1. Understanding Cognitive Disorders Developed by DATA of Rhode Island through a special grant from the RI Department of Human Services

2. Goals To familiarize trainees with common types of cognitive disorders To improve trainee understanding of the functional impairment of persons with cognitive disorders To identify common co-occurring other disorders To identify how approaches to persons with cognitive disorders may be modified

3. Definition Cognitive disorders = disorders in which the central feature is the impairment of memory, attention, perception, and/or thinking processes. Cognitive disorders sometimes underpin other mental disorders such as depression, paranoia and hallucinations Some disorders are transient and others are persisting and progressive

4. Background Used to be called “organic brain disorders” Meant a dysfunction of the brain Meant a dysfunction of the brain Today are referred to as “cognitive disorders” Better reflects nature of problems Better reflects nature of problems Person with cognitive disorder often requires some accommodation in approach and planning Person with cognitive disorder often requires some accommodation in approach and planning Certain types of disorders may require immediate medical attention Certain types of disorders may require immediate medical attention

5. Screening for Cognitive Disorders Screening for Cognitive Disorders Mental Status : brief interview used to assess cognitive disorders 5 major components: 5 major components: 1.Appearance and behavior 2.Mood and affect 3.Thought 4.Perception 5.Sensorium and Intellect Sensorium = consciousness and awareness of surroundings Sensorium = consciousness and awareness of surroundings

6. Cognitive Disorders There are multiple types of cognitive disorders. These include: Delirium, dementia including traumatic brain injury and development disabilities

7. Delirium 1.Features Key feature is disturbed consciousness Key feature is disturbed consciousness Associated features include: Associated features include: Clouded sensorium – no clear awareness of surroundings Problems with attention Disturbance in memory Incoherent speech Perceptual disturbances (e.g., hallucinations)

8. Delirium (cont.) Course Acute onset (within hours or days) and transient course (days to a few weeks) Acute onset (within hours or days) and transient course (days to a few weeks) No such things as life-long delirium Can be superimposed on another disorder (e.g., dementia) Can be superimposed on another disorder (e.g., dementia)

9. Course (cont.) Tends to occur more in certain people: Elderly Elderly Medically ill (e.g., cancer; AIDS) Medically ill (e.g., cancer; AIDS) Dementia Dementia Substance Abusers Substance Abusers

10. Delirium (cont.) 3.Causes Drugs: intoxication, withdrawal, poison Drugs: intoxication, withdrawal, poison Delirium tremens = tremors and vivid hallucinations of vermin associated with alcohol withdrawal Medications Medications Infection Infection Head injury Head injury Various kinds of brain trauma (e.g., stroke) Various kinds of brain trauma (e.g., stroke)

11. Delirium (cont.) 4.Responding to Delirium Attending to precipitating problem Attending to precipitating problem Treating medical condition; counteracting effects of substance withdrawal; using antipsychotic med Recognizing people at risk and paying special attention to those cases to avoid delirium Usually requires professional intervention

12. Dementia 1.Features Key feature of most dementia is gradual impairment of multiple cognitive abilities including memory, language, and judgment Key feature of most dementia is gradual impairment of multiple cognitive abilities including memory, language, and judgment With impaired social/occupational functioning Often global cognitive impairment – (e.g., vocabulary and language) Often global cognitive impairment – (e.g., vocabulary and language) First signs: personality change and memory loss First signs: personality change and memory loss

13. Dementia (cont.) 2.Statistics and course Incidence is highest in older adults, but can onset at almost any age Incidence is highest in older adults, but can onset at almost any age Not accurate to give one prevalence rate, because it differs by age group: Not accurate to give one prevalence rate, because it differs by age group: 65-74:1.29% 75-84:3.83% 85+:10.14%

14. Statistics Incidence is the same for males and females Onset varies by type of dementia e.g., Alzheimer’s vs. vascular dementia e.g., Alzheimer’s vs. vascular dementia People over age 75 at increased risk for dementia

15. Dementia (cont.) 3.Example: Alzheimer’s Disease (most common) A. Development of multiple cognitive deficits manifested by both: 1)Memory impairment 2)One (or more) of the following: a) Aphasia b) Apraxia c) Agnosia d) Disturbance in executive functioning

16. Criteria (cont.) B. Significant impairment and decline C. Gradual onset and continuing decline - Rule out other dementias and mental disorders (depression)

17. Alzheimer’s (cont.) Onset usually in 60’s or 70’s Early signs in 40’s and 50’s (presenile dementia) Early signs in 40’s and 50’s (presenile dementia) Definitive diagnosis can only be made on autopsy where confirms: 1. Gross atrophy of the brain 2. Neurofibrillary tangles 3. Senile plaques

