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Geriatric Changes

A number of changes normally occur in the aging individual. These changes affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment neurocognitive function, organ function, senses, metabolism, sexual function, and sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep patterns. Of particular importance in aging adults, physicians Physicians Individuals licensed to practice medicine. Clinician–Patient Relationship need to understand the difference between normal cognitive decline associated with aging and pathologic decline. History, physical examination, imaging, laboratory studies, and neuropsychological testing may help determine possible causes of pathologic decline. Many conditions that cause pathologic cognitive decline have no cure, but symptoms may be managed with medications and a strong support system.

Last updated: 14 Mar, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Normal Changes in the Elderly

Normal changes in the elderly should not impair daily functioning, such as self-care, everyday activities, managing finances, and medication management.

Neurocognitive changes

Anatomic and physiologic changes:

  • Brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification volume:
    • Greatest in the frontal Frontal The bone that forms the frontal aspect of the skull. Its flat part forms the forehead, articulating inferiorly with the nasal bone and the cheek bone on each side of the face. Skull: Anatomy and temporal lobes
    • White matter White Matter The region of central nervous system that appears lighter in color than the other type, gray matter. It mainly consists of myelinated nerve fibers and contains few neuronal cell bodies or dendrites. Brown-Séquard Syndrome affected more than gray matter Gray matter Region of central nervous system that appears darker in color than the other type, white matter. It is composed of neuronal cell bodies; neuropil; glial cells and capillaries but few myelinated nerve fibers. Cerebral Cortex: Anatomy
  • ↓ Cerebral blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure
  • ↓ Levels of neurotransmitters

Effects:

  • Intelligence: 
    • Decline in reaction time and psychomotor skills
    • Decline in ability to process new information quickly (fluid intelligence)
  • Memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment:
    • Decline in declarative memory, which includes:
    • Nondeclarative memory (learned skills) does not decline with aging.
    • Decline in recall ability
  • Attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment and concentration: 
    • Decline in multitasking abilities
    • ↓ Concentration
  • Language: decline in verbal fluency and naming objects (expressive aphasia Aphasia A cognitive disorder marked by an impaired ability to comprehend or express language in its written or spoken form. This condition is caused by diseases which affect the language areas of the dominant hemisphere. Clinical features are used to classify the various subtypes of this condition. General categories include receptive, expressive, and mixed forms of aphasia. Ischemic Stroke)
  • Decline in visuospatial abilities
  • Decline in executive functioning (ability to plan, solve problems)

Sensory Sensory Neurons which conduct nerve impulses to the central nervous system. Nervous System: Histology function

Anatomic and physiologic changes:

  • Eyes:
    • Periorbital Periorbital Orbital and Preseptal Cellulitis tissue atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation
    • ↑ Flaccidity of the eyelids Eyelids Each of the upper and lower folds of skin which cover the eye when closed. Blepharitis
    • ↓ Lacrimal gland function
    • Conjunctival atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation
    • Corneal deposits
    • Lens Lens A transparent, biconvex structure of the eye, enclosed in a capsule and situated behind the iris and in front of the vitreous humor (vitreous body). It is slightly overlapped at its margin by the ciliary processes. Adaptation by the ciliary body is crucial for ocular accommodation. Eye: Anatomy elasticity Elasticity Resistance and recovery from distortion of shape. Skeletal Muscle Contraction
    • ↓ Ciliary muscle strength Muscle strength The amount of force generated by muscle contraction. Muscle strength can be measured during isometric, isotonic, or isokinetic contraction, either manually or using a device such as a muscle strength dynamometer. Neurological Examination
  • Ears:
    • Thinning of the external auditory canal External Auditory Canal Otitis Externa walls
    • Cerumen Cerumen The yellow or brown waxy secretions produced by vestigial apocrine sweat glands in the external ear canal. Otitis Externa is drier.
    • Loss of hair cells Hair cells Auditory sensory cells of organ of corti, usually placed in one row medially to the core of spongy bone (the modiolus). Inner hair cells are in fewer numbers than the outer auditory hair cells, and their stereocilia are approximately twice as thick as those of the outer hair cells. Auditory and Vestibular Pathways: Anatomy in the organ of Corti

Effects:

