Psychological Aspects Of Alzheimer’S Disease

Psychological Aspects of Alzheimer’s Disease
November 1, 2004
Julie A. Suhr, Ph.D., Associate Professor, Department of Psychology, Ohio University

Introduction

n  Primary consequences of AD are psychological in nature

n  Cognitive decline

n  Emotional and behavioral disturbances

n  Indirect psychological consequences for both patient and caregiver

Goals of Presentation

n  Discuss cognitive symptoms of AD and their assessment

n  Discuss emotional/behavioral symptoms of AD and their assessment

n  Discuss implications of psychological symptoms of AD for functioning

n  Discuss treatments for psychological symptoms of AD

Common Cognitive Symptoms of Alzheimer’s Disease

n  Memory decline

n  Language disturbance

n  Visuospatial/constructional impairment

n  Executive Dysfunction

Assessment of Cognitive Symptoms of AD

n  Brief Screens (like MMSE) not sensitive to early decline

n  Brief Screens not good at differential diagnosis

n  Neuropsychological batteries assess memory, visuospatial skills better

n  Neuropsychologist can better address psychological symptoms and their contribution to cognitive impairments present

Psychological Symptoms of AD

n  Dr. Alzheimer stressed their importance in first descriptions of the disorder

n  Recent data suggests 90% of AD patients will experience significant psychological symptoms at some point in the course of their disorder

“Psychotic” Symptoms

n  Delusions

n  Hallucinations

n  Paranoia

n  Misinterpretations due to cognitive impairment

Agitation/Anxiety/Aggression Symptoms

n  Restlessness

n  Wandering

n  Repetitious Behavior

n  Hiding/Hoarding

n  Irritability

n  Nervousness

n  Aggression

Sleep Difficulties

n  Sundowning

n  Seems to be related to disturbance of circadian rhythms

n  Insomnia, daytime somnolence

Depression

n  50% AD patients have symptoms

n  Apathy in 41% (may not be depression)

n  Tends to be less severe or persistent, less suicidal ideation, less tied to psychosocial factors

n  Recently NIMH developed criteria for depression in AD

Course of Psychological Symptoms in AD

n  Not confined to severe forms of AD

n  Can be first signs of AD

n  Can be exaggeration of premorbid personality characteristics

n  May not be associated with severity of the cognitive symptoms (they are often independent, either can precede the other)

n  Can be trait-like or situational (catastrophizing for example)

Assessment of Psychological Symptoms of AD

n  Self report limitations

n  Caregiver report limitations

n  Observation limitations

n  Behave-AD

n  Neuropsychiatric Inventory

Implications of Psychological Symptoms for Diagnosis

n  Depression versus Dementia (or both?)

n  Depression can present with AD-like symptoms

n  AD can present with pseudodepressed symptoms

n  Good history and comprehensive neuropsychological exam can distinguish

n  Implications for treatment

n  Can co-occur and do

n  Stress in AD

n  DST test at first believed to identify depression in AD (abnormal findings in AD)

n  Now believed to be related to dysregulation of HPA axis

n  Related to increased glucocorticoid levels, which harm hippocampal neurons

n  Longitudinal studies relate elevated cortisol to later cognitive decline

Implications of Psychological Symptoms for Functioning

n  Institutionalization

n  Caregiver burden/burnout

Indirect, Family-Systems Symptoms of AD

n  Patient Grief

n  Changes in Family Dynamics

n  Caregiver Bereavement

n  Caregiver Guilt

Use of Psychiatric Medications in Treatment of Psychological Symptoms of AD

n  Generally not effective, except antipsychotics for psychosis and possibly aggression, and even these are only partially beneficial

n  Often contraindicated in elderly, and in dementia patients in particular, due to side effects

n  Commonly used: benzodiazepines, anticholinergics, neuroleptics

Side Effects

n  Drowsiness

n  Ataxia

n  Dizziness

n  Blurred vision

n  Confusion and memory impairment

n  Cardiovascular effects

n  Tardive dyskinesia/parkinsonism

n  Very high incidence of falls

Other Pharmacological Approaches

n  Acetylcholinesterase inhibitors

n  Antiglucocorticoid agents

Behavioral Interventions: Cognitive Symptoms

n  Reducing environmental demands

n  Structured consistent routines

n  Use of external cues

n  Memory books

n  Procedural memory skills

n  Spaced retrieval

n  All these require individualization and training

n  Requires evolution as disease progresses

n  Intervention often with caregiver, not patient (lack of awareness)

