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Geriatric Neropsychiatric Assessment Seyed Kazem Malakouti, MD Geriatric Medicine Department Iran University of Medical Sciences Seyed Kazem Malakouti,

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Presentation on theme: "Geriatric Neropsychiatric Assessment Seyed Kazem Malakouti, MD Geriatric Medicine Department Iran University of Medical Sciences Seyed Kazem Malakouti,"— Presentation transcript:

1 Geriatric Neropsychiatric Assessment Seyed Kazem Malakouti, MD Geriatric Medicine Department Iran University of Medical Sciences Seyed Kazem Malakouti, MD

2 Element of clinical interview Gestation and birth history Development of milestones Handedness Genetic history of the parents and sibling School history: academic and disciplinary History of violence or criminal behavior history of head injury Psychiatric history Substance abuse history Behavioral and cognitive baseline Occupational history Medical and surgical history Medication regimen Review of systems Survey of vegetative functions Assessment of activities of daily living History of recent changes in behavior and cognition Seyed Kazem Malakouti, MD

3 childhood ADHD: it is not known whether residual ADHD extends into senescence »Difficulty being organized »Low frustration tolerance »Impulsivity »Restlessness »Mood swings Gilles de la tourette’s syndrome Seyed Kazem Malakouti, MD

4 Adolescence, risk-taking behavior Adulthood Substance abuse Cocaine: precipitate stroke LSD: visual hallucination MPTP: parkinson’s Alcohol: dementia, Wernicke-Korsakoff syndrome Reckless driving Head trauma Seyed Kazem Malakouti, MD

5 Adulthood Neurological problems that have particular relevance to the neuropsychiatric evaluation –Brain tumors –Huntington’s disease –Lupus Erythematosus –Multiple sclerosis –Nicotine dependence –Hypertension –Diabetes –hypercholesterolemia Seyed Kazem Malakouti, MD

6 senescence Cohesive sense of integrity Parkinson’s disease Alzheimer’s Frontotemporal dementia Lewy body dementia NPH Subdural hematoma Seyed Kazem Malakouti, MD

7 Cognitive domain assessment in geriatrics Attention Arousal Concentration Memory Learning Recall Recognition Language Spontaneous output, fluency Comprehension Repetition Naming Visuospatial skills Calculation Praxis Executive skills Drive Programming Response control synthesis Seyed Kazem Malakouti, MD

8 Social history Vocation & education Habits & life style Exercise Sleep Sexual activity recreation Seyed Kazem Malakouti, MD

9 VariablesMalesfemales Sexual fantasizing at least once109 (54.8%)30 (15.7%) Feeling desire to masturbate at least one time64 (32.2%)17 (8.9%) Having desire to intercourse at least one time160(80.4%)48 (25.1%) Having at least one sexual night dreams101(50.8%)25 (13.1%) Masturbating for at least once44 (22.1%)14 (7.3%) Feeling pleasure in most of sexual activities118 (59.3%)16 (8.4%) Usually or mostly having Difficulty in achieving orgasm 69 (34.7%)- Experiencing at least one orgasm during sexual intercourse 146 (73.4%)33 (17.3%) Difficulty or inability to communicate sexual desire with the partner 58 (29.1%)- Inability to experience partial of full erection44 (22.1%)- Not experiencing firm enough erection for penetration43 (22.6%)- Premature ejaculation26 (13.1%)- Retarded ejaculation16 (8.0%)- No ejaculation18 (9.0%)- sexual profile of the study subjects during the preceding month Seyed Kazem Malakouti, MD

