Undergraduate yr4 lecture notes date: May 2020

2. BSF
AAMI
MCI
Mild NCD
Dementia
Major NCD
Benign senescent forgetfulness (BSF); Age-associated memory impairment (AAMI); Mild cognitive impairment (MCI)
Mainly memory impairment;
Part of “normal” ageing process
Memory ± other cognitive impairment;
Underlying degenerative/pathological process

3. Ability Possible changes due to NORMAL AGEING Possible changes due to DEMENTIA
'Short-term' memory and learning
new information
Sometimes forgetting people's names or appointments, but
remembering them later
Forgetting the names of close friends or family, or forgetting recent
events - for example, visitors you had that day
Occasionally forgetting something you were told Asking for the same information over and over - for example, 'where
are my keys?'
Misplacing things from time to time - for example, your mobile
phone, glasses or the TV remote - but retracing steps to find them
Putting objects in unusual places - for example, putting your house
keys in the bathroom cabinet
Planning, problem-solving and
decision-making
Being a bit slower to react or think things through Getting very confused when planning or thinking things through
Getting less able to juggle multiple tasks, especially when
distracted
Having a lot of difficulty concentrating
Making a bad decision once in a while Frequently poor judgement when dealing with money or when
assessing risks
Occasionally making a mistake when doing family finances Having trouble keeping track of monthly bills
Language
Having a bit of trouble finding the right word sometimes Having frequent problems finding the right word or frequently
referring to objects as 'that thing'
Needing to concentrate harder to keep up with a conversation Having trouble following or joining a conversation
Losing the thread if distracted or many people speaking at once Regularly losing the thread of what someone is saying
Orientation Getting confused about the day or the week but figuring it out later Losing track of the date, season and the passage of time
Going into a room and forgetting why you went there, but
remembering again quite quickly
Getting lost or not knowing where you are in a familiar place
Visual perceptual skills Vision changes related to cataracts or other changes in the eyes,
such as misty or cloudy vision
Problems interpreting visual information. For example, having
difficulty judging distances on stairs, or misinterpreting patterns,
such as a carpet, or reflections
Mood and behaviour Sometimes being weary of work, family and social obligations Becoming withdrawn and losing interest in work, socialising or
hobbies
Sometimes feeling a bit low or anxious Getting unusually sad, anxious, frightened or low in self-confidence
Developing specific ways of doing things and becoming irritable
when a routine is disrupted
Becoming irritable or easily upset at home, at work, with friends or
in places comfortable or familiar places

4. Reversible
dementia
Only 3% of dementias are
completely reversible; 8% are
partially reversible

5. Reversible
dementia
Only 3% of dementias are
completely reversible; 8% are
partially reversible

6. CURRENT MEANING OF PSEUDODEMENTIA: Cognitive impairment
caused by depression, usually in the elderly, that to some extent
mimics other forms of dementia and may be reversible with
treatment

8. • Symptoms
–Self-report
–Observation
• Assessment
– Neuropsychological
– Neuroimaging
– Biomarker, etc.

9. Delirium
• Substance intoxication
delirium
• Substance withdrawal
delirium
• Medication-induced
delirium
• Delirium due to another
medical condition
• Delirium due to multiple
aetiologies
Major or Mild NCD
• Alzheimer’s disease
• Frontotemporal lobar
degeneration
• Lewy body disease
• Vascular disease
• Traumatic brain injury
• Substance/medication use
• HIV infection
• Prion disease
• Parkinson’s disease
• Huntington’s disease
• Another medical condition
• Multiple aetiologies
• Unspecified

10. Diagnostic
criteria
•Disturbed attention and
awareness
•Acutely developed,
changed over baseline, and
fluctuate
•Another cognitive
disturbance
•Not better explained
•Evidence of a direct
physiological consequence
Specify
whether
•Substance intoxication
delirium
•Substance withdrawal
delirium
•Medication-induced
delirium
•Delirium due to another
medical condition
•Delirium due to multiple
aetiologies
Specify if
•acute/persistent
•hypoactive/ hyperactive/
mixed level of activity