Awareness Training

n  Multidimensional, requires repeated demonstration

n  Must be done in context of potential emotional consequences

n  When aware, can still see resistance to treatment attempts

Management of Behavioral/Emotional Symptoms

n  Aggression/Agitation/Anxiety

n  Nonconfrontation and distraction

n  Reduced environmental demands

n  Increased environmental structure

n  Relaxation training

n  Principles of reinforcement

n  Again, all require significant training

n  Depression

n  Behavior therapy, problem solving approaches successful

General Rules for Behavioral Management

n  Active treatments include both patient and caregiver

n  All require training

n  Don’t assume can’t respond to psychological interventions because cognitively impaired

n  May require adjustment as disease progresses

n  Procedural memory: learning techniques early in course allows their continued use later

Interventions for the Caregiver

n  Education about AD and what to expect

n  Understanding psychological symptoms as manifestations of the neurological disorder

n  Problem solving as changes/crises arise

n  Support group (peers and professionals)

n  Counseling for their psychological reaction and stress

n  Shown in research to be very effective

The attached copy of the NPI-Q was found in Cummings et al. (2002). Guidelines for management of Alzheimer’s disease part 1: Assessment. American Family Physician, 65, 2263-72. The version published there was adapted with permission from Kaufer DI, Cummings JL, Ketchel P, Smith V, MacMillan A, Shelley T, et al. (2000). Validation of the NPI-Q, a brief clinical form of the Neuropsychiatric Inventory. J Neuropsychiatry Clin Neurosci, 12, 233-9. Copyright© J.L. Cummings, 1994.

Neuropsychiatric Inventory Questionnaire

Name of patient: ______Date: ______
Informant: Spouse: ______Child: ______Other: ______
Please answer the following questions based on changes that have occurred since the patient first began to experience memory problems.
Circle "yes" only if the symptom has been present in the past month. Otherwise, circle "no".
For each item marked "yes":
Rate the severity of the symptom (how it affects the patient):
1 = Mild (noticeable, but not a significant change)
2 = Moderate (significant, but not a dramatic change)
3 = Severe (very marked or prominent; a dramatic change) / Rate the distress you experience because of that symptom (how it affects you):
0 = Not distressing at all
1 = Minimal (slightly distressing, not a problem to cope with)
2 = Mild (not very distressing, generally easy to cope with)
3 = Moderate (fairly distressing, not always easy to cope with)
4 = Severe (very distressing, difficult to cope with)
5 = Extreme or very severe (extremely distressing, unable to cope with)
Please answer each question honestly and carefully. Ask for assistance if you are not sure how to answer any question.
Delusions / Does the patient believe that others are stealing from him or her, or planning to harm him or her in some way?
Yes / No / Severity: 1 2 3 / Distress: 0 1 2 3 45
Hallucinations / Does the patient act as if he or she hears voices? Does he or she talk to people who are not there?
Yes / No / Severity: 1 2 3 / Distress: 0 1 2 3 45
Agitation or aggression / Is the patient stubborn and resistive to help from others?
Yes / No / Severity: 1 2 3 / Distress: 0 1 2 3 45
Depression or dysphoria / Does the patient act as if he or she is sad or in low spirits? Does he or she cry?
Yes / No / Severity: 1 2 3 / Distress: 0 1 2 3 45
Anxiety / Does the patient become upset when separated from you? Does he or she have any other signs of nervousness, such as shortness of breath, sighing, being unable to relax, or feeling excessively tense?
Yes / No / Severity: 1 2 3 / Distress: 0 1 2 3 45
Elation or euphoria / Does the patient appear to feel too good or act excessively happy?
Yes / No / Severity: 1 2 3 / Distress: 0 1 2 3 45
Apathy or indifference / Does the patient seem less interested in his or her usual activities and in the activities and plans of others?
Yes / No / Severity: 1 2 3 / Distress: 0 1 2 3 45
Disinhibition / Does the patient seem to act impulsively? For example, does the patient talk to strangers as if he or she knows them, or does the patient say things that may hurt people's feelings?
Yes / No / Severity: 1 2 3 / Distress: 0 1 2 3 45
Irritability or lability / Is the patient impatient and cranky? Does he or she have difficulty coping with delays or waiting for planned activities?
Yes / No / Severity: 1 2 3 / Distress: 0 1 2 3 45
Motor disturbance / Does the patient engage in repetitive activities, such as pacing around the house, handling buttons, wrapping string, or doing other things repeatedly?
Yes / No / Severity: 1 2 3 / Distress: 0 1 2 3 45
Nighttime behaviors / Does the patient awaken you during the night, rise too early in the morning, or take excessive naps during the day?
Yes / No / Severity: 1 2 3 / Distress: 0 1 2 3 45
Appetite and eating / Has the patient lost or gained weight, or had a change in the food he or she likes?
Yes / No / Severity: 1 2 3 / Distress: 0 1 2 3 45