managing cognitive and emotional changes associated with nph
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Managing cognitive and emotional changes associated with NPH. Jeannine Morrone -Strupinsky, Ph.D., ABPP-CN October 30, 2012. Plan of talk. Review cognitive changes associated with NPH Offer suggestions for managing cognitive changes Review mood/behavioral changes associated with NPH - PowerPoint PPT PresentationTRANSCRIPT
Managing cognitive and emotional changes associated
with NPH
Jeannine Morrone-Strupinsky, Ph.D., ABPP-CNOctober 30, 2012
Plan of talk Review cognitive changes associated with NPH Offer suggestions for managing cognitive
changes Review mood/behavioral changes associated
with NPH Offer suggestions for managing mood/behavioral
changes Q & A
NPH—A Brief Review
First described in 1965.
Abnormal buildup of CSF in the ventricles with high normal CSF pressure.
Enlargement of the ventricles causes stretching of surrounding brain tissue (neurons) and blood vessels, particularly in the frontal lobes.
How NPH looks in the brain
CT head scan of a patient with normal pressure hydrocephalus showing dilated ventricles. The arrow points to arounded frontal horn.
T2-weighted MRI showing dilatation of ventricles out of proportion to sulcal atrophy in a patient with normal pressure hydrocephalus.
Normal MRI
www.emedicinehealth.com
NPH—A Brief Review
Can occur in people of any age, but is most common in older adults (60s and 70s).
Secondary NPH is the result of brain injury/insult (e.g., trauma, infection, tumor).
“Idiopathic” NPH is due to unknown causes. NPH may account for up to 5% of individuals
with dementia.
Clinical triad
Incontinence Inability to hold urine Frequent urination Urgency to urinate
Gait disturbance Unsteadiness Wide-based gait Leg weakness Sudden falls Shuffling steps Difficulty taking first step because feet are “stuck” to the floor “freezing” while walking
Cognitive impairment (next slide)
Cognitive Effects of NPH
Slowing down of thoughtsMemory impairment—decline in active
retrieval (immediate and delayed recall) with preserved memory storage (recognition)
Visuospatial perception and visuoconstruction may be impaired
Absence of aphasia, apraxia, and agnosia (“cortical features” seen in AD)
Impairment in executive functions
Cognitive Effects of NPHExecutive functions (“CEO” of the brain)
Planning (and prioritizing) Thinking in a flexible manner (adjusting to
changing situations, coming up with new solutions)
Concentration/working memory (i.e., dialing new phone numbers)
Abstract thinking (learning from experience by extracting broader meaning of events)
Managing time Initiating appropriate actions and inhibiting
inappropriate actions (impulsivity)Selecting relevant sensory information
(focusing attention on what is relevant; i.e., being able to filter out background noise)
Cognitive Effects of NPH
Regarding memory, individuals with NPH display impaired free recall of information but tend to benefit from cues and show relatively spared recognition. This has led some to propose that the mechanism of memory failures may be retrieval search while the storage capacity is preserved.
Memory retrieval is performed by the frontal lobes (affected by bulging ventricles).
Effects of shunting on cognitive impairment
NPH is described as a reversible form of dementia.
However, statistics vary considerably regarding cognitive improvement (30-40% in INPH and 50-70% in secondary NPH).
Memory tends to improve more than executive functions.
More improvement is seen in younger individuals and in women, and in those without other causes of impairment.
Gait impairment and urinary incontinenceare more likely to improve.
5 reasons why a neuropsychological examination is requested by a physician
¨ To find possible problems with brain functioning.
¨ To help clarify a patient’s diagnosis.¨ To define an individual’s relative brain-related
strengths and weaknesses.¨ To guide treatment, or to help patients make
educational or vocational decisions.¨ To determine whether or not there are any
changes in a patient’s cognitive and emotional functions over time.
National Academy of Neuropsychology
Role of the neuropsychologist¨ A neuropsychological examination is a
systematic and scientifically-based assessment of a person’s thinking, problem-solving, and memory capacity that may reveal something about the state of brain function.
¨ The pattern of test findings allows the examining clinician to develop an informed opinion about the patient’s higher cerebral functioning.
¨ Ultimately, the physician must integrate results from a variety of tests to determine the diagnosis.
