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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 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 Márta Balaskó and Gyula Bakó Molecular and Clinical Basics of Gerontology – Lecture 18 COGNITIVE AND AFFECTIVE DISORDERS IN THE ELDERLY 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. Aging-associated cognitive, affective and psychiatric disorders (outline) TÁMOP-4.1.2-08/1/A-2009-0011 • 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 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 Senile dementia of the Alzheimer type (SDAT, Alzheimer’s disease) 1 TÁMOP-4.1.2-08/1/A-2009-0011 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 dropouts: 2× risk) • positive family anamnesis: 4× risk • head trauma: 2× risk • smoking, metabolic syndrome X, atrial fibrillation, stroke, alcohol consumption, TÁMOP-4.1.2-08/1/A-2009-0011 Prevalence of Alzheimer’s disease 60 50% Prevalence (%) 50 40 30% 30 20 16% 10 0 1% 2% 4% 8% 60-64 65-69 70-74 75-79 80-84 Age (years) 85+ 95+ Senile dementia of the Alzheimer type (SDAT, Alzheimer’s disease) 2 TÁMOP-4.1.2-08/1/A-2009-0011 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 Senile dementia of the Alzheimer type (SDAT, Alzheimer’s disease) 3 TÁMOP-4.1.2-08/1/A-2009-0011 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 Senile dementia of the Alzheimer type (SDAT, Alzheimer’s disease) 4 TÁMOP-4.1.2-08/1/A-2009-0011 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 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 TÁMOP-4.1.2-08/1/A-2009-0011 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– TÁMOP-4.1.2-08/1/A-2009-0011 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 TÁMOP-4.1.2-08/1/A-2009-0011 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 TÁMOP-4.1.2-08/1/A-2009-0011 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 Alcohol abuse and consequences in the elderly TÁMOP-4.1.2-08/1/A-2009-0011 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. Consequences of alcohol abuse in the elderly 1 TÁMOP-4.1.2-08/1/A-2009-0011 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! Consequences of alcohol abuse in the elderly 2 TÁMOP-4.1.2-08/1/A-2009-0011 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 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 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, Factors that make the diagnosis of depression especially difficult TÁMOP-4.1.2-08/1/A-2009-0011 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. TÁMOP-4.1.2-08/1/A-2009-0011 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 Differential diagnosis of depression (pseudodementia) and dementia PSEUDO-DEMENTIA TÁMOP-4.1.2-08/1/A-2009-0011 • 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