Upload
kelly-conley
View
215
Download
0
Tags:
Embed Size (px)
Citation preview
COMMUNITY NETWORKS OF COMMUNITY NETWORKS OF SPECIALIZED CARESPECIALIZED CARE
www.community-networks.cawww.community-networks.ca
https://www.youtube.com/watch?v=UR5X7qwKldo&feature=player_detailpage
YouTube HCF Intro Link:
AGING IN AGING IN DEVELOPMENTAL DEVELOPMENTAL DISABILITIESDISABILITIES
DR.JAY RAODR.JAY RAOM.B.B.,S. ,D.P.M. ,M.R.C.PSYCH(U.K.)., F.R.C.P.(C).M.B.B.,S. ,D.P.M. ,M.R.C.PSYCH(U.K.)., F.R.C.P.(C).
ASSOCIATE PROFESSORASSOCIATE PROFESSOR
UNIVERSITY OF WESTERN ONTARIOUNIVERSITY OF WESTERN ONTARIO
1. LIFE EXPECTANCY WAS LOW IN THE 1920s.
2. For Down’s, it was in the early 20s.
3. A large number were in institutions.
4. Cause of death was usually Bronchopneumonia.
5. TODAY, LIFE EXPECTANCY IS AROUND
67 YEARS OF AGE.
General population
there are declines in speed of processing, working memory, inhibitory functions, long term memory, decreases in brain structure
and white matter integrity (Parks, Reuter-Lorenz)
Medical morbidity, health and nutritional risks increase
Psycho-social problems
gather force
Developmentally Disabled
There may be pre-existing cognitive problems
Pre-existing Health and nutrition problems
Pre-existing psycho-social problems
Neuro-medical vulnerabilities
Neuro-developmental issues
Ex: Scaffolding
Neuro-Executive Issues
Developmentally Disabled at higher risk for these
DD at disadvantage due to developmental immaturity of brain architecture
Pre-existing executive brain dysfunction
In the younger brain: specialization of circuitry Ex: Remembering, working memory tasks, Novel
tasks In response to challenges, initially, a wider set of
neural circuits are recruited. These are Scaffolds
As the task is over-learned, a specific, honed circuit is developed.
This provides the ability for efficient cognitive operations
Scaffolds are invoked even to perform familiar tasks and basic cognitive processes
Ex: (working memory tasks):
Young focal, left Para-hippocampal activation
Old Wider Right and left pre-frontal
brain activation
Scaffolds (wider net works) are recruited
even for low levels of task demand (remembering where one put the car keys)
Generating scaffolds and recruiting them is even more inefficient
because of aging pathology
Scaffolding, even in younger ages is inefficient
There is impaired ability to recruit Pre-frontal networks, especially
bilaterally
In older ages neurobiological decline is rapid or more profound in its impact resulting in poor scaffolding capacity
Whatever scaffolding there is , is penetrated by neural pathology leading to collapse of the scaffolds
(Parks, Reuter-Lorenz; Burke and Barnes;)
Neural Connections in Autism
Frontal and Temporal development is stunted at an early stage leading to lack of differentiation
This lack of differentiation leads to hyper-connectivity
Blocks coherence development with other critical brain regions
Connectivity problemsHYPO-connectivity
Orbito-frontalMixed sensory-motorOccipital/Parietal-
TemporalFrontal-posteriorLeft Intra-
hemisphere
HYPER-connectivity
Frontal-temporal
Left Hemisphere intra-hemispheric
EXECUTIVE FUNCTIONSEXECUTIVE FUNCTIONS
Executive FunctionsExecutive FunctionsInhibit
Shift
Emotional Control
Monitor
Working Memory
Plan/ organize
Organization of Materials
Task Completion
Orbitofrontal:Orbitofrontal:
DisinhibitionDisinhibition LabilityLability IrritabilityIrritability ImpulsivityImpulsivity Sexual preoccupationSexual preoccupation DistractabilityDistractability
– May go unrecognizedMay go unrecognized
Lobes of the BrainLobes of the Brain
Ventromedial PC:Ventromedial PC:
