What happens when something goes wrong…..

 Identify
manifestations of
abnormalities in brain function
associated with aging.
 Explore interventions and

treatments to maximize functioning

when pathology is present.
 Delirium
 Depression
 Dementia
 Delirium is often unrecognized
 Delirium might be the only indication of
a life threatening condition
 Extremely important to identify
 Approximately 14-80% of hospitalized elderly
patients experience an episode of delirium
 Can represent a medical emergency and is a

potentially reversible condition

 Requires immediate interventions to prevent

permanent disability and health risks including

death
 increased length of hospitalization and
increased hospital mortality rates of
approximately 25-33%
 greater intensity of nursing care
 more frequent use of physical restraints
 greater in-hospital functional decline
 greater health care costs
 worse outcomes in severe delirium especially
at 6 months (e.g., ADL and ambulatory decline,
nursing home placement and death)
 Disturbance in attention (reduced ability
to direct, focus, sustain, and shift attention)
and awareness (reduced orientation to
environment)
 Develops over a short period of time,
a change from baseline, fluctuates
during the course of a day
 An additional disturbance in cognition
(memory deficit, disorientation, language,
visuospatial ability, or perception)
 Thedisturbances are not better
explained by another preexisting,
established, or evolving neurocognitive
disorder
 Evidence from history, physical exam,
or lab findings that the disturbance is a
direct physiological consequence of
another medical condition, substance
intoxication or withdrawal, or exposure
to a toxin, or is due to multiple
etiologies
 1) Acute onset and fluctuating course
 2) Inattention
 3) Disorganized thinking
 4) Altered level of consciousness

Delirium requires the presence of 1

and 2 plus either 3 or 4
 Hyperactive
◦ Agitated
◦ Restless
◦ Yelling
 Hypoactive
◦ Inactivity
◦ Withdrawal
 Mixed
 Hardest to recognize
 May look like depression
 Subdued, quiet
 Extremely important to recognize and

look for medical cause

 Chronological age – very young and very old
 Sensory deficits
 Dehydration
 Sleep disturbances
 Pre-existing dementia
 Cognitive impairment
 Immobility or use of restraints
 Medications–anticholinergic meds
 Metabolic abnormalities
 Comorbidities
 Presence of urinary catheter
 Under and over treatment of pain
 Withdrawal
 First have to recognize it
 Search for underlying cause
 Environment conducive for orientation
 Maintain safety and comfort
 Encourage mobility – avoid bedrest
 Environment conducive for sleep
 Optimize hearing and vision
 Avoid dehydration
 Avoid catheters
 Avoid deliriogenic medications
 Maximize the familiar and avoid distractions
 Most common psychiatric condition
affecting older adults
 “Common cold” of psychiatry
 Leading cause of disability in the US and

the world (NIMH)

 Often under-diagnosed and under-treated
 Robs elderly of late life satisfaction
 Causes impairment in cognitive, social

and personal functioning

 Involves undue suffering for patient

and often their family

 Causes excess morbidity and mortality
 Could be a symptom of an underlying

medical condition
 Increased risk of suicide
 Increased economic burden
 Could lead to substance abuse or

misuse
 Treatment is often very effective
 In older adults, depression may mask, or
be masked by, other physical disorders.
 Is difficult to disentangle depression from

the many other disorders affecting older

people
 Of the 35 million over age 65 in US, 2
million meet criteria for major depression
and another 5 million have depressive
symptoms
 One primary care study found that 11% of

depressed patients were adequately

treated, 34% were inadequately treated,
and 55% received no treatment.
 Atleast 5 symptoms must be present in
the same 2-week period and must include
either
◦ 1) Depressed mood
◦ 2) Loss of interest or pleasure
 3) Change in appetite or weight
 4) Insomnia or hypersomnia
 5) Psychomotor agitation or retardation
 6) Fatigue or loss of energy
 7) Feelings of worthlessness or guilt
 8) Difficulty with thinking or

concentration
 9) Thoughts of death or suicide
 Elderly may not admit or report sadness
 In general, elderly are less verbal about
feelings
 May be masked by somatic complaints