10 Variables Medical diseases (Odds ratio) Using medication (Odds ratio) GHQ (Odds ratio) Sexual fantasizing at least once 1.29 (0.70-2.36)1.34 (0.73-2.45)1.90 (1.05-3.44) Feeling desire to masturbate at least one time 1.71 (0.92-3.17)1.82 (0.98-3.38)0.87 (0.47-1.62) Having desire to intercourse at least one time 1.07 (0.50-2.31)1.10 (0.51-2.37)2.19 (1.05-4.56) Having at least one sexual night dreams 0.93 (0.51-1.69)0.97 (0.54-1.77)1.03 (0.57-1.85) Masturbating for at least once 1.47 (0.73-2.93)1.42 (0.71-2.84)0.92 (0.46-1.83) Feeling pleasure in most of sexual activities 1.18 (0.65-2.16)1.23 (0.67-2.24)2.14 (1.18-3.87) Experiencing at least one orgasm during sexual intercourse 1.51 (0.71-3.19)1.35 (0.65-2.81)1.47 (0.73-2.94) Difficulty or inability to communicate sexual desire with the partner 0.88 (0.43-1.60)0.80 (0.41-1.54)0.40 (0.21-0.75) Inability to experience partial of full erection 1.05 (0.52-2.14)0.95 (0.74-1.92)2.06 (1.04-4.07) analysis of association of variables with sexual function in male subjects Seyed Kazem Malakouti, MD

11 Variable Male † N (%) Female † N (%) p.value Usually taken to fall sleep (minute) 5 to 20 21 to 30 31 to 60 60 + Usually gotten up in the morning 1.30 to 3.59 4 to 5.59 6 to 7.59 8 to 8.59 9 to 10.59 Hours of actual sleep at night 2 to 5.30 6 to 9 9.30 + 117 (58.8) 26 (13.1) 15 (7.5) 41 (20.6) 20 (11.9) 78 (46.4) 58 (35.5) 5 (3.0) 7 (4.2) 59 (36.2) 102 (62.6) 2 (1.2) 105 (55.0) 23 (12.0) 31 (16.2) 32 (16.8) 14 (7.8) 61 (34.1) 80 (44.7) 16 (8.9) 8 (4.5) 72 (40.9) 102 (58.0) 2 (1.1) 0.06 0.01 NS Seyed Kazem Malakouti, MD

12 Variable Male (N,%) † Female (n, %) † P.value Legs twitching or jerking No Less than once a week More than once a week cannot get to sleep within 30 minute No Less than once a week More than once a week Wake up in the middle of the night or early morning No Less than once a week More than once a week Have to get up to use the bathroom No Less than once a week More than once a week Cannot breathe comfortably No Less than once a week More than once a week Cough or snore loudly No Less than once a week More than once a week 145 (79.7) 14 (7.7) 23 (12.6) 101 (53.4) 44 (23.3) 52 (29.4) 49 (22.6) 85 (48.0) 64 (35.6) 37 (20.6) 79 (43.9) 151 (80.3) 19 (10.1) 18 (9.6) 117 (66.6) 22 (11.6) 51 (26.8) 152 (90.4) 9 (5.4) 7 (4.2) 59 (31.4) 49 (26.1) 80 (42.5) 31 (17.0) 47 (25.8) 104 (57.2) 42 (23.2) 50 (27.6) 89 (49.1) 151 (81.6) 14 (7.6) 19 (10.2) 114 (62.3) 27 (14.8) 41 (22.4) 0.01 0.001 0.01 0.07 NS Seyed Kazem Malakouti, MD

13 VariableP.valueOdds ratio95% CI* Sex (male=reference)0.022.521.14-5.56 Marital (married=reference) 0.360.660.27-1.5 Chronic disease (no=reference) 0.191.520.80-2.86 GHQ (<10=reference)0.0054.141.93-8.87 Factors independently related to sleep quality by Pittsburg cutoff point of 5.0 *Confidence interval Seyed Kazem Malakouti, MD

14 Geriatric Assessment Tools: Dementia and Delirium Clock Drawing Test Confusion Assessment Method Short Portable Mental Status Questionnaire Time and Change Test Seyed Kazem Malakouti, MD

15 Cognitive assessment battery (CAB) Symbol Digit Modalities Test (speed & attention) Text recall (learning and episodic memory) Clox test (Visuospatial functions ) Token test and naming 30 items (language) Stroop test (executive function) Seyed Kazem Malakouti, MD

16 Arousal, alertness, level of consciousness: the patient awareness of stimuli Fully alert Lethargy Obtundation Stupor Semi coma Deep coma Seyed Kazem Malakouti, MD