  • Visual acuity Visual Acuity Clarity or sharpness of ocular vision or the ability of the eye to see fine details. Visual acuity depends on the functions of retina, neuronal transmission, and the interpretative ability of the brain. Normal visual acuity is expressed as 20/20 indicating that one can see at 20 feet what should normally be seen at that distance. Visual acuity can also be influenced by brightness, color, and contrast. Ophthalmic Exam
  • Presbyopia Presbyopia The normal decreasing elasticity of the crystalline lens that leads to loss of accommodation. Refractive Errors (↓ ability to focus Focus Area of enhancement measuring < 5 mm in diameter Imaging of the Breast on nearby objects)
  • Presbycusis (↓ in high-frequency hearing acuity)
  • Trouble with speech discrimination and sound localization
  • Olfaction Olfaction The sense of smell, or olfaction, begins in a small area on the roof of the nasal cavity, which is covered in specialized mucosa. From there, the olfactory nerve transmits the sensory perception of smell via the olfactory pathway. This pathway is composed of the olfactory cells and bulb, the tractus and striae olfactoriae, and the primary olfactory cortex and amygdala. Olfaction: Anatomy → loss of taste (cause is not entirely clear)

Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep patterns

  • ↓ REM and slow-wave sleep
  • Sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep onset latency
  • ↑ Early awakenings
  • ↑ Frequency of nighttime awakenings

Organ system changes

  • Cardiovascular function:
    • Mild ↓ in heart rate Heart rate The number of times the heart ventricles contract per unit of time, usually per minute. Cardiac Physiology and ↓ response to exertion/stressors
    • ↑ Stiffness of vessels → ↑ BP
    • Thickening and calcification of heart valves
    • Impaired diastolic function
  • Pulmonary function:
    • Elastic Elastic Connective Tissue: Histology tissue → ↓ elastic recoil Recoil Vessels can stretch and return to their original shape after receiving the stroke volume of blood ejected by the left ventricle during systole. Arteries: Histology → enlarged alveolar ducts → loss of ⅓ of surface area per volume of lung tissue → ↑ anatomic dead space Anatomic dead space Respiratory Alkalosis
    • Chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall: Anatomy stiffness
    • ↓ Functional reserves
    • ↑ Alveolar-arterial (A-a) oxygen gradient and V/Q mismatch
  • GI function:
    • ↓ Esophageal muscle strength Muscle strength The amount of force generated by muscle contraction. Muscle strength can be measured during isometric, isotonic, or isokinetic contraction, either manually or using a device such as a muscle strength dynamometer. Neurological Examination and coordination Coordination Cerebellar Disorders dysphagia Dysphagia Dysphagia is the subjective sensation of difficulty swallowing. Symptoms can range from a complete inability to swallow, to the sensation of solids or liquids becoming “stuck.” Dysphagia is classified as either oropharyngeal or esophageal, with esophageal dysphagia having 2 sub-types: functional and mechanical. Dysphagia
    • ↑ In reflux esophagitis Esophagitis Esophagitis is the inflammation or irritation of the esophagus. The major types of esophagitis are medication-induced, infectious, eosinophilic, corrosive, and acid reflux. Patients typically present with odynophagia, dysphagia, and retrosternal chest pain. Esophagitis, due to altered contractions and sphincter tone
    • ↓ Transit time → ↑ in constipation Constipation Constipation is common and may be due to a variety of causes. Constipation is generally defined as bowel movement frequency < 3 times per week. Patients who are constipated often strain to pass hard stools. The condition is classified as primary (also known as idiopathic or functional constipation) or secondary, and as acute or chronic. Constipation
  • Renal function:
    • ↓ Renal mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast and ↑ fibrosis Fibrosis Any pathological condition where fibrous connective tissue invades any organ, usually as a consequence of inflammation or other injury. Bronchiolitis Obliterans
    • ↓ Renal blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure
    • ↓ Renal function
    • Creatinine clearance Creatinine clearance Kidney Function Tests
  • Immune function: 
  • Skin:
    • Epidermal thinning
    • ↓ Elasticity
    • ↑ Fragility

