COMMUNITY NETWORKS OF COMMUNITY NETWORKS OF SPECIALIZED CARESPECIALIZED CARE

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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