11. • Associated features
– Disturbed sleep-wake cycle
– Emotional disturbance
– Sundowning phenomenon
• Prevalence
– Highest among hospitalized elderly
– >80% of people at the end of life.
• Course
– May progress to stupor, coma,
seizures, or death
• Risk factors
– Mild/major NCD
– Psychoactive drugs (CNS depressant,
anticholinergics)
• Diagnostic marker
– Often generalized slowing on EEG
• Differential diagnosis
1. Delirium vs. dementia
2. Delirium superimposed on pre-
existing NCD
3. NCD following a delirium

12. Diagnostic Criteria
• Cognitive decline*
• Independence of
everyday activities**
• Not exclusive during
delirium
• NBE
Specify whether due to
• Alzheimer’s disease
• Frontotemporal lobar
degeneration
• Lewy body disease
• Vascular disease, etc
Specify
• With/without
behavioural
disturbance
• Mild/moderate/severe
* Major = significant; Mild = modest
**Major = interfere; Mild = not interfere

13. Established
neurological
disease
• Parkinson
• Huntington
Insidious onset
& gradual
progression
• Alzheimer
• Frontotemporal
• Lewy bodies
• PD
• HD
Cognitive
domain
•AD: 2 or more
•FTD: social cognition/
executive & language
•NCDLB: fluctuating,
VH, parkinsonism
Cognitive
domain
Complex
attention
Executive
function
Social
cognition
Language
Learning &
memory
Perceptual-
motor

14. Vascular
Evidence of vascular event
Cognitive imp after
vascular event
Complex attention &
executive function.
TBI
Evidence of traumatic
brain injury
Cognitive impairment
present immediately after
TBI
HIV
Documented HIV infection
NBE by other infection or
AMC
Prion
Evidence of prion: motor
features or biomarkers
Insidious onset, rapid
progression

15. Presentation
Sequence in
Dementia

16. Expressive
Receptive

17. COMPLEX ATTENTION
Neurocognitive Domain

18. Concentration / focused attention
• Vigilance tests examine the ability
to focus and sustain attention for
detecting target stimuli
• Usually involves sequential
presentation of stimuli over a
period of time with instruction for
the subject to indicate in some way
• Example
• subjects were asked to respond
to every X that appear
randomly on a screen - Rosvold
(1956)

19. Continuous performance test II
(Connor, 2000)
• A computerized test
• Requires subject to indicate every time a letter other
than X appear
• Measures reaction time & accuracy
• 14 minutes to complete
• Put high demand on inhibition to withhold
responding to infrequent X

20. Digits forward
• Examiner read the numbers aloud at rate of one per
second → subject’s task is to repeat the sequence
• Examiner proceed with the next longer sequence,
continuing until the subject
– Fails a pair of sequences, or
– Repeats the highest sequence correctly
• DF measures efficiency of attention (freedom from
distractibility) rather than memory
• Lower scores in
– Anxiety
– Diffuse brain damage (multiple sclerosis (MS),
post-TBI, dementia)
• 9754
• 3825
• 94318
• 68259
• 913825
• 648371
• 7958432
• 5316842
• 86951372
• 51739826
• 719384261
• 163874952
• 9152438162
• 7154856193

21. Digits backward
• The normal score difference between DF and DB  1.0
• 4 to 5 is within normal limit
• 3 is borderline to impaired (depending on educational background)
• 2 is impaired for everyone
• The task involves mental double-tracking
• memory and the reversing operation
• Impairment seen in
• Left hemisphere damage
• Diffuse brain damage
• Solvent abuse, chronic progressive MS, dementia

22. EXECUTIVE FUNCTION
Neurocognitive Domain

24. Introduction - definitions
• EXECUTIVE PROCESSES
– Processes that modulate (control) the operation of other processes and that are
responsible for the coordination of mental activity so that a particular goal is
achieved
– Meta-process
• FRONTAL EXECUTIVE HYPOTHESIS
– Every executive process is primarily mediated by the PFC (prefrontal cortex)
• FRONTAL LOBE SYNDROMES
– Syndrome resulting from frontal lobe damage and subsequent impairment of
executive functions

