02/12/2014 20:37:00

Intellectual Disability
(Intellectual Developmental Disorder)
Deficits in intellectual functioning (must be confirmed by clinical
assessment and individualized, standardized intelligence testing)
Deficits in adaptive functioning
Onset during developmental period (before age 18)

Intellectual Disability
Levels of severity
o Mild
50-70
85%
o Moderate
35-49
10%
o Severe
20-34
3-4%
o Profound
below 20 1-2%

Causes
o Chromosomal abnormality: Downs syndrome
o Genetic: Fragile X syndrome, PKU
o Prenatal factors
o Cultural-familial
Education: mainstreaming
Aging: Unique Stressors
Old age: 65 years +
o 35 million (13%) in U.S.
o Fastest growing segment of society

Prone to illness and injury

More likely to experience loss
o Loss of loved ones and friends
o Loss of independence
o Loss of purpose
Stressors may lead to mental illness
o 50% of elderly would benefit from mental health services
Aging associated with various psychopathologies, including
neurocognitive disorders
Neurocognitive Disorders
Functional versus organic distinction
o Functional: psychological causes
Ex: schizophrenia
o Organic: problem with the brain
Cognitive impairment: Disturbance of thinking and/or memory
Represents change - decline in previous functioning
Every cognitive disorder involves altered brain function; some
involve altered brain structure
Some associated with aging, but not all
Neurocognitive Disorders: Causes
Brain trauma - closed or open head injury
o Closed head injury due to athletic (NFL) and soldiers in
Afghanistan that have closed injury
Medical condition e.g., brain tumor, infection, stroke, degenerative
disorder, nutritional deficiency, epilepsy

Medications or Drug Abuse

Toxins
DSM-5 Neurocognitive Disorders: Some changes
Changed name from cognitive disorders to neurocognitive disorders
Updated criteria for delirium
DSM-IV diagnoses of dementia and amnestic disorder are
subsumed under Major Neurocognitive Disorder
New category: Mild Neurocognitive impairment
o Minor impairment but does suggest that there is something
going on need check up
Delirium
Disturbance in attention and awareness
Develops over short period of time, represents change, and tends
to fluctuate over course of day
Additional disturbance in cognition
Not better explained by another neurocognitive disorder and do not
occur in context of severely disturbed level of arousal
Direct consequence of medical condition, substance, toxin, or
multiple etiologies
Note = may be temporary and reversible thus, important
to diagnose cause
Major Neurocognitive Disorder
Cognitive decline in one or more cognitive domains based on
o Concern individual, informant, clinical
I cant remember things like I used to
o Impairment documented by neuropsychological testing or
clinical assessment
Interfere with independence in everyday activities

Deficits dont occur just during delirium

Not better explained by another mental disorder
Neurocognitive domains that may be impaired: DSM-5
Complex attention
Executive function
Learning and memory
Language
Perceptual-motor abilities
Social cognition
Terms to Know
Aphasia deterioration of language function
Apraxia impaired ability to carry out motor activities (intact
sensory, motor, comprehension abilities)
Agnosia failure to recognize or identify objects (intact sensory
function)
Executive functioning think abstractly and plan, initiate,
sequence, monitor, or stop complex behavior
Before 65 early onset (presenile dementia)
After 65 late onset (senile dementia)
Mild Neurocognitive Disorder
Modest cognitive decline in one or more cognitive domains based on

o Concern of mild decline individual, informant, clinical

o Modest impairment documented by neuropsychological
testing or clinical assessment
Deficits do not interfere with capacity for independence in everyday
activities

Deficits dont occur just during delirium

Not better explained by another mental disorder

Neurocognitive Impairment
Multiple causes e.g.,
o Alzheimers *** leading cause of Neurocognitive impartmnt
o Vascular dementia
o Head trauma
o Huntingtons disease
o Parkinsons disease
o HIV
o Substance abuse

Cause has implications for course and prognosis

Alzheimers Disease: Symptoms
Progressive memory loss
Initially:
o small lapses in memory or attention
o word-finding difficulties (paraphasia)
Later:
o Trouble with complex tasks (meal preparation)
o Trouble remembering appointments and names

o New learning impairedanterograde amnesia

Eventually:
o Trouble with simple tasks (getting dressed) (apraxia)
o older life memories forgotten- retrograde
o personality changes
o aphasia, agnosia
Alzheimers Disease: Genetics
Early onset DSM-5 identifies three possible genes as causative =
o amyloid precursor protein (APP) on chromosome 21
o presenilin 1 (PSEN1) on chromosome 14
o presenilin 2 (PSEN2) on chromosome 1
Susceptibility genes slightly increase risk - e.g., ApoE4 gene
(apolipoprotein E4 gene)
Genes affect proteins involved in NFTs and plaques proteins
function abnormally in those with Alzheimers
Alzheimers Disease: Neural Changes
Neurofibrillary Tangles (NFTs)
o Webs of abnormal protein (tau) fibers or filaments inside
neurons
o NFTs disrupt neuronal signaling and eventually kill cell
o NFTs may begin in hippocampus (memory center) and
eventually spread throughout the brain
o Occur in everyone as they age, but abnormal number in
Alzheimers
Alzheimers Disease: Neural Changes
Amyloid (senile or neuritic) plaques

o Neurons secrete sticky protein substance called beta amyloid

-- if cannot be broken down and cleared away, this substance
leads to protein deposits (plaques) between neurons
o Plaques disrupt cell communication and lead to cell death
o Some normal in aging, but abnormal amount of plaques in
Alzheimers
Alzheimers Disease: Biochemical Changes
Levels of acetylcholine (Ach) (neurotransmitters) are low
o Ach important for memory.
o Many Ach neurons located in hippocampus, first to be affected
by NFTs
o People with Alzheimers have very few Ach neurons in areas
important for memory
o NFTs may first kill Ach neurons, leading to low levels of Ach,
leading to memory loss
Alzheimers Disease: Medication Treatments
No cure
Some drugs (donepezil [Aricept], rivastigmine [Exelon]) increase
Ach levels
o Mild improvement in short-term memory and reasoning
o Early stages
o Side-effects
Memantine (Namenda) - advanced Alzheimers Disease
o Affects glutamate, another neurotransmitter involved in
memory
o Modest improvements
Alzheimers Disease: Therapy Treatments
Teach skills for enhancing memory
Cognitive stimulation

Behavioral treatments work with family of patient

o Teach them how to differentially reinforce desirable behaviors
in family member with Alzheimers
o Helps deter unwanted behavior, like wandering
Psychosocial implications of disease
o Help patient and family cope with diagnosis
o Help them make difficult decisions, like revoking driving
privileges, or residential placement
Alzheimers Disease: Prevention
Estrogen???
Nonsteroid anti-inflammatory agents??
Conclusions from study in Sweden2 recommendations:
o Control blood pressure
o Lead active physical and social life
o The Nun Study

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