17 Glasgow coma scale to monitor arousal state Eye opening (E) Spontaneous 4 To loud voice 3 To pain 2 Nil 1 Best motor response (M) Obeys 6 Localizes 5 Withdraws (flexion) 4 Abnormal flexion posturing 3 Extension posturing 2 Nil 1 Verbal response (V) Oriented 5 Confused, disoriented 4 Inappropriate words 3 Incomprehensible sounds 2 Nil 1 Seyed Kazem Malakouti, MD

18 Geriatric neuropsychiatric assessment in GM 1. cognition 1.MMSE 2.Mood 1.GDS 3.substance Seyed Kazem Malakouti, MD


20 GDS-15, CUT OFF SCORE= 7/8 GDS-11, CUT OFF SCORE=6 Seyed Kazem Malakouti, MD


22 concentration Digit span: 5 digit Reverse digit span: 3 digit Serial 7s Reverse sequence: week, year … Continuous performance: A’s letters, 30 second Reticular activating system Originated from pons and midbrain Thalamus Project to cortex and subcortical areas Frontal, limbic system Seyed Kazem Malakouti, MD

23 Memory 8 – 10 words Learning: word list test (immediate, working memory Retaining: (recognition) with clue Recall: (retrieve) w/o clue Verbal memory : word list, left temporal Visuospatial memory : right temporal, hidden object in the room. Limbic system Medial temporal lobe Fornix Dorsomedial thalamic nuclei Mammillary body Seyed Kazem Malakouti, MD

24 Language, aphasia Aphasia type WritingRepetitionFluencyComprehe nsion NamingReadingCerebral lesion Receptive--+-+ --I Conduction--+++ --+III Expressive---++ --+II Global------I,II,III Precentral Transcortic al sensory -++---A Anomic-+++-+ -B Transcortic al motor -+-+--+C Isolation-+----+A,B,C Seyed Kazem Malakouti, MD

25 Anatomic regions of aphasia Seyed Kazem Malakouti, MD


27 Visuospatial impairment Getting lost in familiar places Difficulty estimating distances Difficulty orienting objects to complete a task Drawing a picture Seyed Kazem Malakouti, MD

28 visuospatial drawing Seyed Kazem Malakouti, MD

29 Executive function Drive »Spontaneous »Motivation »Sustained performance Programming »Recognizing pattern »Time sequence »Rhythmic pattern Response control »Divided attention »Inhibition of incorrect response »Planning »Mental flexibility: changing strategy »Use feedback »Resist stimulus bound behavior Synthesis »Abstraction: similarities, proverb interpretation »Monitoring cognitive performance »anticipation Seyed Kazem Malakouti, MD

30 Programming exam Alternative program Hand sequence: slap, fist, cut Seyed Kazem Malakouti, MD

31 Response control Divided attention: 1-A, 2-B, 3-C, … Verbal fluency: 12 animal or 10 F words in 1 minute initiation, strategy, perseveration Reciprocal programs (go/no-go). Changing mind, stimulus inhibition Tap1-tap2, tap 2-tap1 Tap 1 –tap 2, tap2-tap 0 Multiple loops Clock drawing Stimulus boundedness: put the clock hands. 11:10, brown word. Imitation behavior Seyed Kazem Malakouti, MD





36 synthesis Similarities Proverbs monitoring Seyed Kazem Malakouti, MD



39 Assessment of activities of daily living Bathing Toileting Eating Transporting Dressing Cooking Paying bills Household chores Shopping Driving Telephone calling Seyed Kazem Malakouti, MD





44 Recent cognitive changes Major neuropsychiatric syndroms affects cognitive conditions –Age-related problem –Prefrontal system dysfunction –Generalized cortical systems disorders –Focal cortical dementia syndromes –Subcortical systems disorders Seyed Kazem Malakouti, MD




