhibition.
Mental flexibility)
Learning and memory
(immediate memory, recent memory
[including free recall, cued recall, and
recognition memory], very long term
memory [semantic; autobiographical],
implicit learning.
Language
(expressive language [including naming,
word finding, fluency, and grammar and
syntax] and receptive language)
Perceptual-motor
(includes abilities subsumed under the terms
visual perception, visuoconstructional,
perceptual-motor, praxis, and gnosis)
Social cognition
(recognition of emotions, theory of mind)
A. The criteria are met for major or mild neurocognitive dlsorder,
B. The disturbance has insidious onset and gradual progression
C. Either ( 1 ) or (2):
1. Behavioural variant:
a. Three or more of the following behavioral symptoms:
i. Behavioral disinhibition.
ii. Apathy or inertia.
ii. Loss of sympathy or empathy.
iv. Perseverative, stereotyped or compulsive/ritualistic
behavior.
v. Hyperorality and dietary changes.
b. Prominent decline in social cognition and/or executive
abilities
2.
Language variant:
a. prominent decline in language ability, in the form of speech
production, word finding. object naming, grammar, or word
comprehension
D.
Relative sparing of learning and memory and perceptual-motor function.
E.
The disturbance is not better explained by cerebrovascular disease,
another neurodegenerative disease. The effects of a substance, or another mental,
neurological, or systemic disorder.