25. Executive Processes
1. pay attention to getting the
meal together
2. switch her attention to the
phone call and continue to
switch back and forth
between phone and the
cooking,
3. ignore the baby crying
4. while listening to the phone
plan how to schedule
tomorrow’s activities so as to
include your request
5. and monitor how the cooking
is going.
Executive attention
Switching attention
Response Inhibition
Sequencing
Monitoring
Baby’s crying
Cooking
Telephone
conversation
Scheduling
activities

26. PLANNING
Executive function

27. Mix all ingredients except the
oil for about 2 min or until smooth
Have all the
ingredients
Make three long, thick dough strips and then make them
like a doughnut shape and connect the 2 sides really well
Put the oil in a medium sized pan
on the stove set on med or med high
Keep in for approximately
7 minutes or until gold
Let cool and enjoy!
Sequence operations or events to accomplish a goal
When warm gently
Place in one doughnut
Sequencing [Planning]
How To Make A Doughnut

28. Tower of Hanoi
Frontal Lobe Test
Task: Move all 3 disc to peg 3
Rule: 1) move one disc at a time
2) larger disc cannot be placed on smaller one
3) subjects must solve problem “in their head”
Executive processes involved
1. [selective attention] executive attention
2. [mental flexibility] switching attention
3. Updating working memory
4. Setting a goal and analysis of sub-goals
5. Sequencing of steps
Frontal-lobe patients, particularly patients with damage to the DLPFC,
perform poorly on the Tower of Hanoi problem (Shallice, 1982)

30. DECISION MAKING
Executive function

31. WORKING MEMORY
Executive function

32. The Frontal Lobes And Executive Function
Working Memory
Lateral PFC may provide transient buffer for
sustaining information stored in other cortical
regions. Long-term knowledge is reactivated
and temporarily maintained through the
reciprocal connection between PFC and the
more posterior region of the cortex
A three-part system:
1. Visuo-spatial sketch pad
(visual coding of info)
2. Phonological rehearsal loop
(acoustic coding of info)
3. Central executive system
(executive control: comprehension,
learning, reasoning)

33. The Frontal Lobes And Executive Function
Working Memory

34. FEEDBACK / ERROR
UTILIZATION
Executive function

35. Wisconsin Card-Sorting Test
Task: to sort the card according to color, shape and number using the
feedback given by tester
Measured: categories achieved, trials, errors, and perseverative errors
Working memory, feedback utilization, mental flexibility
number color shape
Frontal Lobe Test

36. OVERRIDING HABITS /
INHIBITION
Executive function

37. Motor Cortex
Superior
Temporal Cortex
Occipital Cortex
Overriding Habits
STROOP TEST
State the color as fast as you can
color
GREEN
word
RED
RED
GREEN
Conflict
Monitor
[cingulate]
Attention
Controller
[DLPFC]
INPUT RESPONSE
DLPFC=dorsolateral prefrontal cortex

38. UtilizationBehavior
The
tendency
to grasp
common
objects
when
presented,
and
perform
the
function
commonly
associated
with the
object.

39. Response Inhibition
Response inhibition is the suppression of a partially
prepared response.
Go/no-go task
Go-No Go - The word "PRESS" is presented on the
screen at regular intervals. The colour of the word
"PRESS" is randomly either red or green. The subject
is required to press a button when they see the word
"PRESS" in green, but not press the button when the
word "PRESS" is in red. Reflects - Capacity for
suppressing well-learned, automatic responses.
PRESSPRESSPRESSPRESSPRESSPRESS

40. PRESS
PRESS
Go trials, when no inhibition is required
Dorsolateral prefrontal [DLPFC] cortex is activated
No-go trials, when response inhibition is required
DLPFC + Orbitofrontal cortex is activated
1) orbitofrontal cortex
2) lateral prefrontal cortex
3) ventromedial cortex
4) limbic system
Response Inhibition

