Neurocognitive Disorders and Psychosocial Needs of the Older Adult (copy)
General Overview
Focus on neurocognitive disorders and associated psychosocial needs in older adults.
Neurocognitive Disorders
Dementia
Definition: Slow developing, progressive impairment of intellectual or cognitive functions (e.g., memory, language, problem-solving) that gradually worsens over months or years and significantly interferes with daily functioning.
Memory Loss: Typically involves a gradual loss of recent memories (from the last months or years), which is often irreversible. Patients might forget recent conversations or events, while older memories may remain intact initially.
Progression: Initial symptoms often include subtle difficulties like word searching (anomia) or mild forgetfulness. These progress to more pronounced sparse speech, reduced comprehension, and eventually lead to mutism and a profound loss of verbal communication skills in later stages.
Delirium
Definition: Sudden and acute changes in cognitive functioning with an identifiable underlying cause. It is frequently associated with medical conditions such as infections (e.g., pneumonia, UTI), severe illness, surgery, electrolyte imbalances, or medication side effects.
Onset: Abrupt, characterized by a rapid change (over hours to days) from the individual's baseline mental state. The symptoms often fluctuate throughout the day.
Symptoms:
Impaired verbal recall, often reversible once the underlying cause is addressed.
Disturbed sleep/wake cycle, leading to daytime drowsiness and nocturnal agitation or sleeplessness.
Speech can be incoherent, confused, and often inappropriate (e.g., misnaming people or objects, rambling nonsensically).
Causes and Contributors to Delirium
Contributing Factors
Drugs: Includes prescription medications (e.g., sedatives, opioids, anticholinergics like diphenhydramine), recreational drugs, and polypharmacy leading to drug-drug interactions.
Emotional state: High levels of stress, anxiety, or acute grief can exacerbate or trigger delirium.
Electrolyte imbalances: Conditions like hyponatremia (low sodium), hyperkalemia (high potassium), or imbalances in calcium/magnesium can severely affect brain function.
Low oxygen levels (Low PO2): Caused by conditions such as pneumonia, COPD exacerbation, heart failure, or anemia, leading to cerebral hypoxia.
Infections: Particularly prevalent with urinary tract infections (UTI) in older adults, but also systemic infections like sepsis, influenza, or pneumonia.
Sensory reduction or deprivation: Lack of environmental cues, such as insufficient sunlight, prolonged bedrest, social isolation, or uncorrected vision/hearing impairment, can disorient individuals.
Seizures or postictal states: The period immediately following a seizure often involves confusion and altered consciousness.
Undernutrition: Deficiencies in essential nutrients like proteins, calories, vitamin B12, or folate, as well as dehydration, significantly impair cognitive function and overall brain health.
Poorly controlled diabetes: Both severe hypoglycemia (low blood sugar) and hyperglycemia (high blood sugar) can rapidly lead to cognitive changes.
Subdural hematoma: A collection of blood on the surface of the brain, often caused by head trauma (which can be minor in older adults due to brain atrophy), leading to increased intracranial pressure and confusion.
Delirium Assessment Tool: PNEUMONIC
AMNESIA: Refers to the loss of memory, which can be either short-term (e.g., inability to recall recent events) or long-term (e.g., forgetting personal history).
Impairments and Disorders Related to Cognitive Function
Apraxia
Definition: Difficulty initiating and executing purposive motor movements, despite having intact motor strength, sensation, and coordination. It’s a deficit in motor planning.
Impact: Inability to perform familiar Activities of Daily Living (ADLs) such as dressing, bathing, or eating, and Independent Activities of Daily Living (IADLs) like paying bills, washing the car, cooking a meal, or managing medications.
Examples of IADLs: Paying bills, washing the car, managing medications, cooking, shopping, using transportation, using the telephone.
Agnosia
Impaired ability to interpret sensations or recognize familiar objects, persons, sounds, or forms, even though the sensory organs (e.g., eyes, ears) and memory are functioning normally. This leads to difficulties in responding or understanding sensory information (e.g., visual agnosia, tactile agnosia).
Example: A person with visual agnosia might see a fork but not recognize it as an eating utensil, or not recognize a familiar face (prosopagnosia).
Communication Disorders
Aphasia
Definition: A language disorder that affects the ability to communicate, stemming from damage to the brain areas that control speech and language, most commonly after a stroke. It can impact speaking, understanding, reading, and writing.
Types include: Broca's aphasia (non-fluent, difficulty expressing words), Wernicke's aphasia (fluent, difficulty understanding, speech may be nonsensical), and Global aphasia (severe impairment in all language modalities).
Communication Strategies:
Keep It Simple: Speak in short, simple sentences, using common words to reduce cognitive load.
Be Patient: Allow ample time for the individual to process information and formulate a response; engage directly with the individual, making eye contact, rather than speaking for them or to a caregiver.
Remove Distractions: Turn off background noise (e.g., radios, TVs) to create a calm environment conducive to communication.
Be Creative: Use alternative communication methods such as writing, gestures, pointing to pictures, or utilizing communication tools like an iPad with picture symbols.