48 cognition Validation of a Mini-Mental State Examination (MMSE) for the Persian population: a pilot study. Ansari NN, Naghdi S, Hasson S, Valizadeh L, Jalaie S.Ansari NNNaghdi SHasson SValizadeh LJalaie S Faculty of Rehabilitation, Tehran University of Medical Sciences, Enghelab Ave., Pitch-e-shemiran, Tehran, Iran. Abstract The objective of the study was to develop and validate a translated and culturally adapted Mini- Mental State Examination (MMSE) for the Persian-speaking population. The MMSE was translated into Persian. Two groups of neurologically intact subjects (n = 100) and subjects with Alzheimer's disease (n = 13) were studied. The difference between groups on the mean total scores of the Persian MMSE was statistically significant (control = 28.62 +/- 2.09; subjects with Alzheimer's disease = 11.77 +/- 5.66; p <.001). The cutoff score of 23 was the best cutoff score for our subjects with a sensitivity and specificity of 98% and 100%, respectively. There was a significant correlation between the Persian MMSE score and the level of education (r =.46) and with age (r = -.77). There was no significant correlation between the Persian MMSE and gender. The Persian MMSE was found to be valid for discrimination of cognitive impairment in the Persian-speaking community. Seyed Kazem Malakouti, MD


50 ارزیابی مراحل عملکردی Functional Assessment Staging اگر در هر قسمت فکر می کنید که علت ایجاد مشکل برای بیمار، موضوع دیگری به جز بیماری فراموش است (مانند فلح، ارتریت و.....) لطفا گزنیه "خیر" را علامت بزنید و آن عامل را کنار قسمت مربوطه بنویسید. کدعنوان قسمتبله از چند وقت قبل این مشکل وجود داشته است؟ خیر نرمال1 چه از نظر بیمار و چه از نظر اعضای خانواده وی که در جریان زندگی بیمار قرار دارند، او هیچ مشکلی ندارد Pre-MCI MMSE=28-29 2 بیمار از فراموش کردن محل اشیاء شکایت می کند و در انجام وظایف شغلی خود مشکلی دارد-احساس ذهنی فراموشی در بیمار وجود دارد MCI MMSE=24-28 3 اختلال در عملکرد شغلی برای همکاران بیمار مشخص است و در رفتن به مکان های جدید مشکل دارد. ظرفیت های سازماندهی کارها تقلیل پیدا کرده. MILD DEMENTIA MMSE=19-20 4 توانایی بیمار در انجام امور پیچیده کاهش یافته است (مانند رسیدگی به امور مالی، به طور صیحیح مشکل دارد، حاضر کردن غذا، خرید کردن از مغازه) 5 بیمار برای انتهاب لباس متناسب با فصل و مناسبتها نیاز به راهنمایی دارد 6a در پوشید لباس و کفش به طور صحیح و یا بستن دکمه، بند کفش و کمر بند به طور حیحی مشکل دارد 6b نمی تواند به درستی حمام کند، برای حمام کردن مقاومت می کند و یا از حمام رفتن می ترسد 6c نمی تواند از توالیت به درستی استفاده کند، نمی تواند خود را به درمستی تمیز کند یا توانلت را تمیز نگه دارد 6dبیمار اغلب در طی هفته های گذشته بی اختیاری ادار داشته است 6eاغلب در طی هفته های گذشته بی اختیاری در دفع داشته است 7a توانایی بیمار در صحبت کردن محدود شده است (یک تا شش کلمه در روز) 7b میزان لغات قابل فهم بیمار کاهش یافته یا شدیدا کم شدشده است. ممکن است کلماتی در دائما تکارکند 7c بیمار نمی تواند بدون کمک افراد راه برود 7d نمی تواند بصورت مستقل بنشیند 7e نمی تواند لبخند بزند 7fنمیتواند سرش را بالا نگه دارد Seyed Kazem Malakouti, MD

