Cognitive Problems and Dementia in the Elderly

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Cognitive Problems/Confusion/Dementia

The progressive loss of mental ability as one gets older is almost a universal fear. In the community it affects up to 10% of >65yrs and up to 30% >80yrs.

The 3 D’s:
Dementia – group of illnesses characterised by a global progressive decline in intellectual function and other cognitive skills from a previous level occurring in clear consciousness (irreversible); affects ability to carry out ADL’s, social and occupational functions; all intellectual functions impaired – memory, orientation, ability to learn, abstraction, visospatial perception, language function and higher order functions, such as planning and organisation.
Delirium – acute and fluctuating decline in global intellectual function with clouded consciousness (reversible); generally has an abrupt onset with incoherent speech, illusions, hallucinations; medical emergency (may be fatal due to underlying disease); may accompany infections, fever, metabolic and neurological disorders, drugs (eg anticholinergics, barbiturates, diazepam, digitalis, lithium, methyldopa, prednisone, propranolol, tricyclic antidepressants);
Depression – sadness, crying, low self-attitude, fatigue, insomnia, hopelessness, usually worse in morning.

Alzheimer’s disease – accounts for > half of the cases of dementia.
‘Benign senile forgetfulness’ – age related memory loss due to slowing of neural processing (not pathologic).

Cognitive defects can be:
• Aphasia – a deterioration in language function
• Apraxia – the impaired ability to execute motor activities when motor function is intact
• Agnosia – the impaired ability to recognise objects when sensory function is intact
• Executive function disturbances – can not think abstractly – problems with planning, organising and sequencing

Tools to assess status:
Folstein Mini Mental State Examination (MMSE)
Short Portable Mental Status Questionnaire (SPMSQ)
Geriatric Evaluation of Mental State (GEMS)

Other mental illnesses can occur in older ages (eg depression, schizophrenia, psychoses, and phobias)  affect cognitive abilities.

Early signs of dementia :
Changes in memory:
• repeating the same questions or stories
• being absent minded or forgetful
• losing valuable, keys, wallet
• getting lost in once familiar environments
Changes in orientation:
• difficulty remembering the year, date, month, day
• difficulty remembering the names of friends, loved ones, home address
Changes in behaviour:
• impaired judgement
• poor planning and organising ability
• deterioration in appearance and hygiene
• behaving in ways which are not normally the way the person would behave, such as swearing more, or becoming more withdrawn
Changes in emotions:
• easily aroused, readily changed moods
• unable to handle stress or noise, perhaps become agitated
• withdrawing socially
• losing drive and interest in things which used to provide interest and motivation such as fishing, bowls, clubs
Changes in thinking:
• less flexible, more rigid
• difficulty mastering new tasks
• difficulty finding the right word, reduced language fluency
• difficulty starting new topics, thinking beyond the present
• mundane conversation, repeated phrases, words, ideas

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