Disturbances in Emotional Experience:: Behavioral and Psychological Symptoms of Dementia Psychopathological Features
Disturbances in Emotional Experience:: Behavioral and Psychological Symptoms of Dementia Psychopathological Features
PSYCHOPATHOLOGICAL FEATURES
● Circadian Rhythms:
● Sleep pattern changes are prevalent in individuals with
dementia.
● Changes may include hypersomnia, insomnia,
sleep-wake cycle reversal, fragmented sleep, and rapid
eye movement sleep behavior disorder.
● Factors contributing to sleep disturbances include pain,
medications, and stimulants.
● Alzheimer's Disease:
● Prominent symptoms include apathy, agitation, depression, anxiety,
delusions, and irritability.
● Less common are hallucinations and elation.
● Three basic behavioral syndromes predominate: few abnormalities,
psychosis, and mood disorder.
● Agitation and apathy may coexist with other behavioral symptoms.
● Neurobiological changes include lower metabolism and perfusion in
frontal and temporal lobes.
● Agitation and psychosis correlate with a high burden of neurofibrillary
tangles.
● Genotypes associated with behavioral disturbances involve
serotoninergic, cholinergic, and dopaminergic systems.
● Dementia with Lewy Bodies:
● High prevalence of neuropsychiatric symptoms, often prominent at
presentation.
● Complex visual hallucinations are recurrent, accompanied by illusions
and misidentification phenomena.
● Visual hallucinations linked to profound visuoperceptual dysfunction
and reduced uptake in occipital areas.
● High numbers of Lewy bodies in temporal lobe and amygdala; deficits
in cortical acetylcholine.
● Apathy, anxiety, delusions, and depression are common and persist
over time.
● Rapid Eye Movement Sleep Behavior Disorder (RBD) history suggests
dementia with Lewy bodies.
● Vascular Dementia:
● Neuropsychiatric symptoms as common and important as in
Alzheimer's disease.
● Mood symptoms like depression, emotional lability, and apathy are
particularly common.
● Strong relation between cerebrovascular disease, especially
white-matter lesions, and depression.
● Other symptoms include anxiety disorders and psychosis.
● Frontotemporal Dementia:
● Unique behavioral symptoms: disinhibition, apathy, and elation; often
precede memory deterioration.
● Compulsive disorders with stereotypical and ritualized behaviors.
● Changes in appetite with carbohydrate cravings and dietary changes.
● Behavioral symptoms correlate with involvement of right hemisphere
frontal and temporal-lobe structures.
Treatment
● Non-pharmacological Interventions:
● Behavioral therapies, environmental changes, exercise,
and music therapy are effective.
● Educational interventions for carers help reduce
symptom escalation and improve relationships.
● Carers may need interventions for depression, anxiety,
and substance use to reduce morbidity.
● Pharmacological Treatment:
● Antipsychotics, mood stabilizers, antidepressants,
anxiolytics, and sedative-hypnotics commonly used.
● Limited randomized controlled trials for psychotropic
drugs in dementia; evidence supporting effectiveness is
limited.
● Atypical antipsychotics approved in some regions for
agitation and psychosis in dementia.
● However, no drug specifically approved for any BPSD
indication by the US FDA.
● Prescription of psychotropic drugs widespread despite
lack of systematic evidence and regulatory approval.
● Antipsychotic Medications:
● Atypical antipsychotics most studied; several trials show
efficacy in reducing agitation and psychosis.
● Conventional antipsychotics also effective but associated
with increased rates of parkinsonism and tardive
dyskinesia.
● Risperidone and olanzapine, commonly used for BPSD,
associated with increased risk of cerebrovascular
events.
● Caution required in the use of antipsychotic drugs due to
increased risk of mortality.
● Anticonvulsant Medications:
● Used as second-line treatments in patients resistant to
antipsychotic drugs.
● Associated with adverse events such as sedation and
gait instability.