Confirm Understanding: Repeat back what you think the individual is trying to convey, or ask them to confirm your understanding, to ensure mutual comprehension.
Take Your Time: Understand it may take longer for the individual with aphasia to respond, and avoid rushing or interrupting them.
Express Needs: Encourage and allow the person to express what communication method works best for them, adapting your approach accordingly.
Use Assistive Devices: Employ visuals like photos, diagrams, communication boards, or use paper and pen for writing or drawing.
Acknowledge Frustration: It's normal for both the individual and caregiver to experience frustration; maintain patience and offer reassurance.
If Stuck: Discuss the difficulty openly, recap the conversation to find the point of confusion, and collaboratively decide whether to continue the topic or revisit it later.
Key Notes:
Individuals with aphasia communicate differently but retain their intellectual capacity; the language impairment does not reflect their intelligence.
Their auditory processing is intact (they can hear); shouting does not aid communication and can be distressing.
Aphasia is not contagious.
Psychosocial Issues Related to Aging
Depression in Older Adults
The highest population of suicide is observed among older adult males, a risk often exacerbated by feelings of isolation post-retirement, loss of friendships, bereavement (e.g., loss of a spouse), or chronic illness.
Aging itself is not classified as a risk factor for suicide; however, rates are notably high among the aging population, often linked to psychosocial changes and health declines.
Difficulty in treating depression is common due to patients often being on multiple medications (polypharmacy), increasing risks associated with adverse drug-drug interactions and side effects that can mimic depressive symptoms.
Anxiety in Older Adults
Increased prevalence of anxiety as various health problems develop with advancing age (e.g., heart disease, arthritis, diabetes, respiratory conditions).
Contributing factors include frequent doctor visits, concerns about health, lack of adequate insurance coverage, financial constraints, limited social interaction (due to loss of peers or mobility issues), and reduced physical activity.
Complications Contributing to Delirium
Factors:
Sundown syndrome: A common phenomenon in older adults, characterized by increased confusion, agitation, disorientation, and restlessness in the late afternoon and evening hours.
Prolonged hospital stays: The unfamiliar environment, disruption of routine, sleep deprivation, and exposure to multiple medications can contribute to delirium.
Inadequate nutrition and dehydration: Malnutrition and insufficient fluid intake are common in older adults and can precipitate delirium.
Anticholinergic medications: These drugs (e.g., some antihistamines, certain antidepressants, bladder control medications) can cross the blood-brain barrier and contribute to cognitive impairment and delirium-like symptoms.
Drug-drug interactions: The simultaneous use of multiple medications can lead to unforeseen side effects or potentiate the effects of cognitive-impairing drugs.
Symptoms of Delirium:
Hallucinations (visual or auditory), agitation, easy distraction, disorientation to person, place, or time, rambling or disorganized speech, withdrawal from social interactions, increased restlessness, and profound confusion.
Types of Dementia
Subtypes of Dementia
Five Recognized Subtypes:
MCI (Mild Cognitive Impairment): A noticeable but not debilitating decline in cognitive abilities (e.g., memory, thinking skills) that is greater than normal age-related changes but does not interfere with daily activities to the extent of dementia.
AD (Alzheimer’s Disease): The most common cause of dementia, characterized by the progressive degeneration of brain cells due to the accumulation of amyloid plaques and tau tangles, leading to widespread cognitive decline.
VaD (Vascular Dementia): Caused by reduced blood flow to the brain, often due to strokes or mini-strokes (TIAs). Symptoms can vary depending on the affected brain areas and may progress in a step-wise fashion.
LBD (Lewy Bodies Disease): Characterized by abnormal protein deposits (Lewy bodies) in the brain. Symptoms include fluctuations in cognition, visual hallucinations, and Parkinsonian motor symptoms (e.g., rigidity, tremors).
FTD (Frontal Temporal Disease): Involves the degeneration of nerve cells in the frontal and temporal lobes of the brain. Often presents with changes in personality, behavior, and language, rather than primary memory loss.
Alcohol-Induced Dementia
Risk Factors: Older adults, particularly males, are at a higher risk for substance abuse, including alcohol, which can lead to permanent brain damage and cognitive impairment.
Implications of aging on substance abuse: Physiological changes with aging, such as decreased renal blood flow (due to reduced cardiac output) and reduced liver metabolic capacity, complicate the body's ability to process alcohol and medications, thereby increasing vulnerability to toxicity and complicating treatment and medication management.
Ageism and Vulnerable Populations
Definition of Ageism: Prejudice or discrimination directed against an individual based on their age, often manifested as stereotypes or negative assumptions about older adults.
Vulnerable Groups: Elderly individuals and pregnant women are considered the most vulnerable to abuse, exploitation, and neglect.
Elder Abuse: Older adults are often dependent on caregivers, making them susceptible to abuse. Approximately 90% of elder abuse cases involve family members (e.g., spouses, children, grandchildren) as perpetrators. Abuse can be physical, emotional, financial, or involve neglect.