© cengage learning 2016 neurocognitive and sleep-wake disorders 13

© Cengage Learning 2016 © Cengage Learning 2016

Neurocognitive and Sleep-Wake Disorders

13

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• Major neurocognitive disorder

• Minor neurocognitive disorder

• Delirium

Types of Neurocognitive Disorders

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• Steps in assessment– Gather background information

– Evaluate overall mental functioning, personality characteristics, and coping skills

– Rule out sensory conditions or emotional factors

– Test to pinpoint areas of cognitive difficulty

Assessment of Brain Damage and Neurocognitive Functioning

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• Medical tests– EEG

– CT

– MRI

– PET

• Comprehensive baseline assessments– Used to monitor progress or decline in

functioning

Assessment Process (cont’d.)

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• For diagnosis, must show significant decline in:– One or more cognitive areas

• Deficits in multiple areas are common

– Ability to independently meet daily living demands

• Clinicians specify underlying medical reason, if known

Major Neurocognitive Disorder

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• Decline in mental function and self-help skills– Resulting from major neurocognitive disorder

• Examples of affected areas: memory, problem solving, and impulse control

• Gradual onset and continuing cognitive decline

• Age is strongest risk factor for dementia

Dementia

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Areas of Possible NeurocognitiveDysfunction

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• Modest decline in at least one major cognitive area

• Individuals able to participate in normal activities– May require extra time to complete tasks

– Overall independent functioning not compromised

• Often an intermediate stage between aging and major neurocognitive disorder

Minor Neurocognitive Disorder

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Normal Aging or Neurocognitive Disorder?

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• Often goes undiagnosed– Early detection can allow individual to plan for

future care before the disorder progresses

• Sometimes major neurocognitive disorder is downgraded to minor– As a result of recovery from stroke or

traumatic brain injury

Minor Neurocognitive Disorder (cont’d.)

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• Acute state of confusion characterized by disorientation and impaired attentional skills– Abrupt onset

• Develops over a period of several hours or days

– Symptoms can be mild or severe

– Psychotic symptoms may be present

– Treatment: identify underlying cause

– Hospitalized individuals and the elderly at increased risk

Delirium

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• Result from variety of medical conditions

• Some involve specific events– Stroke

– Head injury

• Some become worse over time

• Neurodegeneration– Progressive brain damage involving death of

brain cells

– Individuals show decline, not improvement

Etiology of Neurocognitive Disorders

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Neurodegenerative Disorders

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Event Causes of Neurodegenerative Disorders

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Multipath Model of Neurocognitive Disorders

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• Traumatic brain injury– Can result from bump, jolt, blow, or physical

wound to the head

• 1.7 million people per year receive emergency care for traumatic brain injury

• Effects can be temporary or permanent

• Neurocognitive disorder diagnosed with:– Persisting cognitive impairment due to a brain

injury

Neurocognitive Disorder Due toTraumatic Brain Injury (TBI)

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• Most common type of TBI

• Trauma-induced changes in brain functioning

• Symptoms include headache, dizziness, nausea, and sensitivity to light– Usually temporary (few weeks), but

sometimes last much longer

• Many occur in competitive sports and recreational activities– About half are unreported

Concussion

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• Bruising of the brain– Occurs when brain strikes skull with sufficient

force to cause bruising

– Involves actual tissue damage to both side of the impact and opposite side

– Symptoms similar to those of a concussion

• Neuroimaging can detect brain damage and monitor swelling

Cerebral Contusion

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• Open head injury

• Brain tissue is torn, pierced, or ruptured

• Immediate medical care involves reducing bleeding and preventing swelling

• Symptoms vary with severity of laceration

Cerebral Laceration

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• Progressive, degenerative condition

• Diagnosed in individuals who have had multiple episodes of head injury

• Associated with psychological symptoms and increased risk of dementia

• Four stages of CTE– Each with different symptoms

Chronic TraumaticEncephalopathy (CTE)

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• Can result from a one-time cardiovascular event (stroke) or from unnoticed, ongoing disruptions to cardiovascular system

• Often begin with atherosclerosis

• Stroke– Obstruction of blood flow to or within the

brain, leading to loss of brain function

Vascular Neurocognitive Disorders

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• Hemorrhagic stroke– Involves leakage of blood into the brain

• Ischemic stroke– Caused by a clot or severe narrowing of the

arteries supplying blood to the brain

– 87% of strokes

• Transient ischemic attack (TIA)– “Mini-stroke” resulting from temporary

blockage of arteries• Symptoms often precede ischemic stroke

Types of Strokes

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• Fourth leading cause of death in U.S.– Significant cause of disability

• Can occur at any age– One-third of strokes occur under age 65

• Some risk factors– Cigarette smoking (major contributor)