Body mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast and metabolism

  • Lean LEAN Quality Measurement and Improvement muscle mass Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast 
  • ↑ Body fat
  • Bone Bone Bone is a compact type of hardened connective tissue composed of bone cells, membranes, an extracellular mineralized matrix, and central bone marrow. The 2 primary types of bone are compact and spongy. Bones: Structure and Types density 
  • ↓ Basal metabolic rate
  • ↓ Caloric consumption needs

Sexual changes

  • Men:
    • Slower erection Erection The state of the penis when the erectile tissue becomes filled or swollen (tumid) with blood and causes the penis to become rigid and elevated. It is a complex process involving central nervous system; peripheral nervous systems; hormones; smooth muscles; and vascular functions. Penis: Anatomy and ejaculation
    • Longer refractory period
  • Women: vaginal atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation, thinning, and dryness (due to ↓ in estrogen Estrogen Compounds that interact with estrogen receptors in target tissues to bring about the effects similar to those of estradiol. Estrogens stimulate the female reproductive organs, and the development of secondary female sex characteristics. Estrogenic chemicals include natural, synthetic, steroidal, or non-steroidal compounds. Ovaries: Anatomy)

Pathologic Cognitive Decline

While some changes in cognition are observed in normal aging, some patients may experience more cognitive impairment than expected, which affects intellectual performance or daily functioning. This unexpected impairment should prompt an evaluation.

Clinical presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor

  • Memory Memory Complex mental function having four distinct phases: (1) memorizing or learning, (2) retention, (3) recall, and (4) recognition. Clinically, it is usually subdivided into immediate, recent, and remote memory. Psychiatric Assessment lapses and forgetfulness
  • Inability to focus Focus Area of enhancement measuring < 5 mm in diameter Imaging of the Breast
  • Difficulty finding words
  • Inability to complete tasks independently
  • Decline in reasoning Reasoning Decision-making Capacity and Legal Competence and judgment Judgment The process of discovering or asserting an objective or intrinsic relation between two objects or concepts; a faculty or power that enables a person to make judgments; the process of bringing to light and asserting the implicit meaning of a concept; a critical evaluation of a person or situation. Psychiatric Assessment
  • Personality changes
  • Mood changes

Screening Screening Preoperative Care for cognitive decline

  • Recommended only if clinical suspicion is present
  • Mini–Mental State Examination ( MMSE MMSE Major Neurocognitive Disorders): 
    • 30-point questionnaire 
    • Used extensively in clinical settings to measure cognitive impairment
    • Includes the following:
      • Orientation to time  
      • Orientation to place 
      • Registration 
      • Attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment and calculation 
      • Recall 
      • Language 
      • Repetition
      • Complex commands
    • Interpretation:
      • ≥ 24 points is considered normal.
      • 19–23 points indicates mild dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders.
      • 10–18 points indicates moderate dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders.
      • ≤ 9 points indicates severe dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders
  • Mini–cognitive test has 89% specificity Specificity Specificity is the probability of correctly determining the absence of a condition. Immunoassays for dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders, involving the following: 
    • 3-item recall
    • Clock draw test

Evaluation

  • Review medications.
  • Screen for depression.
  • Laboratory evaluation:
    • TSH → hypothyroidism Hypothyroidism Hypothyroidism is a condition characterized by a deficiency of thyroid hormones. Iodine deficiency is the most common cause worldwide, but Hashimoto’s disease (autoimmune thyroiditis) is the leading cause in non-iodine-deficient regions. Hypothyroidism
    • Vitamin B12 and CBC → vitamin B12 deficiency
    • Rapid plasma Plasma The residual portion of blood that is left after removal of blood cells by centrifugation without prior blood coagulation. Transfusion Products reagin → tertiary syphilis Tertiary Syphilis Syphilis
  • Neuroimaging Neuroimaging Non-invasive methods of visualizing the central nervous system, especially the brain, by various imaging modalities. Febrile Infant (CT or MRI) to evaluate for:
    • Cerebrovascular disease
    • Normal-pressure hydrocephalus Hydrocephalus Excessive accumulation of cerebrospinal fluid within the cranium which may be associated with dilation of cerebral ventricles, intracranial. Subarachnoid Hemorrhage
    • Subdural hematoma Hematoma A collection of blood outside the blood vessels. Hematoma can be localized in an organ, space, or tissue. Intussusception
    • Mass lesion
  • Neuropsychological testing (in-depth cognitive testing)