● Modest efficacy shown in small randomized controlled
trials, but not consistently effective compared to placebo.
● Antidepressant Medications:
● Widely used despite limited evidence for superiority over
placebo.
● Selective serotonin reuptake inhibitors commonly used
due to favorable side-effect profile.
● Sertraline shown to reduce mood symptoms in patients
with Alzheimer's disease.
● Combined serotonin and noradrenalin reuptake inhibitors
represent alternative but poorly studied option.
● Benzodiazepines:
● Generally not advised in people with dementia due to
susceptibility to side-effects and potential exacerbation of
behavioral disinhibition.
● Exception is low-dose clonazepam for management of
rapid eye movement sleep-behavior disorder.
● Treatment of Cognitive Symptoms:
● Cholinesterase inhibitors (donepezil, galantamine,
rivastigmine) may reduce behavioral symptoms in
Alzheimer's disease.
● Memantine, an N-methyl-D-aspartate receptor
antagonist, can also reduce BPSD in Alzheimer's
disease.
● Limited evidence-based information guides treatment
choices for BPSD management in dementia, relying on
expert guidance and personal prescribing experience.
DELIRIUM
Mood.
Cognitive Change.
Catastrophic Reaction.
Patients with dementia also exhibit a reduced ability to apply what Kurt
Goldstein called the "abstract attitude." Patients have difficulty
generalizing from a single instance, forming concepts, and grasping
similarities and differences among concepts. Furthermore, the ability to
solve problems, to reason logically, and to make sound judgments is
compromised.
Sundowner Syndrome.
If you have a mild neurocognitive disorder, you can still perform daily
activities with independence. You can complete your usual complex
activities, although they may require more effort than before.
The DSM-5 discusses groups of symptoms that individuals with major and
mild neurocognitive disorders may have. Common symptoms among
neurocognitive disorders include:
● anxiety
● depression
● elation
● agitation
● confusion
● insomnia (difficulty sleeping)
● hypersomnia (oversleeping)
● apathy
● wandering
● disinhibition
● hyperphagia (extreme hunger or eating)
● hoarding
● hallucinations
● delusions
https://courses.lumenlearning.com/wm-abnormalpsych/chapter/neurocogni
tive-disorder-due-to-alzheimers-disease/#:~:text=The%20most%20commo
n%20early%20symptom,%2Dcare%2C%20and%20behavioral%20issues.
Frontotemporal DEMENTIA
https://www.nia.nih.gov/health/frontotemporal-disorders/what-are-frontote
mporal-disorders-causes-symptoms-and-treatment#:~:text=Frontotempora
l%20disorders%20(FTD)%2C%20sometimes,work%2C%20or%20difficulty
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Alzheimer's Disease:
1. Age of Onset:
● Alzheimer's Disease typically occurs later in life, usually
after the age of 65, although early-onset forms can
occur.
● FTD often presents at a younger age, typically between
40 and 65 years old, although it can occur at older ages
as well.
2. Symptom Presentation:
● Alzheimer's Disease commonly presents with memory
loss as a primary symptom, along with progressive
cognitive decline affecting various domains such as
language, visuospatial skills, and executive function.
● FTD typically presents with changes in behavior,
personality, and language skills, rather than memory
loss. Behavioral symptoms may include disinhibition,
apathy, social withdrawal, and inappropriate behaviors.
Language symptoms may include difficulties with speech
production or comprehension.
3. Neuroanatomical Changes:
● In Alzheimer's Disease, neurodegeneration primarily
affects the hippocampus and other regions of the
temporal and parietal lobes, which are associated with
memory and higher cognitive functions.
● In FTD, neurodegeneration primarily affects the frontal
and temporal lobes, particularly the frontal cortex and
anterior temporal lobes, which are involved in behavior,
personality, and language.
4. Neuropathological Features:
● Alzheimer's Disease is characterized by the
accumulation of beta-amyloid plaques and tau protein
tangles in the brain.