18. Dementia (cont.) 4.Causes of dementia Direct cause linked to type of dementia Direct cause linked to type of dementia Plaques and tangles  Alzheimer’s Blocked artery  vascular dementia Genetic factors linked to some dementias Genetic factors linked to some dementias Multiple genes  Alzheimer’s risk Single dominant gene  Huntington’s disease Head trauma (Traumatic Brain Injury) Head trauma (Traumatic Brain Injury)

19. Causes (cont.) Vascular dementia can be influenced by diet as well as genetic factors (link to heart disease) Psychosocial factors Higher education level is associated with lower dementia risk Higher education level is associated with lower dementia risk Social resources and family support can improve life for patients with dementia Social resources and family support can improve life for patients with dementia

20. Dementia (cont.) 5.Treatment of dementia Limited – some drugs can improve cognitive functioning, but only temporary Limited – some drugs can improve cognitive functioning, but only temporary Psychosocial treatments Psychosocial treatments Memory wallet Memory skills training Teach to use navigational cues to avoid getting lost In more progressed cases, more active care giver roles required

21. Traumatic Brain Injury (TBI) 50 to 70% of persons with TBI resulting in hospitalization are intoxicated at the time of the injury 50% of TBI survivors return to alcohol and/or drug use after the injury TBI occurs in about 2% of population TBI is heavily associated with certain types of other disorders including substance abuse, personality disorder and ADHD

22. Developmental Disability A condition that begins before the age of 21 and is likely to continue indefinitly. Caused by a mental or physical impairment Results in substantial impairment in functional abilities including language, learning, decision making, self care and other areas. Types of disabilities include: Mental retardation, autism, cerebral palsy and other disorders

23. Developmental Disabilities and Cognitive Functioning Cognitive issues in various levels of mental retardation Cognitive issues in Autism Spectrum Disorder Cognitive issues in Asperger’s Disorder Cognitive issues in Pervasive Developmental Delay Cognitive issues in childhood TBI Cognitive issues in lead poisoning, drug addiction in-utero, fetal alcohol syndrome

24. Learning Disabilities Defined: a disorder in one or more of the basic psychological processes involved in understanding or in using written or spoken language. A learning disability may manifest itself in an imperfect ability to listen, think, speak, read, write, spell, or do mathematical calculations Common Learning Disabilities: ADHD, Dyslexia, developmental reading and writing disorders

25. Common co-occurring mental disorders It is estimated that 40% or more of persons with cognitive disorders have other mental disorders. These include: Depression and anxiety (most common) Substance Dependence (particularly with persons with TBI) Persons with milder levels of mental retardation are at higher risk of substance abuse Persons with cognitive disorders are at higher risk of victimization and trauma

26. Impact of Cognitive Impairment Neuropsychological deficits contribute to the inattention, distractibility and apparent lack of motivation early in services. Understanding the cognitive weaknesses and strengths is useful for making and in providing realistic with realistic expectations about service goals and expectations.

27. Lessons Learned about persons with cognitive disorders Slowed mental processing = increased stress and anxiety Word finding difficulty = decreased verbal communication Poor retrieval = loss of learned information Executive difficulty = poor self-cueing, difficulty with understanding, empathy, planning and problem solving Executive difficulty = poor impulse control, failure to learn from negative experience, poor self guidance.

28. Practical tips for interviewing a person with Cognitive Disorders Often persons with cognitive disorders experience a high degree of shame and embarrassment about their limitation Listening Skills (LISTEN CAREFULLY) Look at the person to whom you are speaking Look at the person to whom you are speaking Interest yourself in the conversation Interest yourself in the conversation Speak less than half the time Speak less than half the time Try not to interrupt or change the topic Try not to interrupt or change the topic One question at a time One question at a time Simple and clear language Simple and clear language Clarify what is said Clarify what is said Notice body language and facial expression Notice body language and facial expression Don’t rely on verbal instructions or promises Don’t rely on verbal instructions or promises Use visual aids to support learning and retention Use visual aids to support learning and retention

29. More Tips Break tasks into smaller steps, and give directions verbally and in writing; giving the clients more time to finish certain tasks that may require reading or writing; Make sure the person with reading problems has written materials read out loud so they better understand Make sure the person with listening difficulties has materials in writing When possible allow the person to review information with a trusted other person

30. Modifying services for persons with cognitive impairments Model Concent. Impairmnt MemoryImpairmntExecutiveImpairmnt MotivatiionalSummarize: Verbal Cues, NonverbalCues Familiariza- tion, notes, audio tape, rehearsal, homework Role rever. Paper/pen problem solving Coaching Behavioral Repeat info Use Nonverbal & verbal cueing Provide Verbatim written materials Memory books HomeworkCoaching Role Plays

31. Summary Cognitive disorders involve an impairment of memory, attention, perception, and thinking that represents an impairment in functioning With adaptations of services and approach persons with disabilities can successfully participate in services

32. QUESTIONS