◦ Common are headache, nausea,

constipation, anorexia, “Just don’t feel well,”
GI upset, pain
◦ Preoccupation with physical health
 Less interest in hobbies or recreational
activities
 Daily chores left undone
 Social withdrawal
 Less interest in sex
 May neglect personal hygiene or
appearance
 Less able to experience pleasure
 Most often, decreased appetite but may
be increased
 Monitor weight
 May complain that food has no taste
 At risk for dehydration, electrolyte
imbalance, and malnutrition
 Insomnia or hypersomnia
 Early morning awakening
 Middle insomnia
 Waking too early
 Agitation– restlessness, irritable,
appear anxious and distressed, hand
wringing
 Slowness in movement, slowed

speech, latency of response

 Tired and worn out
 Everything is just too much effort
 Poor time management
 Apathetic
 “It’s too much work.”
 Blames self for things done and undone
 Feelings of being of “no value”
 Hopelessness, worry
 Future is bleak
 Self-reproach, critical of self and others
 “Don’t spend time with me; I’m not worth it.”
 May be delusional
 Slowed thinking
 Inability to focus or concentrate
 Indecisive
 Feels confused and bewildered
 Ruminations about insignificant problems
 Negativity
 Weary of life
 Life isn’t worth living
 “I’d be better off dead.”
 “You’d be better off if I weren’t here.”
 Passive suicide

◦ Refuse to eat
◦ Refuse medications
 Interaction of biological and psychosocial
factors
 Possible genetic contribution
 Reaction in response to losses
 Unresolved grief
 Physical illnesses may lead to depression
 Medications may cause symptoms of

depression
 Involve the person’s family
 Obtain an evaluation by a professional
 Every interaction has the potential to help
 Communicate a caring attitude
 Support and encourage
 Provide opportunity for social interactions
 Involve in scheduled or structured activities
 Spend time with the person and listen
 Encourage physical activity
 Mobilize support systems
 Monitor physical health

◦ Medication monitoring
◦ Nutrition and weight
◦ Sleep
◦ Comfort and relaxation
◦ Management of pain
 Beware of being “too cheerful”
 Antidepressant medications take time to
exert a therapeutic effect
 Monitor for suicidal thoughts, especially as

depression starts to improve

 Promote a positive attitude toward the future

– “I know that you feel this way now, but you

won’t always.”
 Remember that depression is usually very

treatable over time

A subjective state of dysphoric
apprehension or expectation
accompanied by physiological
responses
 Symptom of many disorders including
depression, dementia, delirium
 Primary symptom of anxiety disorders
 Excessive worry that person finds difficult to
control
 Complaints of shakiness, restlessness,

jitteriness, jumpiness, trembling, tension,

irritability, impatience, poor concentration,
memory problems, unrealistic fears
 Feeling of impending doom
 Anticipation of the worst that could happen
 Physical symptoms including:
◦ palpitations, chest pain
◦ dizziness, lightheadedness
◦ tingling, numbness
◦ stomach upset, diarrhea
◦ too hot or too cold, sweating
◦ shortness of breath, sensation of lump
in throat or choking
◦ sleep disturbance
 Medical illnesses
◦ hypoglycemia, hyperthyroidism
 Medications

◦ caffeine, stimulants, sympathomimetics

 Withdrawal states

◦ alcohol, benzodiazepines
 Situational anxiety

◦ going to a dentist, flying

 Panic disorder
 Agoraphobia
 Phobias
 Obsessive-Compulsive disorder
 Posttraumatic stress disorder
 Acute stress disorder
 Generalized anxiety disorder
 Minimize caffeine
 Social interaction
 Relaxation techniques
 Diversion and recreational activities
 Physical exercise
 Counseling or psychotherapy
 Medication, if use is justified
Minor Neurocognitive Disorder

Major Neurocognitive Disorder

 Complex attention (Sustained and divided
attention, processing speed)
 Executive ability (Planning and decision

making)
 Learning and memory (Recall and recognition)
 Language (Expressive and receptive)
 Visuoconstructional-perceptual activity

(Construction and visual perception)