41. Imitation Behavior
• Imitation Behavior refers to a tendency to imitate the
examiner’s gestures or movements.
• For example, the patient might cover his/her mouth, wave, or
clap hands in response to observing the examiner make these
same movements.
• It persists even after the patients are explicitly told not to
imitate or copy, and are provided with negative feedback after
they have copied movements.
Echopraxia (imitating the examiner's gestures) Echolalia (repeating the examiner's words)

42. MENTAL / COGNITIVE
FLEXIBILITY
Executive function

43. Mental/Cognitive Flexibility
Trail Making Test, Part B
1
2
3
4
5
6
7
A
B
C
D
E
F
G
Switching attention between 2 processes: counting 1,2,3,4,5… and A,B,C,D,E…

44. The tendency to repeat the previous response is called perseveration
Perseveration

45. LEARNING & MEMORY
Neurocognitive Domain

46. Understanding Memory
• Type of information to be remembered
• Declarative / Explicit Memory
• Semantic Memory (facts)
• Autobiographical
Memory
• Episodic Memory (events)
• Non-declarative / Implicit Memory
• Procedural Memory
• Classical Conditioning
• Non-associative learning
46

47. • Length of storage
– Sensory Memory
• Iconic Memory
• Echoic Memory
– Working Memory
• Short-term or Immediate Memory
– Phonological & visuo-spatial
– Long-term Memory
• Delayed Memory
• Recent Memory
• Remote Memory

48. Amnesic Syndrome:
Pure form of amnesia without any other cognitive deficiencies

50. Auditory-Verbal Learning Test
• Uses 15-word lists (A, B and C)
• Measures learning and retention
• Immediate word span under
overload (trial I)
• Final acquisition level (trial V)
• Total acquisition (total trial I-V)
• Immediate recall (trial VI)
• Delayed recall (trial VII)
• Recognition
50

51. 51
•Examiner reads a list of
15 words (List A)
•Free recall
•Trial I, II, III, IV, and V
Learning
•Examiner reads a list of
15 words (List A)
•Free recall
Interference
•Immediate free recall
(trial VI)
•Delayed recall (trial VII)
Post-interference
recall
•identify the original
words among 50 words
from A and B lists plus
words that are related
(semantic/ phonetic)
Recognition

52. LANGUAGE
Neurocognitive Domain

53. Nominal aphasia
Visuo-spatial
Visuo-constructional apraxia
Recent memory
Cognitive impairment in Alzheimer’s Disease

54. Verbal Fluency Test
• The verbal fluency test is a short
test of verbal functioning. It
typically consists of two tasks:
category fluency (sometimes called
semantic fluency) and letter
fluency (sometimes called
phonemic fluency).
• In the standard versions of the
tasks, participants are given 1 min
to produce as many unique words
as possible within a semantic
category (category fluency) or
starting with a given letter (letter
fluency).

55. PERCEPTUAL-MOTOR
Neurocognitive Domain

56. Dressing apraxia Ideo-motor apraxia Agnosia Prosopagnosia

57. SOCIAL COGNITION
Neurocognitive domain

58. Theory of Mind (ToM)
• The ability to attribute mental states – beliefs, intents,
desires, pretending, etc. – to oneself and others and to
understand that others have beliefs, desires, and intention
that are different from one’s own
• In the experiment, the child is presented with two dolls,
Sally (who has a basket) and Anne (who has a box). Sally
puts a marble in her basket, and leaves the room. While
Sally is away, Anne takes the marble from the basket, and
hides it in her box. Finally, Sally returns to the room, and
the child is asked three questions:
1. Where will Sally look for her marble? (The “belief”
question)
2. Where is the marble really? (The “reality” question)
3. Where was the marble at the beginning? (The
“memory” question)
https://www.youtube.com/watch?v=0bi0WCLJveM

59. Social Cognition [comportment]
"Comportment" is a term that refers to social behavior, insight, and
"appropriateness" in different social contexts. Normal comportment
involves having insight and the ability to recognize what behavior is
appropriate in a particular social situation and to adapt one's behavior
to the situation.
For example, while it may be perfectly natural and acceptable to take
one's shoes and socks off at home, it is probably not the thing to do
while in a restaurant.

