1 Dementia

2 Phenomenology Dementia P Disorder of Cognitive Function

3 The Cognitive Functions < Attention and Concentration < Language function < Memory < Visuospatial Ability < Perceptual Capacity < Conceptualization and Abstract Reasoning < General Intelligence

4 Dementia Other aspects of The MSE P General Presentation < varied with level < care taking

5 Dementia Other aspects of The MSE P Emotions < Mood B Generally euthymic B dysphoria, frustration early on B May become A or A < Affect B May be appropriate B Blunted B Inappropriate

6 Dementia Other aspects of The MSE P Thought < Process B impoverished < Content B hallucinations rare B > w/ Sensory impairment B delusions B poorly formed

7 Neuritic Plaques P Amyloid accumulation

8 Tangles and Degeneration

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12 Delirium vs. Dementia Things Different P Delirium B usually reversible < Dementia rarely so P Pathology < Dementia: B Usually identifiable pathological findings B at least on autopsy < Delirium B more often physiological

13 Drugs approved for AD Cholinesterase Inhibitors –Tachrine (Cognex) –donepezil (Aricept) –rivastigmine (Exelon) –galantamine (Reminyl) NMDA antagonists –Memantine (Axura)

14 Treatment of Dementia Non-pharm. treatments < Psychosocial Treatments B Provide structure B Adjust to ability < Attention to the care givers < Education

15 Child Psychiatry

16 “A Child is a Psychotic Dwarf with a Good Prognosis” Anonymous Adult Psychiatrist

17 Kids get it too… drug abuse Depression Mania Anxiety Schizophrenia But full syndrome may not yet be present

18 Same thing, different name: Conduct disorder = antisocial PD Identity dis.= borderline PD

19 Early and only in C/A Reactive attachment Eating/elimination Separation anxiety

20 Never in C/A Organic mental diseases of aging

21 Early and Forever MR Autism LD ADHD

22 ADHD Inattention Hyperactivity and Impulsivity

23 Inattention –Cannot focus or sustain tasks –Careless mistakes –Poor organization –Forgetful, easily distracted

24 Hyperactivity –Fidgety, gets up a lot. –Runs, climbs, moves around inappropriately –Talks a lot, Cannot quiet down. Impulsivity –Blurts things out, can’t wait turn –Interrupts.

25 Epidemiology 3-10% Changing definitions ♂:♀ = 3:1 Increase of adult ADHD.

26 Etiology Runsin families. Association with other disorders –Mood, antisocial, substance abuse, learning. Possible link with mutation on D 4 gene –May make clinical sense Prenatal factors

27 Imaging studies Decreased volume and hypoperfusion of prefrontal and basal ganglia

28 Course of ADHD Variable Abt ½ do well

29 Treatment Pharmacological treatment –Psychostimulants Amphetamines others –Antidepressants TCAs bupropion

30 Psychotherapies Behavioral therapy. –Positive reinforcement –Firm, nonpunitive limit setting. Environmental management –Decrease distraction in the environment Education –Of parents.

31 Some general points about psychotherapy in children.

32 Use of Antidepressants

33 Dramatic Increase in Psychopharm everything is biological newer drugs are much safer you don't need the full diagnosis anymore (symptomatic medicine) –treating the partial syndrome (schizophrenia, mania, anxiety, disorders, personality disorders). hello polypharmacy –adjunctives –nonspecific use (antipsychotics for agitation, mood stabilizers for aggressivity, SSRI for "neurosis") "ask your doctor about Prozac“ managed care

34 Medications in Children psychostimulants (dx., abuse) antidepressants (old and new) antipsychotics (old and new) anti-anxiety (addictive, the street) mood stabilizers (all the rage, taper the antiseizure meds, slowly) antiaggressivity (clonidine, tenex) (autonomic, N.S. effect) increase and decrease slowly tapering side effects can include serotonin-like syndrome, increased BP, withdrawal, agitation, seizures, recurrence of psychotic symptoms the tendency toward non-compliance.