● FTD is characterized by abnormal protein aggregates,
including tau, TDP-43, and FUS, which accumulate in
affected brain regions.
5. Rate of Progression:
● Alzheimer's Disease typically progresses gradually over
several years, with memory loss and cognitive decline
worsening over time.
● FTD may progress more rapidly, particularly in cases
where behavioral symptoms are prominent, although the
rate of progression can vary widely between individuals.
6. Familial Risk:
● While Alzheimer's Disease can have a genetic
component, with certain gene mutations increasing the
risk of developing the disease, it is generally not as
strongly hereditary as some forms of FTD.
● FTD can have a stronger familial component, with
certain gene mutations associated with familial forms of
the disease, such as mutations in the MAPT, GRN, and
C9orf72 genes.
Cognitive Symptoms
● DLB Presentation:
● Early onset of dementia, often accompanied by visual
hallucinations.
● Extrapyramidal motor symptoms akin to Parkinson's
Disease (PD) often arise concurrently or shortly after
dementia onset.
● Progressive Cognitive Decline:
● Cognitive decline typically begins early, often after age
55.
● Initial cognitive domains affected may vary, with
impairment in attention, executive function, and
visual-spatial skills being common.
● Early difficulties in multitasking, maintaining
conversations, and occasional navigation problems (e.g.,
getting lost while driving) may manifest.
● Short-term memory loss is notable, often reflecting
retrieval issues rather than encoding deficits seen in
Alzheimer's Disease (AD).
● Memory Impairment:
● Short-term memory loss significant, resembling
hippocampal-dependent memory encoding deficits in
AD.
● However, in DLB, short-term memory loss often stems
from retrieval problems, potentially improved with cues.
● Progression of Cognitive Impairment:
● Cognitive deficits worsen over time, spreading to affect
additional cognitive domains.
● When cognitive impairments impact social or
occupational functioning, meeting criteria for dementia
diagnosis.
Neuropsychiatric Symptoms
● Visual Hallucinations:
● Recurrent and complex visual hallucinations are
common in DLB, often appearing early in the disease
course.
● Hallucinations typically involve well-formed and animate
figures such as adults, children, deceased family
members, or animals.
● Initially, hallucinations are usually unimodal, lacking
sound, smell, or touch, and may be emotionally neutral
or occasionally dysphoric/fear-provoking.
● Distinguishable from visual illusions where objects are
misinterpreted, common particularly in dimly lit
environments.
● Delusions:
● Delusions may develop later in the disease progression,
often with a paranoid quality.
● Common delusions include infidelity, house intruders,
and theft, often resulting in misplaced items around the
home.
● Capgras syndrome may occur, where patients believe
familiar individuals, like spouses or caregivers, have
been replaced by imposters due to loss of emotional
associations with memories.
● Fluctuations of Attention and Arousal:
● Attention and alertness can fluctuate, leading to
episodes of staring, disrupted flow of ideas, or daytime
drowsiness and frequent naps.
● These fluctuations need differentiation from other causes
like medication side effects or infections.
● The Dementia Cognitive Fluctuation Scale, which
aggregates prior scales, can help assess fluctuations,
requiring positive responses to specific questions
regarding coherence of thoughts, daytime sleep,
drowsiness, and ease of arousal.
Overall, while there is overlap between DLB and PDD in terms of clinical features and
underlying pathology, the timing and prominence of cognitive symptoms, presence of
visual hallucinations, fluctuations in attention, response to medication, and
neuroimaging findings can help differentiate between the two disorders. However, a
comprehensive clinical evaluation, including neuroimaging and neuropsychological
testing, is often necessary for an accurate diagnosis.
https://www.webmd.com/alzheimers/dementia-head-injury
Vascular Dementia
https://www.nia.nih.gov/health/vascular-dementia/vascular-dementia-caus
es-symptoms-and-treatments
neurocognitive disorders:
neurocognitive disorders.