Differentiating mild versus more severe neurocognitive changes

  • Mild neurocognitive decline:
    • Mild decline in ≥ 1 cognitive domain
    • Normal functioning in all daily activities 
  • Major neurocognitive decline ( dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders):
    • Severe decline in ≥ 1 cognitive domain
    • Significant irreversible decline in all daily activities 
    • Marked functional impairment

Differential Diagnosis

  • Major depressive disorder Major depressive disorder Major depressive disorder (MDD), commonly called depression, is a unipolar mood disorder characterized by persistent low mood and loss of interest in association with somatic symptoms for a duration of ≥ 2 weeks. Major depressive disorder has the highest lifetime prevalence among all psychiatric disorders. Major Depressive Disorder: mood disorder marked by depressed mood, sleep disturbances, anhedonia Anhedonia Inability to experience pleasure due to impairment or dysfunction of normal psychological and neurobiological mechanisms. It is a symptom of many psychotic disorders (e.g., depressive disorder, major; and schizophrenia). Schizophrenia, feelings of guilt or worthlessness, loss of energy, low concentration, weight or appetite changes, psychomotor retardation or agitation Agitation A feeling of restlessness associated with increased motor activity. This may occur as a manifestation of nervous system drug toxicity or other conditions. St. Louis Encephalitis Virus, and suicidal ideation Suicidal ideation A risk factor for suicide attempts and completions, it is the most common of all suicidal behavior, but only a minority of ideators engage in overt self-harm. Suicide. In elderly patients, pseudodementia may also be present. Diagnosis is clinical but requires ruling out other potential diagnoses. Treatment options include pharmacotherapy, psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy, and electroconvulsive therapy Electroconvulsive therapy Electrically induced convulsions primarily used in the treatment of severe affective disorders and schizophrenia. Major Depressive Disorder.
  • Alzheimer disease Alzheimer disease As the most common cause of dementia, Alzheimer disease affects not only many individuals but also their families. Alzheimer disease is a progressive neurodegenerative disease that causes brain atrophy and presents with a decline in memory, cognition, and social skills. Alzheimer Disease: chronic neurodegenerative disease. Alzheimer disease Alzheimer disease As the most common cause of dementia, Alzheimer disease affects not only many individuals but also their families. Alzheimer disease is a progressive neurodegenerative disease that causes brain atrophy and presents with a decline in memory, cognition, and social skills. Alzheimer Disease is the most common cause of dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders. The etiology of this disease is unclear but is thought to be multifactorial. Alzheimer disease Alzheimer disease As the most common cause of dementia, Alzheimer disease affects not only many individuals but also their families. Alzheimer disease is a progressive neurodegenerative disease that causes brain atrophy and presents with a decline in memory, cognition, and social skills. Alzheimer Disease causes a decline in memory, thought processes, behavior, and functional abilities. Diagnostic considerations involve history, exam, imaging, lab test, and neuropsychological testing; however, definitive diagnosis is made only postmortem with evidence of amyloid plaques and neurofibrillary tangles Neurofibrillary Tangles Abnormal structures located in various parts of the brain and composed of dense arrays of paired helical filaments (neurofilaments and microtubules). These double helical stacks of transverse subunits are twisted into left-handed ribbon-like filaments that likely incorporate the following proteins: (1) the intermediate filaments: medium- and high-molecular-weight neurofilaments; (2) the microtubule-associated proteins map-2 and tau; (3) actin; and (4) ubiquitins. As one of the hallmarks of alzheimer disease, the neurofibrillary tangles eventually occupy the whole of the cytoplasm in certain classes of cell in the neocortex, hippocampus, brain stem, and diencephalon. The number of these tangles, as seen in post mortem histology, correlates with the degree of dementia during life. Some studies suggest that tangle antigens leak into the systemic circulation both in the course of normal aging and in cases of alzheimer disease. Alzheimer Disease at autopsy. There is no cure.