– Stress

– Poor eating and sedentary lifestyle

– Depression

Stroke

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• Use of drugs or alcohol– Can result in delirium or chronic brain

dysfunction

• Mild neurocognitive disorder common with history of heavy substance use– Symptoms continue with initial abstinence but

can improve over time

Neurocognitive Disorder Due to Substance Abuse

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• Most prevalent neurodegenerative disorder– Affects more than 5 million Americans

• Involves progressive cognitive decline

• Age a major risk factor

• Clear physiological indicators required to predict whether patients with mild memory impairment will likely develop AD

Neurocognitive Disorder Due to Alzheimer’s Disease (AD)

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• Progressive decline in cognitive and behavioral functioning

• Physiological processes that produce AD begin years before onset of symptoms– Early symptoms

• Memory dysfunction, irritability, and cognitive impairment

– Other symptoms that often appear • Social withdrawal, depression, apathy, delusions,

impulsive behaviors, neglect of personal hygiene

• No cure exists

Characteristics of AD

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• Memory loss occurs for a variety of reasons– Early symptom of AD

– Gradual loss of brain neurons due to aging

– Temporary conditions• Infections or reactions to prescription drugs

• Older adults continue to generate new brain cells– Brain reorganizes to maximize cognitive

efficiency

Other Factors Affecting Memory Loss

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• Shrinkage of brain tissue

• Abnormal structures– Neurofibrillary tangles

• Twisted fibers of tau found inside nerve cells

– Beta-amyloid plaques• Beta-amyloid proteins aggregate in spaces

between neurons

• Brain changes appear years before dementia appears

Alzheimer’s Disease and the Brain

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• Believed to be influenced by hereditary and environmental factors– APOE-e4 allele of the APOE gene increases

risk for AD• People with this genotype do not necessarily

develop AD

• Three rare genetic mutations identified for autosomal-dominant AD

• Lifestyle variables associated with stroke and cardiovascular disease– Also affect AD

Etiology of Alzheimer’s Disease

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• Link between sleep and amount of beta-amyloid in the brain– Older adults with poor sleep quality or

quantity had more beta-amyloid deposits

Etiology of Alzheimer’s Disease (cont’d.)

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• Second most common form of dementia• Characteristics

– Progressive cognitive decline– Unusual movements seen in Parkinson’s

disease– Significant fluctuations in attention and

alertness– Hallucinations– Impaired mobility– Sleep disturbance

Neurodegenerative Disorders Due to Dementia with Lewy Bodies (DLB)

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• Lewy bodies– Brain cell irregularities

– Result from the buildup of abnormal proteins in the nuclei of neurons

– Also present in Parkinson’s disease

– When present in the cortex• Deplete the neurotransmitter acetylcholine

– When present in the brain stem• Deplete dopamine

DLB

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• Fourth leading cause of dementia

• Several variants depending on affected brain region

• Symptoms– Changes in behavior, personality, and social

skills

– Difficulty with fluent speech or word meaning

– Muscle weakness

– Average age of onset is between 45 and 64

Neurocognitive Disorder Due to Frontotemporal Lobar Degeneration (FTLD)

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• Four primary symptoms– Tremor of the hands, arms, legs, jaw, or face– Rigidity of the limbs and trunk– Slowness in initiating movement– Drooping posture, or impaired balance and

coordination

• Motor symptoms evident at least one year prior to notable cognitive decline– Mild cognitive impairment affects about 27

percent of those with PD

Neurocognitive Disorder Due to Parkinson’s Disease (PD)

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• Second most common neurodegenerative disorder in the U.S.

• Later stages of PD– Cognitive and behavioral symptoms similar to

those of DLB

• Disorder occurs more frequently in Northern Midwest and the Northeast in urban settings– Raises questions about environmental toxins

Parkinson’s Disease (cont’d.)

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• Rare, genetically-transmitted degenerative disorder

• Symptoms– Involuntary twitching movements– Eventual dementia

• Early symptom– Difficulty in executive functioning

• No effective treatment• Death occurs 15-20 years after symptom

onset

Neurocognitive Disorder Due to Huntington’s Disease (HD)

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• Cognitive impairment sometimes the first sign of untreated HIV infection– Slower mental processing– Difficulty concentrating

• AIDS dementia complex (ADC)– HIV becomes active in the brain

• Antiretroviral therapies can prevent or delay onset– Brain changes still occur in half of those

taking antiretroviral medications

Neurocognitive Disorder Due to HIV Infection

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• Treatment approaches vary widely due to different causes, symptoms, and dysfunctions

• Major interventions– Rehabilitative services

– Biological interventions

– Cognitive and behavioral treatment

– Lifestyle changes

– Environmental support

Treatment Considerations with Neurocognitive Disorders

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• Must be comprehensive and sustained