Decreased verbal outputDecreased verbal output Diminished motor initiationDiminished motor initiation WithdrawalWithdrawal apathyapathy
Lobes of the BrainLobes of the Brain
Dorsomedial PC:Dorsomedial PC:
ApathyApathy AkineticmutismAkineticmutism incontinenceincontinence
Lobes of the BrainLobes of the Brain
Dorsolateral PC:Dorsolateral PC:
Working memoryWorking memory SpatialSpatial Object-facesObject-faces VerbalVerbal
Executive functionsExecutive functions Language sequencingLanguage sequencing
Caudate-putomen-orbitofrontal:Caudate-putomen-orbitofrontal:
OCDOCD Response bias toward stimuli related to Response bias toward stimuli related to
socioterritorial concerns about danger, violence, socioterritorial concerns about danger, violence, hygiene, order, sex mediated by orbitofrontal-hygiene, order, sex mediated by orbitofrontal-subcortical circuitssubcortical circuits
Inadequate repression (filtering) in caudate of Inadequate repression (filtering) in caudate of input from the orbital cortex (worry)input from the orbital cortex (worry)
Cortex – (caudate) – globus pallidus Cortex – (caudate) – globus pallidus
Thalamus takes over
Frontal lobe:Frontal lobe:
Dysfunction results in:Dysfunction results in:
DisinhibitionDisinhibition Emotional labilityEmotional lability IrritabilityIrritability Lack of drive, motivationLack of drive, motivation Deficits in memoryDeficits in memory Attentional deficitsAttentional deficits Apathy – akinesia – AbuliaApathy – akinesia – Abulia AphasiaAphasia
Temporal lobe:Temporal lobe:
Dominant:Dominant: EuphoriaEuphoria Auditory hallucinations, illusionsAuditory hallucinations, illusions Thought disorderThought disorder Anterograde amnesiaAnterograde amnesia Receptive language deficitsReceptive language deficits Memory impairmentMemory impairment
Non-dominant:Non-dominant: DysphoriaDysphoria Disinhibition of sexual and aggressive behavioursDisinhibition of sexual and aggressive behaviours Cognitive difficultiesCognitive difficulties
Parietal:Parietal:
Dominant:Dominant: Alexia, agraphia, acalculiaAlexia, agraphia, acalculia Agnosis, left-right disorientationAgnosis, left-right disorientation
Non-dominant:Non-dominant: Impaired spatial abilityImpaired spatial ability AnosognosiaAnosognosia AutopagnosiaAutopagnosia Apraxia, etc.Apraxia, etc.
Occipital:Occipital:
Disturbed spatial orientation Disturbed spatial orientation (metamorphopsia)(metamorphopsia)
Visual illusionsVisual illusions
Visual hallucinations, etc.Visual hallucinations, etc.
1. Predilection to early Alzheimer’s
2. However, many questions still not satisfactorily answered.
A) there has been no methodologically satisfactory population based study of Down’s
B) No Neuro-pathological confirmation on a large enough sample.
Therefore calculation of the size of the problem skewed.
Brains of Down’s adults shows Alzheimer’s like organization.
In most of these, there is no clinical evidence of cognitive decline.
Other conditions mimic Dementia (Depression)No comparison of similar IQ bearing syndromal
groups with Down’s.
However, the Incidence and Prevalence of Dementia may be higher in Down’s.
But we have no population based data on Incidence and prevalence in other Developmentally disabled for specific comparison.
Alzheimer’s-like brain pathology alone does not indicate Alzheimer’s in Down’s.
Down’s, even in their 20s may have such brain configuration without actually manifesting any clinical decline.
Depression as Dementia38 yr. old female, admitted with two months
history of poor memory, disinhibition, emotional dyscontrol, incontinence of urine and bowels.