  • Vascular dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders: declines in mental function caused by brain damage after insufficient or impaired blood supply to the brain. This type of dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders characteristically causes stepwise progression of decline in thought processes, executive functioning, and daily functional abilities. Exact symptoms vary by area of the brain impacted by impaired blood flow Flow Blood flows through the heart, arteries, capillaries, and veins in a closed, continuous circuit. Flow is the movement of volume per unit of time. Flow is affected by the pressure gradient and the resistance fluid encounters between 2 points. Vascular resistance is the opposition to flow, which is caused primarily by blood friction against vessel walls. Vascular Resistance, Flow, and Mean Arterial Pressure. Diagnosis is aided by imaging studies. Management is focused on control of risk factors and conditions such as hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. Hypertension, dyslipidemia, and diabetes Diabetes Diabetes mellitus (DM) is a metabolic disease characterized by hyperglycemia and dysfunction of the regulation of glucose metabolism by insulin. Type 1 DM is diagnosed mostly in children and young adults as the result of autoimmune destruction of β cells in the pancreas and the resulting lack of insulin. Type 2 DM has a significant association with obesity and is characterized by insulin resistance. Diabetes Mellitus.
  • Frontotemporal dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders: group of rare brain disorders, including Pick disease, associated with atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation in the frontal Frontal The bone that forms the frontal aspect of the skull. Its flat part forms the forehead, articulating inferiorly with the nasal bone and the cheek bone on each side of the face. Skull: Anatomy and temporal lobes of the brain. This atrophy Atrophy Decrease in the size of a cell, tissue, organ, or multiple organs, associated with a variety of pathological conditions such as abnormal cellular changes, ischemia, malnutrition, or hormonal changes. Cellular Adaptation leads to personality and behavioral changes, as well as diminished thought processes and language abilities. Diagnosis is made clinically in combination with imaging, neuropsychological tests, and other tests to rule out other conditions. Management involves antipsychotics and antidepressants, as well as speech therapy Speech Therapy Treatment for individuals with speech defects and disorders that involves counseling and use of various exercises and AIDS to help the development of new speech habits. Myotonic Dystrophies.
  • Lewy body dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders: 2nd most common progressive dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders. Lewy body dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders develops because of abnormal deposition of Lewy bodies Lewy bodies Intracytoplasmic, eosinophilic, round to elongated inclusions found in vacuoles of injured or fragmented neurons. The presence of lewy bodies is the histological marker of the degenerative changes in lewy body disease and parkinson disease but they may be seen in other neurological conditions. They are typically found in the substantia nigra and locus coeruleus but they are also seen in the basal forebrain, hypothalamic nuclei, and neocortex. Parkinson’s Disease in the nerve cells of the brain, leading to impaired mental functions related to thinking, movement, behavior, and mood. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship will also have visual hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia, Parkinson’s disease–like movement abnormalities, and fluctuating cognition. The diagnosis is made clinically and through imaging and testing to rule out other conditions. There is no cure, but medications may help manage symptoms. 
  • Normal-pressure hydrocephalus Hydrocephalus Excessive accumulation of cerebrospinal fluid within the cranium which may be associated with dilation of cerebral ventricles, intracranial. Subarachnoid Hemorrhage: abnormal accumulation of CSF inside the ventricles of the brain, typically due to a blockage in the drainage pathway. This accumulation causes pressure and stretching of the periventricular white matter Periventricular White Matter Multiple Sclerosis, Normal-pressure hydrocephalus Hydrocephalus Excessive accumulation of cerebrospinal fluid within the cranium which may be associated with dilation of cerebral ventricles, intracranial. Subarachnoid Hemorrhage is marked by gait Gait Manner or style of walking. Neurological Examination abnormalities, incontinence, and dementia Dementia Major neurocognitive disorders (NCD), also known as dementia, are a group of diseases characterized by decline in a person’s memory and executive function. These disorders are progressive and persistent diseases that are the leading cause of disability among elderly people worldwide. Major Neurocognitive Disorders. Imaging of the brain Imaging of the brain Today, CT and MRI, especially the latter, are the preferred imaging methods for the study of the cranial vault and its contents. In conditions where emergent management is decided on the basis of presentation and imaging, CT has the advantage of rapid scan time and wider availability. Imaging of the Head and Brain, lumbar puncture Lumbar Puncture Febrile Infant, and intracranial pressure Intracranial Pressure Idiopathic Intracranial Hypertension monitoring help make the diagnosis. Management involves placing a shunt in the brain to drain the CSF. 