60. Personality
Change: A
Tale of
Phineas
Gage

61. Common causes of frontal lobe syndrome are traumatic
brain injury & frontotemporal lobe dementia
FRONTAL LOBOTOMY
http://www.cerebromente.org.br/n02/historia/lobotomy.htm
Moniz was awarded the 1949 Nobel Prize for Physiology
or Medicine for the development of prefrontal leucotomy
("white matter cutting") as a radical therapy for certain
psychoses, or mental disorders.
The procedure basically involves severing the frontal
lobes from the rest of the brain.
In 1945, Dr Freeman invented the “ice-pick lobotomy”
which requires no more than a few minutes to perform.
This procedure was very popular for a while in the US.
In 1947, a study failed to provide evidence of the positive
effects of lobotomies . At the same time, there were many
reports of severe collateral effects of the surgery on the
personality and emotional life of the patients.
Dr. Egas Moniz
Ice-pick lobotomy

62. Frontal Lobe Syndromes
or Dysexecutive syndromes
• Difficulties initiating behavior
• Perseveration (the inability to stop a behavioral pattern once
started)
• Exaggerated imitative and utilization behavior
• Difficulties in planning and problem solving
• May be incapable of creative thinking
• Difficulties with holding complex structures in mind

63. ORBITOFRONTAL LOBE
SYNDROME
FRONTAL CONVEXITY
SYNDROME
MEDIAL FRONTAL SYNDROME
(Disinhibited) (Apathethic) (Akinetic)
◼ Disinhibited
◼ Impulsive behavior
(pseudopsychopathic)
◼ Inappropriate jocular affect,
euphoria
◼ Emotional lability
◼ Poor judgment and insight
◼ Distractibility
◼ Apathy
◼ Indifference
◼ Psychomotor retardation
◼ Motor perseveration and
impersistence
◼ Stimulus-bound behavior
◼ Motor programming deficits
◼ Poor word list generation
◼ Paucity of spontaneous
movement and gesture =
akinetic
◼ Sparse verbal output
◼ repetition may be
preserved
◼ Lower extremity weakness
and loss of sensation
◼ Incontinence
Frontal Lobe Syndromes
OFC
ACC
Frontal Lobe
▪Motor Cortex
▪Prefrontal Cortex (PFC)
•Orbitofrontal Cortex (OFC)
•Dorsolateral Prefrontal Cortex (DLPFC)
•Anterior Cingulate Cortex (ACC)

64. Behavior in Dementia
Behavior is often disorganized, inappropriate, distractible, and restless.
There are a few sign of initiative. Changes in personality may manifest as
an antisocial behavior, which sometimes include sexual disinhibition or
shoplifting.
Goldstein (1975) describes the ways in which behavior can be affected by
cognitive defects. Typically there is reduction of interests [shrinkage of
milieu] and, rigid and stereotyped routines [organic orderliness] and,
when the person is taxed beyond restricted abilities, a sudden explosion
of anger or other emotion [catastrophic reaction]

65. Frontotemporal Dementia
FTD is associated with Kluver-Bucy syndrome [KBS]. The most common
symptoms of KBS in FTD is hyperorality manifested as bingeing, altered food
preferences especially for sweets, food fads, weight gain or increased smoking

66. Behavioral and Psychological Symptoms of Dementia
Most
distressing
Moderately
distressing Manageable
PSYCHOLOGICAL
Delusions
Hallucinations
Depressed mood
Sleeplessness
Anxiety
BEHAVIORAL
Physical
aggression
Wandering
Restlessness
PSYCHOLOGICAL
Misidentifications
BEHAVIORAL
Agitation
Culturally
inappropriate
behavior and
disinhibition
Pacing
Screaming
BEHAVIORAL
Crying
Cursing
Lack of drive
Repetitive
questioning