ALZHEIMER’S DISEASE : PSYCHIATRIC SYMPTOMS AND SOCIAL FUNCTIONINGDR. CRISTINA BREDICEAN

TIMISOARA, ROMANIA

• Alzheimer's disease is a cortical dementia with an insidious onset and relatively

slow progression. In the early stages and throughout most of the disease, memory

impairment is the primary problem.

• Any manifestation of psychiatric symptoms is generally secondary to the amnesia,

the paramount symptom of early Alzheimer's disease.

• The psychiatric symptoms emanate from the memory impairment – testing

memory is essential.

• The first stage of Alzheimer's disease commonly is marked by anxiety and

depression secondary to memory impairment, and delusions.

• In the second stage, delusions often become more bizarre. Impairment of

visuospatial memory, improper advances, and obscene language begin to replace

disinhibited behavior, often to the point of violence directed at others. Increasing

agitation requires restraints.

• In the third and final stage, screaming, banging, and cursing are common features.

Verbal and behavioral perseverations are very common.

PSYCHIATRIC SYMPTOMS

• Although Alzheimer’s disease (AD) is usually considered a cognitive disorder, almostall people diagnosed with AD develop neuropsychiatric symptoms (NPS) at somestage during their disease.

• Population-based studies show that the frequency of NPS is much higher in peoplewith AD and mild cognitive impairment (MCI) than in the general population.

• Of all the NPS, depression and apathy are the most frequently observed symptomsin people with MCI and early AD, although the incidence of verbal and physicalagitation is also high across all stages of MCI and AD.

• As the disease progresses, delusions, hallucinations, and aggression become morecommon, whereas apathy is the most persistent and frequent NPS throughout allthe stages of AD.

• Additionally, circadian sleep-wake rhythms become exaggerated as compared withthe phase shifts associated with normal aging.

DEPRESSION

• Depression is one of the main differential diagnoses for dementia. Therefore, thefact that dementia and depression can occur concomitantly should be considered,where depression as an antecedent of a dementia picture can represent a riskfactor for, or prodrome to, dementia.

• Full anamnesis and assessment of psychic status are fundamental for reaching adifferential diagnosis between depression and dementia.

Characteristics Major Depressive Episode (MDE) Alzheimer type Dementia (AD)

Diagnosis Frequently meets criteria for MDE Symptoms typically less intense than in MDE

Age at onset Under or over the age of 60 years Uncommon at less than 60 years of age

Onset Typically acute Insidious

Course Fluctuations, often with congruent mood Progressive

Memory complaints Usually present Variable

Mood Depressive Depressive or euthymic

Sleep-wake cycle Often changed Variable

Aphasia/apraxia/ Uncommon Manifests as disease progresses

agnosia

Memory • Performance better than self-assessment • Performance worse than self-assessment

• Performance better with cues for evoking • No performance improvement with use of cues

• Intrusion of previously learned information • Intrusion of previously learned information upon

atypical evoking new material

Executive dysfunction Typical Variable, occurs later

Processing speed Slowed Normal

Effort Reduces with cognitive demand, disproportionate Usually normal

compromise on more demanding tasks, “don’t

know” responses

Table 3. Differential diagnosis between Alzheimer type dementia and depression.

APATHY

• It is highly prevalent across different forms and stages of dementia, including inmild cognitive impairment (MCI), Alzheimer’s disease (AD), frontotemporaldementia (FTD), and vascular dementia.

• That apathy is prevalent in dementia, whether the origin is probable AD or FTD, isnot a new finding, but the higher association of apathy with depressive features inAD calls attention to the negative mood disruption in AD patients with apathy incontrast to FTD patients, who are more likely to have apathy without anyaccompanying depression.

• When present, apathy usually involves changes in affect, behavior, and cognition. Itis associated with the co-occurrence of major mood or behavioral disturbances thatmay not be anticipated if physicians focus too closely on the apathy itself.

DELUSIONS

• Delusional ideas (false believes strongly held, enduring, and irrefutable) can varywidely in respect to complexity, systematization, conviction, and the extent towhich patients take action in response to them.

• The delusions are typically less complex and organized than those observed in non-demented psychotic patients and the usual content of delusional thoughts involvessuspiciousness, abandonment, and misidentification.

• Common examples include the conviction that: people are coming into the homeand hiding/stealing objects; the place in which one is residing is not one’s home;conviction that spouse is an impostor (Capgras delusion); accusation of a conspiracyto abandon or institutionalize; conviction that spouse is unfaithful; believes thatother persons have acted maliciously; or with discriminatory intent.

• When associated with severe depression, delusional thoughts can involve guilt,worthless, reference, and persecution.

• Delusions, are associated with more rapid decline in intellectual function in AD.

HALLUCINATIONS

• Visual hallucinations, misperceptions and family misidentification in the context of

dementia represent a major treatment challenge for patients, families and care

providers.

• Although visual hallucinations are a core feature in dementia with Lewy bodies(DLB), this feature also occurs in Alzheimer’s disease (AD).

• When visual hallucinations occur in AD, they tend to be associated with greatercognitive impairment and a more advanced stage of the dementia

AGITATION

• Agitation has been defined as “inappropriate verbal, vocal, or motor activity that is

not judged by an outside observer to result directly from the needs or confusion of

the agitated individual”.

• This term is used interchangeably with aberrant motor behavior and encompasses arange of activities such as wandering away from home; repetitive, purposelessbehaviors; social inappropriate activities including those associated withdisinhibition (tendency to disregard social and cultural norms and not restrain innerfeelings, such as sexual drives).

CIRCADIAN RHYTHMS

• Sleep disorders are among one of the most common behavioral disturbances inpersons with AD, with 25% to 50% having major sleep problems and almost 75%sleeping for extended periods during the day.