• Physical, occupational, speech, and language therapy– Individual’s commitment and participation in

therapy plays an important role

– Depression, pessimism, and anxiety can stall progress

• Constraint-induced therapy– Repeated and intensive use of affected side

of the body

Rehabilitation Services

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• Objective: prevent, control, or reduce symptoms

• Medication– Levodopa increases dopamine availability

– High doses of vitamin E can slow AD progression

– Antidepressants

• Early stages of research into deep brain stimulation

Biological Treatment

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• Psychotherapy– Enhance coping and participation in

rehabilitation efforts

– Reduce frequency and severity of problem behaviors

• Meditation and mindfulness-based stress reduction– Reduced brain atrophy

Cognitive and Behavioral Treatment

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• Can help prevent or reduce progression of some neurocognitive disorders

• Cardiovascular fitness

• Smoking cessation

• Weight reduction

• Control of blood sugar, cholesterol, and blood pressure

Lifestyle Changes

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• Neurodegenerative disorders involving dementia– Irreversible

– Best managed with supportive environment

• Exposure to bright lighting– Improve sleep and decrease agitation and

depression

• Family visits

• Labeling family photos

Environmental Support

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• Family and friends who provide care may need support– May feel overwhelmed, helpless, frustrated,

anxious, or angry

• Skilled nursing or assisted-living– Alternatives to individual remaining at home

Caregiver Support

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• Good quality sleep associated with mental and physical resilience

• Most adults need seven to nine hours of sleep per night

• Normal sleep pattern– Non-rapid eye movement (NREM) sleep

– Rapid eye movement (REM) sleep• Associated with dreaming

Sleep-Wake Disorders

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• Insomnia disorder– Difficulty in falling asleep or maintaining sleep

– Caused by various factors

• Hypersomnolence disorder– Excessive sleepiness

– Naps do not provide relief from sleepiness

– Sleep inertia• Significant grogginess and impaired alertness

upon waking

Dyssomnias

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• Very rare sleep disorder

• Irresistible or overwhelming need for daytime sleep– Even when adequate sleep occurs at night

• Individuals go immediately into REM sleep

• Many individuals experience cataplexy– Sudden loss of muscle function

– Often triggered by laughter, anger, or fear

• Can go undiagnosed for many years

Narcolepsy

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• Common breathing-related sleep disorder

• Soft tissue in rear of throat collapses– Obstructs upper airway

– Repeatedly interferes with breathing during sleep

– Brain sends signals to resume breathing• Results in snoring or gasping for breath

• Remains undiagnosed in 80-90 percent of individuals with this condition

Obstructive Sleep Apnea

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• Pattern of recurrent sleep disturbance– Caused by disrupted biological sleep-wake

cycle

• Jet lag– Temporary disruption in circadian rhythm

• Shift work can produce problems– Work schedule opposes sleep-regulating cues

associated with sunlight

Circadian Rhythm Sleep Disorder

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• NREM sleep arousal disorders– Sleep terrors

– Sleepwalking

• Nightmare disorder– Dreams of danger frightening enough to

produce awakening

• REM sleep behavior disorder– Involves vocalizations and motor behavior

during sleep

Parasomnias

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• Causes of sleep problems– Neurological vulnerabilities

– Psychological factors• Stress, anxiety, and depression

– Environmental factors• Noise, light, other stimuli

– Heath or behavioral habits

Etiology of Sleep-Wake Disorders

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• Dyssomnias– Tend to be associated with lifestyle and

psychological factors

• Parasomnias– Less known about etiology

• Many with sleep disorders have family members with sleep difficulties

Etiology of Sleep-Wake Disorders (cont’d.)

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• Maintaining a regular sleep-wake cycle

• Exercising regularly

• Avoiding caffeine, naps, and heavy meals

• Avoiding alcohol and nicotine within two hours of sleep

• Relaxed frame of mind– Minimize worry about not sleeping

• Eliminating distractions from bedroom

Treatment of Sleep-Wake Disorders

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• Cognitive-behavioral therapy– Effective for treatment of insomnia

• Sleep apnea treatments– Losing weight, side sleeping

– Continuous positive airway pressure mask

• Medications– Clonazepam

– Melatonin

– Variety of sleep-inducing medications

Treatments (cont’d.)

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• Medical professionals continue to emphasize lifestyle changes to reduce vulnerability

• Research efforts– Identification of early biomarkers for

neurodegenerative diseases

– Therapies to stop degeneration once it has begun

– Relationship between sleep impairment and psychiatric disorders

Contemporary Trends and Future Directions

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• How can we determine whether someone has a neurocognitive disorder?

• What are the different types of neurocognitive disorders?

• What are the causes of neurocognitive disorders?

• What treatments are available for neurocognitive disorders?

• What do we know about sleep disorders?

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