  • Prion diseases: also known as transmissible spongiform encephalopathies Transmissible Spongiform Encephalopathies Transmissible spongiform encephalopathies (TSEs) are diseases caused by prions. Prions differ from viruses in that they are small, infectious pathogens that do not contain nucleic acid. Recognized TSEs include Creutzfeldt-Jakob Disease (CJD), variant Creutzfeldt-Jakob Disease (vCJD), Kuru, fatal familial insomnia (FFI), and Gerstmann-Straussler syndrome (GSS). Transmissible Spongiform Encephalopathies. Prion diseases are a large group of rare, progressive neurodegenerative diseases that can affect Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment both humans and animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic. Symptoms include behavioral changes, ataxia Ataxia Impairment of the ability to perform smoothly coordinated voluntary movements. This condition may affect the limbs, trunk, eyes, pharynx, larynx, and other structures. Ataxia may result from impaired sensory or motor function. Sensory ataxia may result from posterior column injury or peripheral nerve diseases. Motor ataxia may be associated with cerebellar diseases; cerebral cortex diseases; thalamic diseases; basal ganglia diseases; injury to the red nucleus; and other conditions. Ataxia-telangiectasia, myoclonus Myoclonus Involuntary shock-like contractions, irregular in rhythm and amplitude, followed by relaxation, of a muscle or a group of muscles. This condition may be a feature of some central nervous system diseases; (e.g., epilepsy-myoclonic). Nocturnal myoclonus is the principal feature of the nocturnal myoclonus syndrome. Neurological Examination, and seizures Seizures A seizure is abnormal electrical activity of the neurons in the cerebral cortex that can manifest in numerous ways depending on the region of the brain affected. Seizures consist of a sudden imbalance that occurs between the excitatory and inhibitory signals in cortical neurons, creating a net excitation. The 2 major classes of seizures are focal and generalized. Seizures. Unfortunately, these diseases are associated with long incubation Incubation The amount time between exposure to an infectious agent and becoming symptomatic. Rabies Virus periods (≥ 20 years), and once symptoms occur, progression to death is rapid. Diagnosis is often made on postmortem brain biopsy Biopsy Removal and pathologic examination of specimens from the living body. Ewing Sarcoma
  • Vitamin B12 deficiency: potential cause of reversible cognitive decline. Low levels of vitamin B12 can be due to a decline in absorption Absorption Absorption involves the uptake of nutrient molecules and their transfer from the lumen of the GI tract across the enterocytes and into the interstitial space, where they can be taken up in the venous or lymphatic circulation. Digestion and Absorption with increasing age, poor diet, alcoholism Alcoholism A primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic. Wernicke Encephalopathy and Korsakoff Syndrome, and pernicious anemia Pernicious anemia A megaloblastic anemia occurring in children but more commonly in later life, characterized by histamine-fast achlorhydria, in which the laboratory and clinical manifestations are based on malabsorption of vitamin B12 due to a failure of the gastric mucosa to secrete adequate and potent intrinsic factor. Megaloblastic Anemia. Clinical manifestations include fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia, psychotic symptoms Psychotic symptoms Brief Psychotic Disorder, and decline in concentration, visual-spatial tasks, and executive functioning. Diagnosis is made via vitamin B12 blood testing and neuropsychological evaluation. Management involves vitamin B12 replacement.

References

  1. Taffet, G. (2021). Normal aging. In Givens, J. (Ed.), UpToDate. Retrieved June 27, 2021, from https://www.uptodate.com/contents/normal-aging
  2. Dugdale, D. (2020). Aging changes in the heart and blood vessels. MedlinePlus. Retrieved March 12, 2021, from https://medlineplus.gov/ency/article/004006.htm
  3. (2019). Alzheimer’s disease and related dementias. CDC. https://www.cdc.gov/aging/dementia/index.html
  4. Besdine, R.W. (2019). Physical changes with aging. MSD Manual Professional Version. Retrieved June 27, 2021, from https://www.msdmanuals.com/professional/geriatrics/approach-to-the-geriatric-patient/physical-changes-with-aging
  5. Flint, B., Tadi, P. (2020). Physiology, aging. StatPearls. Retrieved June 27, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK556106/

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