• Sleep disturbances cause excessive caregiver burden and have a negative impact oncognition and social isolation on both the caregiver and person affected bydementia.

• These include hypersomnia, insomnia, sleep-wake cycle reversal, fragmented sleep,and rapid eye movement sleep behavior disorder. Patients with dementia oftenshow daytime napping and nighttime awakenings associated with poor quality ofsleep.

SOCIAL FUNCTIONING…

• Social functioning defines an individual's interactions with their environment andthe ability to fulfill their role within such environments as work, social activities,and relationships with partners and family.

• Social functioning is a broad concept, embracing all human relationships andactivities. Social functioning therefore is multidimensional and cannot be measuredmeaningfully in a single scale. Physicians caring for older people will need routinelyto assess at least some aspects of the social functioning of their patients.

• In some instances, physicians will also need to understand and use assessmentsdone by the social worker on his or her own hospital teams, by local authority socialworkers (in the United Kingdom), or by case managers in community long-term careprograms (in the United States).

SOCIAL FUNCTIONING IN DEMENTIA…

Activities of daily living (ADL)

• Bathing

• Dressing

• Grooming

• Toileting

• Continence

• Transferring

Instrumental activities of daily living

(IADL)

• Using a phone

• Travel

• Shopping

• Preparing meals

• Housework

• Medication management

• Money management

SOCIAL COGNITION – SOCIAL FUNCTIONING RELATION

Social functioning

Social cognitionNeurocognition

SOCIAL COGNITION

• The means by which we make sense of ourselves in relation to others and theenvironment in which we live (Fiske, 1993).

• Any cognitive process that is engaged to understand or interpret the self inrelation to others (Forbes & Grafman, 2010).

• Social cognitive processes form the basis of the complex and dynamic set ofbehaviors and mutually shared expectations that enable individuals tosuccessfully interact with one another across a range of different scenarios andenvironments.

ETIOLOGY OF SOCIAL COGNITIVE DEFICITS IN AD

• Social cognitive symptoms may represent a specific manifestation ofdisease pathology that is anatomically and/or behaviorally distinctfrom general cognitive impairment.

• Alternatively, social cognitive deficits in AD may stem from moregeneral cognitive deficits. For example, it has beensuggested that impaired emotion recognition and ToM may reflectdeficits in visuoperception or executive functioning (Shany-Ur et al., 2012).

NEUROANATOMIC SUBSTRATES

• Orbitofrontal and ventromedial PFC

• Anterior cingulate

• Insula

• Anterior temporal cortex

Right SidedNetwork

Anterior cingulate cortex (ACC)

error detection

self conciousness

empathy

Prefrontal cortex

executive functioning

control of social behaviorOrbito-frontal cortex

decisions making

ToM

Recognition and processing of

emotions

Temporo-parietal cortex

distinction of the self

ToM

Paracingular cortex

Amygdala

BRAIN STRUCTURES INVOLVED IN SOCIAL COGNITION

ELEMENTS OF SOCIAL COGNITION

Social Cognition

Emotion Perception

Perspective Taking

Social Knowledge

Moral Reasoning

Empathy & Self-Monitoring

Decision Making & Behavior

SOCIAL KNOWLEDGE

• Represents the ability to identify social roles, social rules, and social contexts.

• It involves decoding and interpreting the social aspects of people around us.

• In view of this, the following are important:

• Nonverbal processes

• Voice intonation

• The content of the discourse

EMOTION RECOGNITION

• The ability to recognize and understand other people's emotions

• It consists of 4 subcomponents:

oIdentifying emotions

oFacilitating emotions

oUnderstanding emotions

oManaging emotions

THEORY OF MIND

• The ability to attributeindependent mental andemotional states to anotherindividual (TOM; Baron-Cohen etal., 1999).

• Cognitive TOM: The ability toappreciate the differencebetween one’s knowledge andthe knowledge of anotherindividual (Gregory et al., 2002,Freedman et al., 2012).

ATTRIBUTION OF INTENTION

Verdon et al. (2007): Is there a specific deficit in reasoning aboutpsychological causality (i.e., intention) versus physical causality?

Cartoon Task (Sarfati et al., 1997): Subjects must identify theappropriate ending to a cartoon story.

•Psychological Cause

•Physical Cause

MMSE <=25

Progressive and pervasive impaired understanding of what causes persons to behave; AD would affect first the understanding of deliberate actions as leading to achieve intended goals, and would later affect understanding of unintentional behavior resulting from unexpected physical circumstances

SOCIAL COGNITION IN AD

• In contrast to behavioral variant frontotemporal dementia (FTD),early AD is frequently characterized by preservation of socialcognition (Rankin, Kramer, Mychack, & Miller, 2003).

• Social cognition often remains intact into the moderate stages ofthe disease (Sabat & Gladstone, 2010; Sabat & Lee, 2010).

• However, some individuals with AD evidence marked changes insocial cognition early in the disease, sometimes severe enough toelicit misdiagnoses of FTD.

• Even in cases that fit the typical AD profile with amnestic deficitsbeing prominent, individuals have been shown to demonstrateimpairment on objective social cognitive tests (Freedman, Binns,Black, Murphy, & Stuss, 2012; Miller et al., 2012), and in somecases these impairments can be commensurate with those in FTD.

CONCLUSIONS…

• Dementia causes a decline in intellectual functioning and a decrease in commondaily activities such as washing, dressing, feeding, personal hygiene.

• Early diagnosis of dementia is a challenge because it causes a decrease in medical,social and economic problems.

• Stabilizing neuroprotective decline (vascular, hypoxic, metabolic and toxic factors)can significantly delay disease progression from one phase to the next.

• Diagnosis and early therapeutic intervention lead to an adequate socialfunctioning.