Worked as a cashier in a store for 12 years previously ( job shadowing)
All investigations normal.Mental status exam unproductive
DEMENTIA AS DEPRESSION:67 year old man in a group home, previously
well functioning, gradually became more withdrawn, irritable, forgetful, paranoid, impulsive.
Did not enjoy activities, became very quiet.Treated with anti-psychotics, anti-depressants.Became more irritable, rages, ParkinsonianNeuro psychological assessment revealed
serious deficits.MRI indicated degenerative changes
As in the general population, aging brings the following problems:
PHYSICAL PROBLEMS
1. Cardiovascular disease
2. Musculo-skeletal disease
3. Gastro-intestinal problems
4. Sensory problems
( HIGHER INCIDENCE AS ONE GETS OLDER)
1. Depression
2. Anxiety disorders
3. Mood disorders
4. Psychosis
Slower ability to process informationMemory problemsAttention DifficultiesExecutive function deficits (impulsivity, poor problem
solving ability, difficulty in shifting, mood dysregulation)Communicational difficulties
Developmentally disabled may already have:
1. Epilepsy
2. Brain tumors (Tuberous sclerosis)
3. Immature, miswired cortex.
4. Eye (cataracts) and hearing problems
5. Poor articulation, expressive and Receptive language problems
7. Thyroid problems (ex: Down’s)
8. Cardiac defects (ex: Down’s, VCF, Tuberous Sclerosis)
9. GI malformations/ Swallowing difficulties
10. Kidney problems (tuberous sclerosis)
11. Skeletal Deformities
12. Lung/Immune deficiencies
13 Anxiety disorders.14 Mood instability15 Executive function deficits16 Memory and Attention difficulties
Given such pre-existing conditions, the developmentally disabled are more likely to decline faster, with aging.
Often, these are not known because of inadequate health evaluation.
MORE LOSSES AND INCONSISTENCIES WHILE IN CARE
POORER ACCESS TO MEDICAL FACILITIESFINANCIAL HARDSHIPSPOORER NUTRITIONLESS ACCESS TO RECREATION AND
APPROPRIATE JOB/ OCCUPATIONAL INVOLVEMENT
EVALUATIONEVALUATION
MULTIFACTOR EVALUATION is essentialMULTIFACTOR EVALUATION is essential Careful researching of past medical history and family Careful researching of past medical history and family
history.history. Multidisciplinary involvementMultidisciplinary involvement Use of structured inventories/rating scalesUse of structured inventories/rating scales
BUT REMEMBER: BUT REMEMBER:
THESE SCALES ARE NOT DIAGNOSTIC THESE SCALES ARE NOT DIAGNOSTIC INSTRUMENTS but tools to enable managementINSTRUMENTS but tools to enable management
INVESTIGTIONSINVESTIGTIONS
CT, EEG,MRI,ULTRA SOUND,X-RAYCT, EEG,MRI,ULTRA SOUND,X-RAY BLOOD WORK – THE USUALBLOOD WORK – THE USUAL Neuro-cognitive assessmentsNeuro-cognitive assessments Skills assessments (OT)Skills assessments (OT)
TreatmentTreatment
Assessment is the cornerstoneAssessment is the cornerstone
Treat physical as well as psychiatric issuesTreat physical as well as psychiatric issues
Dementia forms a small proportion of the Dementia forms a small proportion of the problems in this populationproblems in this population
Physical decline, cognitive difficulties, isolation, Physical decline, cognitive difficulties, isolation, loneliness, losses, poor nutrition,loneliness, losses, poor nutrition, neglected neglected health issues, mood instability are more health issues, mood instability are more pressing problems in this populationpressing problems in this population
Aging is a more challenging problem than Aging is a more challenging problem than dementia dementia
This is true in the developmentally This is true in the developmentally disabled because of the neuro-bio-disabled because of the neuro-bio-psycho-social decline.psycho-social decline.
As more of the developmentally As more of the developmentally disabled get older, we may need to disabled get older, we may need to develop strategies for support ,and develop strategies for support ,and anticipate the resource implicationsanticipate the resource implications