 Social cognition (Emotions and behavioral

regulation)
 Evidence of minor cognitive decline
from a previous level of performance
 Deficits not sufficient to interfere with

independence
 Deficits do not occur exclusively in

context of delirium
 Greater cognitive deficits in at least one
(typically 2 or more) cognitive domains
 Evidences of significant cognitive decline

from previous level of performance

 Deficits sufficient to interfere with

independence
 Deficits do not occur exclusively in context

of delirium
A chronic, progressive,
irreversible, neurological disorder
affecting memory, cognition, ability
to function, personality, language,
and behavior
 Preclinical – pathophysiological
changes in the brain, but cognitively
normal
 Mild cognitive impairment due to AD –
clinical and research criteria
 Dementia due to Alzheimer’s Disease –
Possible, Probable, Probable with
evidence of AD pathophysiology
 Cerebral spinal fluid
◦ Phospho-tau concentration elevated
◦ Amyloid beta (1-42) peptide reduced
◦ AT Index <1 consistent with Alzheimer’s

 PET scan with special imaging agent

◦ Demonstrates amyloid burden
 Blood or urine tests – not available yet
 Alzheimer’s is the most common
form of dementia
 5.4 million people in US have DAT
 1 in 8 elderly has DAT
 About 500,000 Americans <65 years
old have a dementia; 40% of those
have DAT
 Alzheimer’s is the 6th leading cause
of death in the US
Neurofibrillary
tangles
Amyloid plaques
Cerebral atrophy
Short-term memory
- Hippocampus involved
◦ Can’t make deposits into “memory bank”
◦ Like a computer with a faulty save
function
◦ “Floating” reference point for time
 Memory
 Judgment and decision making
 Abstract thinking
 Inhibition control
 Organizational skills
 Motivation and attention
 Personality stability
 Emotions
 Language
 Praxis
 Visual spatial skills
◦ Sudden onset
◦ Step-wise progression
◦ Focal neurological signs and symptoms
◦ Evidence of cerebrovascular disease on
brain imaging
◦ History of hypertension, diabetes,
dyslipidemia, atrial fib, smoking, prior
TIAs or stroke
 Likely accounts for 75% of vascular dementia cases
 Affects small arterioles, venules and capillaries in
the brain
 Hypertension is a major risk factor
 Seen on MRI as small focal areas of infarction,
hyperintensities, microbleeds, or enlarged
perivascular spaces
 Subacute symptoms include cognitive impairment
(executive dysfunction, slowing of psychomotor
speed, memory problems), mood disorders, gait
disturbances
 Progression less predictable
 Focus on stroke prevention

◦ Manage hypertension
◦ Treat diabetes
◦ Lipid lowering agents
 Alzheimer’s drugs generally not beneficial
 Memory impairment evident with
progression, but not always early
 Abnormal proteinaceous (alpha-synuclein)

cytoplasmic inclusions called Lewy bodies

develop in cells throughout the brain
 Progressive dementia – deficits in attention,
executive function, memory, language and
visual spatial abilities
 Two of three core features

◦ Parkinsonism
◦ Recurrent visual hallucinations
◦ Fluctuating attention and concentration
 Dementia onset before or within one year of

parkinsonism onset
 SupportiveFeatures
◦ REM sleep behavior disorder
◦ Antipsychotic medication sensitivity
◦ Syncope
◦ Repeated falls
◦ Autonomic dysfunction
◦ Complex delusions
◦ Tremor at rest
◦ Rigidity
◦ Bradykinesia
◦ Postural instability
◦ Usually asymmetric onset of symptoms
◦ Dementia in 20 – 60%
 MultipleSystem Atrophy
 Corticobasal Degeneration
 Progressive Supranuclear Palsy
 FTD with Parkinsonism
A neurodegenerative disorder affecting
the frontal and/or temporal lobes of the
brain that presents predominantly with
behavioral or language disturbance, with
relative preservation of memory and
spatial skills early in the illness
-Earlier age of onset - 50% before age 65
-Survival 6.6 – 10 years after symptoms onset
-Personality changes and decline in social
skills
-Impaired executive functions
-Emotional blunting; apathy
-Behavioral disinhibition; bizarre behavior
-Language changes
-Prominent temporal and/or frontal atrophy
 Behavioral variant – prominent
changes in behavior and personality
 Progressive nonfluent aphasia –

expressive language changes

 Semantic dementia – can’t

understand words or recognize

familiar people and objects
 Insidious onset and gradual progression
 Early decline in social interpersonal conduct
 Early impairment in regulation of personal

