Friday, 5 May 2017

Public Lecture: Neuropsychology of Dementia by Dr Luke Smith


Today, I went to Swinburne University, Hawthorn campus to attend a public lecture on the neuropsychology of dementia, mainly because I got interested in ageing, mental health in older adults and diseases that are common in older adults from my psychopathology lecture on cerebral disorders this week. It was my first time visiting Swinburne University, so it was definitely a good thing that I arrived at the uni 15 minutes early to locate the venue of the lecture.

So, this is just a brief overview of what topics were covered in the public lecture. It is by no means complete with all the notes in the slides, but it will be a summary of the main points that I manage to jot down during the lecture.

This public lecture is part of a series of seminars on ageing which runs every year for more than 6 years already. So basically, this lecture is the continuation of previous lectures on related topics in ageing. Dr Luke Smith is a Clinical Neuropsychologist and he conducts neuropsychological testing with older adults who were often brought in by their concerned family members to examine if the individual has illnesses that can cause dementia.
1. Cognitive Domains
Dr Smith started the lecture by talking about the cognitive domains that are tested in a neuropsychological assessment for dementia. They are information processing (a fancy scientific work for how fast you can think), attention and concentration (divided into attention span, sustained attention and attention to detail), working memory (ability to hold information and manipulate them simultaneously), visuo-perceptual processing (how a person construct, integrate and organisation visual information), and finally language (which includes semantic processing [word finding], verbal fluency [naming as many words as possible starting with the letter F] and repeating sentences. When a neuropsychologist assess an individual, he will usually use "thinking and learning" instead of cognition to describe what tests he will be administering to the patient. This is because not many people understand what cognition means, therefore using phrases that people can understand will be essential for effective communication. Testing will also require 3-4 hours, including approximately 1 hour of history taking, which comprises interview with the client's family and friends, asking about premorbid functioning, social, occupational, educational history and so on.

-Learning and Memory
A special mention on learning and memory here is because the general public (or us) often think that memory problem is the early sign of dementia, however Dr Smith explained that this is not the case. Learning is usually the aspect that becomes impacted first. It starts with learning problem, where the person is not able to take in much information from his/her surroundings, and also may never encode the information. Hence, the memory problems that are observed by caregivers are because the information was never learned / encoded in the first place.

Other aspects that are assessed are free-recall memory (ability to recall something without prompts), and recognition memory (ability to recognise if a word was on a list or not).

-Executive Functioning
I remember learning this in my capstone subject at my university, although I still don't really know what executive functioning means. So, Dr Smith describes executive functioning as top-down processing. It involves ability to generate ideas, divide attention, inhibit attention, reason and problem solve, planning and organising, and finally having insight.

Often, individuals presenting with symptoms and signs of dementia are refered by carers or other people as being in denial. However, there is a crucial difference between being in denial versus having no insight. When one has no insight, there is no awareness of the problem to begin with, whereas being in denial is when the individual knows that there is a problem, but does not want to acknowledge it or is actively ignoring it.

2. Behavioural Changes
Secondly, a neuropsychologist assesses a client's behavioural changes by interviewing family and friends of this individual. A clinician / diagnostician needs to be mindful of the possibility of an observed behaviour to be just eccentricities of the individual which may be present for all of the client's life. The behaviour of interest has to be a change from a person's pre-morbid presentation. Examples of these include: being disinhibited and impulsive, irritable, agitated, aggressive, being rigid and inflexible, being repetitive (i.e., repeating same things over and over), being hyper-oral (i.e., having a sweet tooth), and apathy (i.e., not caring about things they used to care about or anything at all).

3. Social Cognition
Third aspect that is assessed in a client to determine if the client may have dementia is social cognition. Social cognition is our ability to judge and interpret others' emotions. This ability is crucial for us to understand what others are feeling. It allows us the capacity to empathise and is essential for communication. Generally, we have more difficulty judging negative emotions such as disgust and confusion compared to positive emotions such happiness and excitement. The participants of this lecture (me included) completed an activity on social cognition, where we had to identify another person's emotions based on what they express on their faces. In dementia presentation, the individual will generally have difficulty expressing emotions, and the way they express emotions may changes as well. This is called affective expression. They may also have difficulty judging the emotional tone of another person's voice. As a participant brought up the issue of the appropriate action when the client being in a culturally and linguistically diverse (CALD) background compared to an Australian born and raised clinician, Dr Smith explained that he usually cuts out all forms of sarcasm and tones, and just being very formal and neutral when conducting the assessment. This cuts down the chance that the client misinterpreting what was said.

4. Disease Syndromes
Fourth aspect which will be examined in a neuropsychological assessment is which of the syndromes does the client's presentation fit in, Alzheimer's disease, Dementia with Lewy Bodies, Vascular Dementia, Frontal-Temporal Dementia, or others.

For Alzheimer's Disease (AD), a common form of neuropsychological disorder in older adults, patients often present with naming (word finding) difficulties, visuo-construction problems (unable to copy a drawing of a house), and rapid forgetting where prompting no longer helps. Interestingly, in initial stages of AD, patients often do not present much executive and behavioural changes. A neuropsychologist can also administer a test called Block-Design test where the patient is required to recreate a design using colour blocks as shown.

Vascular dementia was also discussed. But unfortunately I didn't jot a lot of information down. I did include a link so that you can have a read if you like.

Next was dementia with Lewy bodies. This forms of dementia have presentation including visuo-perceptual problems, hallucinations (often nocturnal, meaning at night time), problems with executive functioning, attention problems, and REM sleep behaviour disorder (which means patients act out their dreams). A point was also highlighted about the importance for clinicians to be able to constant differentiate the presentation of the client and ruling out what may not likely be the diagnosis.

Furthermore, we have frontal-temporal dementia. This is when the person can show language changes (i.e., repeating sentences), and carers may report the patient has sexual disinhibition (i.e., cheating on their spouse when they never would have before developing dementia).

Dr Smith also highlighted the relationship between movement disorders such as Parkinson's Disorder, Huntington's Disease and Motor-Neurone Disorder with progression towards development of dementia. In particular, almost 100% of people with Huntington's disease will develop dementia later in life.

5. Decision Making Capacity
Decision making involves ability to do four things: Understand, retain, communicate and weigh up information. The assessment of this capacity will involve corroborating information from the patient's family and friends, followed by a structured capacity interview and finally a comprehensive cognitive and behavioural assessment. The point is to assess if the patient has the cognitive capacity to make well-reasoned decisions in their daily life.

6. Behaviour management
Contrary to what we usually think is the main problem with dementia, such as memory, it is in fact behaviours of the patient that cause most distress to his/her family and friends, and also health professionals. Behavioural management is now considered first-line therapy for patients diagnosed with dementia. It is based on models of behavioural change and includes evidence-based strategies. Anyone can learn methods of managing behaviour of patients with dementia. Connecting with the person's long-term memories is also important to build rapport with the individual, as the person's short-term memory is often impaired.

Finally, although at present there is no cure for dementia, getting an individual to seek help from a multidisciplinary team, involving geriatric specialists, neuropsychologist, dietician, speech pathologist, occupational therapist, nurse and social worker is likely to help the individual in the most comprehensive way possible.

I hope you enjoyed my summary. Please share with others who you think this information might be helpful for.