Compensating for cognitive difficulties in NPH
If the person with NPH has difficulty shifting tasks quicklygive adequate notice that he or she needs to get
ready to go somewherepost an agenda for the day
If the person with NPH has difficulty focusing reduce background distractionsperform only one activity at a time, and try to
complete the activity before starting another activity
take frequent breaks to allow the individual to regroup
Compensations for cognitive difficulties in NPH
If the person with NPH has difficulty sequencinguse procedural checklists (i.e. to program TiVo, cook
meals, follow a grooming routine)
If the person with NPH has difficulty making decisions limit choices/provide optionsuse concrete examplesbreak down large projects into component parts
Compensating for cognitive difficulties in NPH
If the person with NPH has difficulty recalling information use a memory notebook, day planner, or voice recorder use placards use a beeping watch/timer to remember to do something (i.e., turn off
hose in the yard) use a pill box use forms to remember to do things that occur periodically (i.e., change
air filters) provide cues to aid memory use organizing strategies (grouping) face-name recall technique
Face-name recall technique
Focus on the name. Repeat it to yourself several times. Associate the name with something already stored in
your memory. If you know someone with the same name, that will be the
association. Visualize an image of the new person with the person you already know who has the same name.
If the person has a name that you do not know, create an association by breaking down the name into words to which you form visual images.
Visualize the person with the visual images you have created. Drawing a picture with the association or making up a short story about the images helps even more.
Example…associations
Maggie Bobrowitz, RN, MBANeuroscience Program Coordinator
Famous Margarets…
Bob………………..row…..itz
Ann-MargretMargaret Thatcher
Grouping example
Read the following list of sports one time. When you are done, write down as many of the sports as you can without looking back at the list.
snow skiing basketball tennislong jump bobsledding 100-m dashhockey baseball ice skatingdiscus golf high jumpvolleyball javelin soccerluge curling cricketdecathlon hurdles
www.utexas.edu/student/utlc/class/mkg_grd/improving.html
Grouping example
You can organize material by grouping similar concepts, or related ideas together.
For exampleWinter sportsTrack and field sportsSports using a ball Individual sportsTeam sports
www.utexas.edu/student/utlc/class/mkg_grd/improving.html
Another grouping example…
NPH and mood changes Depression is present in some individuals with NPH.
Average prevalence of major depressive disorder in the elderly population is 1.8%.
DSM-IV criteria for depression (>5 of the following):depressed mooddecreased interest (apathy*) or pleasure in activities
(anhedonia)significant weight loss* insomnia* or excessive sleep*psychomotor retardation or agitation loss of energy (anergia)* feelings of inappropriate guilt recurrent thoughts of death
Differentiating depression from apathy
Sometimes it looks like the individual with NPH is depressed, but rather s/he is apathetic or is unconcerned or unaware of his or her condition.
Apathy is defined as a primary loss of motivation, loss of interest, and loss of effortful behavior, features also present in depressed individuals.
This is likely due to disruption of medial frontal lobe functioning due to bulging of the ventricles into the brain tissue.
Treatment of depression in NPH Treatment of depression in NPH is important because
depression has a negative influence on cognitive performance, activities of daily living, and perceived quality of life.
In the case of mild depression, options include behavioral activation and/or supportive psychotherapy.
A clinical psychologist or social worker can be helpful in this adjustment period, particularly in helping identify life stressors that may be contributing to the depression.
Psychotherapy also helps the individual with NPH accept the diagnosis, employ coping strategies, and work through the emotional consequences of having to deal with the diagnosis.
Treatment of depression in NPH, cont’d
A long-term plan must then be structured to minimize stress and improve quality of life. Patients should be encouraged to develop a daily exercise routine within their capabilities.
In case of more significant depression, pharmacological treatment is warranted (antidepressant medication).
Keenan et al. (2005) demonstrated a reduction in reported symptoms of apathy following a dose of methylphenidate, which increases the action of dopamine, a chemical in the brain.
NPH and sleep disturbance
Individuals with NPH may experience sleep disturbance. This can be due to changes in mood or in the functioning of brain regions associated with sleep.
Practicing sleep hygiene can improve sleep.Go to bed the same time every night.Keep bedroom cool, dark, and quiet.Use the bedroom only for sleep and intimacy.Get up and do something sedentary if you are
unable to fall asleep.
“Pseudodementia” in NPH A common referral question is the differentiation
of cognitive dysfunction caused by NPH from a “pseudodementia” attributable to depression.
Patients with NPH and depression show worse cognitive performance when compared with patients without depression, particularly on tests of executive functioning.
Depression and even mild cognitive impairment contribute significantly to disability inpatients with NPH.
Salvador Dalí. (Spanish, 1904-1989). The Persistence of Memory. 1931.