conduct
 Early emotional blunting
 Early loss of insight
 Decline in personal hygiene and grooming
 Mental rigidity and inflexibility
 Distractibility and impersistance
 Hyperorality and dietary changes
 Perseverative and stereotyped behavior
 Utilization Behavior
 Speech and language changes
◦ Rapidly progressive, fatal
◦ Cognitive and behavioral changes
◦ Loss of coordination
◦ Myoclonus
◦ Spongiform changes in frontal cortex
◦ A type of prion disease misfolded proteins
◦ Autosomal dominant pattern of inheritance
◦ Defect of chromosome 4
◦ Basal ganglia affected
◦ Movement and coordination affected
◦ Loss of intellectual abilities and emotional
and behavioral disturbances
◦ Subdural hematoma

◦ Traumatic brain injury

◦ Hypoxemic anoxia
◦Alcohol/substance abuse
◦Heavy metals
◦Carbon monoxide poisoning
◦Drugs
◦ AIDS dementia
◦ Viral encephalitis
◦ Bacterial meningitis
◦ Neurosyphilis
◦ Dementia
◦ Ataxia
◦ Urinary Incontinence

◦ “Wild, wet, and wacky”

It is important to know
what PERSON the disease
has, not what disease the
person has.
-Sir William Osler 1849-1919
 Difficulty
learning new things
 Misplaces items
 Forgets to tend to appliances
 Trouble following recipes/directions
 Can’t remember the date/time
 Trouble recalling recent events or
conversations
 Forgets to pay bills or repays
 Trouble following plot in stories or on TV
 Use calendars, notes, reminders
 Write important information
 Repeat explanations or directions
 Try to limit distractions and simplify
 One specific location for keys,

glasses, important items

 Supervise medications, finances, and

for safety needs

 Provide reminder cues in conversations
or in the environment
 Try to endure repetitiveness
 Help locate missing items
 Monitor appetite and weight
 Don’t force reality orientation
 Discuss positive memories from the past
 Judgment and decision making
 Abstract thinking
 Inhibition control
 Organizational skills
 Motivation and attention
 Loss of sense of risk and danger
 Financial vulnerability
 Difficulty problem-solving
 May appear more dependent and
indecisive
 May trust strangers or be
“inappropriately familiar”
 Unable to prioritize activities
 Identify surrogate decision maker/s
 Avoid extended logical explanations
 Set limits on unrealistic demands
 Anticipate safety needs and safety proof

surroundings
 Avoid situations where failure is likely
 Use distraction rather than confrontation
 Maintain the person’s integrity
 Takes more time to understand
 Difficulty with time relationships
 Trouble with calculations and money
 Unable to “figure out” complex problems
 Poor interpretation of social cues
 Change in sense of humor
 Allow time to process verbal
communication
 Be alert for misunderstandings
 Interpret what is occurring in the

environment
 Help identify the function of objects
 Use discretion with humor
 More impulsive – desires immediate
gratification
 Frustrated easily – quick to react
 May make hurtful/insensitive comments
 May have inappropriate social behavior
 Possibility for sexual disinhibition
 Anticipate needs and possible
overreaction
 Maintain a calm environment
 Don’t take insensitive comments

personally
 Use a matter of fact approach for socially

inappropriate behavior
 Assist in covering social “mistakes”
 Unable to plan, organize, sequence
activities
 Don’t remember “how” to get started

on tasks
 May appear apathetic or disinterested
 Trouble following directions
 Simplify the environment
 Continue with familiar routine
 Provide structured activities, but be
flexible
 Break tasks into individual steps
 Give one-step directions
 Inconspicuously give cues
 Avoid sounding controlling or bossy
 If resistive, stop and try again later
 Problems with initiation
 Can’t switch mental gears easily
 Trouble completing tasks or “gets stuck”
 Loss of mental flexibility
 Difficulty maintaining effortful activities
 Distractibility
 Eliminate competing stimuli in the
environment
 Provide cues and prompts
 Plan activities that do not require sustained

periods of concentration
 Attempt distraction if the person is “stuck”
 Plan frequent rest periods
 Problems with
◦ Stopping
◦ Starting
◦ Switching
◦ Socialization
◦ Planning
◦ Judgment
 Disinhibited/impulsive
 Blurtout socially inappropriate remarks
 Frontal release signs (grasp reflex,