51 تشخیصStageعلایم فقدان دمانس Stage 1: No Cognitive Decline بیمار عملکرد طبیعی دارد، فراموشی ندارد، از نظر روانی طبیعی است. فقدان دمانس Stage 2: = PRE MCI فراموشی طبیعی قابل مشاهده است، مانند اسامی، جابچا گذاشتن اشیاء، این علایم برای اعضاء خانواده و پزشک ملموس نیست فقدان دمانس Stage 3: MCI اشکال در تمرکز فکر، کاهش عملکرد؛ احتمال گم کردن مسیر، اشکال در پیدا کردن لغات صیحیح، عضو خانواده متوجه اختلال می شود، این مرحله 7 سال قبل از شروع دمانس ظاهر می شود. مرحله اول دمانس Stage 4: = MILD DEMENTIA اشکال در تمرکز فکر، کاهش حافظه اخیر، اختلال در مدیریت مالی و انجام جابجا شدن در شهر به تنهایی در شهر، اختلال در انجام کارهای پیجیده و انکار این اختلال، انزوا از دوست و خانواده، کشف اختلال واضح شناختی توسط پزشک، مدت متوسط این مرحله 2 سال. مرحله دمانس خفیف MILD Stage 5: Mild to moderate dementia اختلال بارز حافظه؛ نیاز به کمک در کارهای روزمره مانند حمام کردن، لباس پوشیدن)، اختلال در گفتن شماره تلفن و ادرس، اختلال در شناسایی روز و ساعت. مدت زمان 1.5 ساعت مرحله متوسط دمانس Stage 6: moderate dementia کمک زیادی برای انجام کارهای روزمره خود دارد، نام اعضاء خانواده خود را از دست میدهد، اختلال در شمردن اعداد از 10 به پایین، اختلال کنترل ادرار یا مدفوع، بروز هذیان، اختلال شخصیت، رفتارهای وسواسی، اضطراب و بیقراری. متوسط دوره 2.5 سال. مرحله نهایی Stage 7: severe dementia قادر به تکلم نیست، قادر با برقراری ارتباط نیست، در بسیاری از کارهای روزمره نیاز به کمک دارد، اختلال در حرکت، مهارت هایی مانند راه رفتن. متوسط دوره 2.5 سال. Seyed Kazem Malakouti, MD

52 Prefrontal system dysfunction Dorsal convexity dysexecutive sydrome Cognitive Flexibility Ordering recent events Planning ahead Regulating actions based on environmental stimuli Learning from experience Concrete Perseverative Impairment in reasoning and flexibility Pay bills on time Organize daily activities Keep a tidy house Cook balance meals Seyed Kazem Malakouti, MD

53 Orbitofrontal disinhibition syndrome, Mania, witzelsucht Connection with limbic Behavioral response to various environmental stimuli and anticipate the consequences Poor impulse control Aggressive outburst Jocularity Lack interpersonal sensitivity Seyed Kazem Malakouti, MD

54 Mesial frontal apathetic syndrome Balance between the cingulum and supplementary motor area Dysemotional sydrome ranging from apathy to akinetic mutism Neurovegetative of depression Exist ideas for activity but no motivation Perceived as a willful indifference Seyed Kazem Malakouti, MD

55 Generalized cortical systems disorders Alzheimer’s disease Frontotemporal dementia Lewy body dementia Seyed Kazem Malakouti, MD

56 focal cortical dementia syndromes Progressive frontal lobe syndromes Progressive aphasia motor aphasia, naming, mixed Progressive perceptual motor syndromes progressive bi-temporal syndrome Seyed Kazem Malakouti, MD

57 Fluent aphasia Wernike’s aphasia Nonsensible speech Not able to comprehend others speech Damage to unimodal association cortex in area 22 Superior temporal gyrus Seyed Kazem Malakouti, MD

58 Non-fluent aphasia Broca’s aphasia Agrammatic Telegraphic speech Difficulty using the words: but, if, or, to, from Seyed Kazem Malakouti, MD



61 Progressive perceptual-motor syndromes Visual syndromes Occipitoparietal network Occipitotemporal network Asimultagnosia Able to describe the details unable to integrate entirely Visual disorientation Balint’s syndrome Asimultagnosia Optic apraxia Optic ataxia Visual agnosia (bilateral occipitotemporal) Inability to name the objects prosopagnosia Motor syndromes First one(frontoparietal) Hemispasticity Hemiparesis Hemisensoryimpairment »Astereognosis » agraphesthesia, myoclonus Second one Mixed apraxia Limb apraxia: combing, brushing Gestural apraxia: imitating Constructional apraxia: drawing Writing apraxia Seyed Kazem Malakouti, MD


63 Progressive bitemporal syndromes Progressive amnesia Progressive prosopagnosia Kluver-Bucy syndrome –Bilateral amygdala destruction –Hyperorality –Emotional placidity –Hypersexuality –Compulsive exploration of the environment –Psychic blindness Seyed Kazem Malakouti, MD