palmomental reflex)
 Compulsive eating
 Unable to resist impulse to use or touch

objects
 Lack of motivation
 Unable to initiate
 Inability to maintain effortful behavior
 Apathy
 Perseveration
 Lack of mental flexibility
 Self management difficulty to make

any change
 Improper emotional responses
 Poor interpretation of social cues
 Difficulties secondary to lack of

motivation, personality changes,

and uninhibited behavior
 Insensitive to others
 Unable to “read” social signals

from others
 Inability
of volition
 Cannot multitask
 Non compliance because can’t plan
 “Stubborn” – “Uncooperative”
 Unable to anticipate consequences
 Can’t prioritize
 Lack empathy
 Little or no insight
 Personality stability
 Emotions
 Language

 Praxis
 Visual spatial skills
 Apathy vs irritability
 Paranoia
 Abnormal beliefs
 Delusions or hallucinations
 Fearfulness
 Clinging/shadowing
 Anger/frustration
 Tryto exhibit the desired demeanor
 Be aware of your limits and stress level
 Clearly identify the purpose of cares
 Avoid arguments about abnormal beliefs
 Depression
 Anxiety
 Denial – lack of insight
 Labile emotions
 Withdrawal
 Address depression if it is suspected
 Provide environmental and

interpersonal supports to minimize

fears and anxiety
 Distract rather than confront
 Maintain a calm, routine, predictable

environment
 Encourage social activities
 Word-finding problems
 Trouble with names – talks “around”

names
 Loses train of thought in mid-sentence
 Can’t filter out distractions during

conversations
 Less use of nouns
 May not recognize objects
 Approach slowly from the front or side
and gain the person’s attention before
talking
 Speak slowly and clearly
 Maintain relaxed body language
 Face the person, establish eye
contact, and smile
 Introduce yourself and call the person
by name
 Eliminate distracting background noises
 Speak in low pitched tones
 Begin with social conversation or “small

talk”
 Keep sentences short
 Keep to one clearly defined subject at a

time
 Use nouns or names rather than pronouns
 Use the same word every time to refer to

common tasks/objects
 Avoid open ended questions
 Limit the number of decisions the person

has to make
 Accompany verbal communication with

appropriate non-verbal cues

 Exaggerate gestures or facial expressions if
hearing or vision impaired
 Use gentle touch that is not task oriented
 Break down tasks into individual steps and

ask the person to do one at a time

 Repeat explanations or directions as

needed
 Try to match requests to the person’s

current level of functioning

 Allow sufficient time for the person to
process information
 Focus on the feeling tone of the

conversation rather than content of words

 State positive directions; limit the use of

“don’ts”
 Talk about pleasant memories from the past
 Try supplying a word if it is appreciated
 Repeat the last few words to help regain

train of thought if blocking is a problem

 Allow word mistakes to go by “unnoticed” if

the general meaning is understood

 Inconspicuously give prompts during

interactions
 Avoid “quizzing” or forcing a response
 Make “educated guesses” of what intent

could be if verbal statements are unclear

 Give reassurance by making general

statements if that provides comfort

 Use humor appropriately
-Loss of “motor memory”
-Need more time to complete tasks
-Need assistance with daily tasks
-Don’t rush well
 Allow more time to complete tasks
 Provide prompts and step-by-step

directions
 Demonstrate the desired action
 Do not rush the person
 Unaware of relationship to environment
◦ Might fall
◦ Unable to find way or gets lost
◦ May wander
 Geographic disorientation
 Evaluate fall risk
 Use way finding cues
 Use personal items to help recognize room
 Be aware of social distance in conversations
 Avoid abrupt movements toward the person
 Aggression/Agitation
 Delusions/hallucinations
 Depression
 Apathy
 Sleep disorders
 Wandering
 Sexually inappropriate behavior
 Others
 University of Nebraska Medical Center

-Prevention Trial -Mild AD study -Moderate AD study

-Asymptomatic AD -MMSE 20-26 -MMSE 12-22
-≥65 years -ages 55-90 -ages 55-85
-Monthly IV x 3yr -Monthly IV x 18m -oral med x 1yr
-Solanezumab -Solanezumab -T-817MA
-a4study.org -expedition3study.com -adcs.org (studies)

Current Alzheimer’s Trials at UNMC

Interested? Call 402-552-6241