64 Subcortical system disorders 5 neural loop (Alexander, Crutcher-1990 Striatum Globus pallidus Dorsomedial thalamus Supplementary motor area Frontal eye fields Dorsolateral prefrontal (cognition) Orbitofrontal (social comportment) Anterior cingulate (motivation) Seyed Kazem Malakouti, MD

65 Movement manifestation of BG dysfunction Tremor Agitation Akatisia Shuffling gait Bland expression Striatal hand: ulnar deviation, flexion of fingers at the metacarpal phalangeal joints Pill rolling tremor Loss of agility Involuntary movements chorea Seyed Kazem Malakouti, MD

66 Localizing neuropsychiatric findings biparietal HistoryMental statusSensorimotor Spatial disorientationAsimultagnosiaInferior quadrantanopia Ocular apraxia Optic ataxia Seyed Kazem Malakouti, MD

67 Cognitive manifestation of BG dysfunction Cognitive problem: mental torpor, cognitive dilapidation, apathy, depression. Learning, speech and language, praxis, calculation are intact. Retrieved material impaired. Required number of prompt indicate the degree of impairement. Impersistence and slowed completion of task Huntington’s disease Parkinson’s disease Lacunaire syndrome Tumors Progressive supranuclear palsy Multisystem atrophy Wilson’s disease Corticobasal degeneration Seyed Kazem Malakouti, MD

68 Localizing neuropsychiatric findings frontal History Disorganization Disinhibition apathy Mental status High-level attention deficit Luria motor sequences deficit Go/no-go task deficit Decrease in verbal fluency Perseveration Losses of set Confabulation Witzelsucht dilapidation Sensorimotor Gait apraxia Mitgehen Ipsilateral gaze preference Primitive reflexes Seyed Kazem Malakouti, MD

69 Localizing neuropsychiatric findings BG History Motor impairment Social withdrawal Cognitive impairement Mental status Dilapidation Mental torpor Retrieval deficit sensorimotor Hypokinesia Masked facies Stooped posture Festinating gait abnormal movement Muscular rigidity Cogwheeling Gegenhalten/negativ ism Downward gaze palsy Seyed Kazem Malakouti, MD

70 Localizing neuropsychiatric findings parietal HistoryMental statusSensorimotor Spatial disorientation Inconvenient view test Butters test Benton test (spatial memory) Localizing things (where) Dyslexia Visual & touching disharmony hemiagnosia Anosognosia (rt) Autotopagnosia (lt) Simultaneous extinction (rt) Asteregnosia Rt & lt disorientation (lt) Acalculia (lt) Agraphestesia Agraphia (lt) Apraxia, dressing Constructional apraxia (rt) Painting problem Inferior quadrantanopia Ocular apraxia Optic ataxia Sensory deficit (opposite) Seyed Kazem Malakouti, MD

71 Localizing neuropsychiatric findings right hemisphere History Confusion state Delusions Spatial disorientation Neglect Denial of deficit Dressing difficulties Left-sided motor impairment Mental status Dysprosodia Visuoconstructive deficit Spatial analysis deficit Left hemineglect Visual memory deficit Dressing apraxia sensorimotor Left hypertonus Left babinsky sign Left astereognosis Left dysgraphesthesia Double simultaneous extinction Posturing of left hand/arm with tandem gait Left pronator drift left quadrantanopia Seyed Kazem Malakouti, MD

72 Localizing neuropsychiatric findings left hemisphere History Right-sided motor impairment Language impairment Math impairment Mental status Ideomotor apraxia Dysphasia Dyslexia Dyscalculia Dysgraphia Right/left disorientation Finger agnosia sensorimotor Right hypertonus Right babinski sign Right asterognosis Right dysgraphestesia Posturing of right hand/arm with tandem gait Right pronator drift Right quadrantanopia Seyed Kazem Malakouti, MD

73 Localizing neuropsychiatric findings bitemporal History Placidity Hyperorality Hypersexuality Mental status Amnesia Agnosia Visual: right Auditory: left Anomia Prosopagnosia Sensorimotor Superior quadrantanopia Seyed Kazem Malakouti, MD

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