Alzheimer’s disease (AD) presents one of the most urgent health care issues of our time. AD is a disease of the brain and mind, and as such, neuropsychology has an essential and evolving role to play in addressing this growing public health concern. Measurement of key cognitive functions, such as delayed recall of recently presented information, is crucial in the diagnosis and monitoring of the disease. In addition to the importance of advancing scientifically informed disease-specific measurement of cognition, neuropsychology has a growing role to play in the design and implementation of nonpharmacological interventions for AD. The neuropathological hallmarks of AD are senile plaques (SP), neurofibrillary tangles (NFTs), and cell and synapse loss in multiple brain areas. Granulovacuolar degeneration (GVD) has long been recognized to be present in the brains of AD patients.
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- Go to chapter: Barriers and Applications of Medication Therapy Management in the Homeless Population
Medication therapy management (MTM) remains a challenging endeavor to optimally implement in the homeless population. Working in various settings in collaboration with other health professionals, pharmacists are spearheading patient-centered efforts to optimize MTM and assist the homeless with attaining health insurance and continuity of care. In the case of MTM, homeless persons may face significant hardship in not only procuring and using effective drug therapy, but also in following-up with their providers and establishing provider–patient relationships that will help them to meet their target therapeutic goals. This chapter enumerates a review of the more common barriers to MTM in the homeless population, followed by a number of practical applications of MTM in optimizing the health of the homeless. In order to appreciate the value and role that stable MTM can offer the homeless, the chapter briefly discusses perspectives on homeless health and the concept of MTM.
Cardiovascular disease (CVD) remains the leading cause of death in older homeless people. Traditional CV risk factors, such as hypertension, diabetes, smoking, and hyperlipidemia, and nontraditional CV risk factors, such as substance abuse, psychological stress, and lack of diagnostic and preventative medical care, contribute to CVD in this population. Barriers to CV prevention and treatment in homeless individuals include their environment, lack of access to care, substance dependence, mental illness, food insecurity, and medication non-adherence. Healthcare models that provide Housing First and just-in-time care by non-judgmental multidisciplinary teams have been shown to improve the CV health of people who are homeless. CV health requires prevention, as well as prompt intervention, and close follow-up. CV healthcare practice adaptations for homeless clients include ascertaining living conditions, improvising the physical exam, scheduling longer clinic appointments with frequent follow-up, prioritization of the plan of care, and simplification of the medication regimen.
The population of geriatric homeless individuals diagnosed with serious mental illness is a largely underrepresented subpopulation in the research literature despite the notion that this population is one of the most vulnerable to negative outcomes due to physical, mental, and psychosocial factors. This chapter briefly summarizes the separate impact of each of these three factors: being homeless, being in the geriatric population, and being diagnosed with a serious mental illness (SMI). In addition, the chapter illustrates how these three factors combined impact overall subjective quality of life and poor outcomes for mental health through the use of a case vignette of a homeless, geriatric individual with a severe mental illness. It also provides case example illustrating that high comorbid substance abuse along with an SMI (i.e., dual diagnosis) associated with complex medical conditions create seemingly insurmountable challenges for the interdisciplinary care team.
Old age brings with it unique challenges in diagnosis, treatment, and care; dementia complicates these issues even more. Improving the management and care of persons with dementia has positive implications for patients, caregivers, and physicians alike. Two types of secondary complications can be analyzed in relation to dementia: conditions that arise outside of the dementia and then conditions that appear to develop due to the neurological degeneration inherent in dementia. Examples of psychiatric complications include depression, anxiety, and psychosis. Medical problems consist of issues such as stroke, cardiovascular problems, cancer, infections, orthopedic issues, diabetes, nutritional disorders, vision and hearing problems, as well as general pain. The high comorbidity of dementias with other psychiatric and medical issues can complicate the diagnosis and treatment of patients with dementia. Issues in the central nervous system (CNS) have long been looked at as possible predictors of dementia.
Geriatric homelessness (GH) is a significant and growing social, political, economic, and humanistic issue throughout the United States. This chapter presents case studies that will highlight the GH in four urban areas and among veterans. It defines geriatric homelessness, outlines its general dimensions, explicates its two primary etiologies (loss of employment and the lack of affordable housing in the areas where most homeless persons are located), and gives examples of the diversity of the problem and attempts at solutions in four cities and among veterans. The case examples show that the solution to the medical and psychological issues in the GHP involves much more than traditional medical practices and therapies. The solutions, involving among others politics, economics, and housing, are those of communities and localities acting to positively affect the lives of individuals and families of all ages, particularly the growing population of GHPs in the United States.
Delirium, also known as acute confusional state, organic brain syndrome, brain failure, and encephalopathy, is a common occurrence among medical and surgical patients and causes extensive morbidity and mortality. This chapter provides an updated review of delirium, including pathophysiological correlates, clinical features, diagnostic considerations, and contemporary treatment options. The defining features of delirium include an acute change in mental status characterized by altered consciousness, cognition, and fluctuations. The chapter explores the risk factors for delirium. These can be divided into two categories: predisposing factors and precipitating factors. Imbalances in the synthesis, release, and degradation in gamma-aminobutyric acid (GABA), glutamate, acetylcholine, and the monoamines have also been hypothesized to have roles in delirium. GABA is the primary inhibitory neurotransmitter in the central nervous system (CNS) and medications such as benzodiazepines and propofol have known actions at GABA receptors and have been associated with delirium.
Dementia pugilistica (DP) is a form of chronic traumatic encephalopathy (CTE) that involves gross impairment of cognitive and motor functioning due to repetitive blows to the head from boxing. Rapidly increasing in popularity among fight fans and fighters is mixed martial arts (MMA). In the area of sport-related concussion, there are two other frequently used terms that are necessary to distinguish from DP and CTE: postconcussion syndrome (PCS) and second impact syndrome (SIS). The classical clinical signs and symptoms of DP include combinations of dysarthria, incoordination, gait disturbance, pyramidal and extrapyramidal dysfunction, and cognitive impairment. Some media reports about concussion and the potential link between repetitive concussions and long-term problems include eye-catching and emotionally provocative titles. This chapter has provided an overview of the many complex issues surrounding the effects of repeat concussive trauma, particularly in sports.
Dementia with Lewy bodies (DLB) is a clinical syndrome characterized by progressive dementia, cognitive fluctuations, visual hallucinations (VH), and parkinsonism. In 1961, Okazaki, Lipkin, and Aronson reported two patients with dementia and parkinsonism with cortical neuronal inclusions similar to the brain-stem Lewy bodies (LB) seen in Parkinson’s disease (PD). LBs are intra-cytoplasmic neuronal inclusions containing α-synuclein and ubiquitin. There are other associated pathological features in DLB such as spongiform change neuronal loss, and Alzheimer’s disease (AD) pathology includes amyloid plaques and neurofibrillary tangles (NFTs). DLB and other entities such as PD and multiple system atrophy (MSA) have been grouped under the term synucleinopathies due to the existence of α-synuclein inclusions in the brain. The central feature required for a diagnosis of DLB is the presence of dementia: a progressive cognitive decline of sufficient magnitude to interfere with normal social or occupational function.
Depression is common in older adults and associated with poor medical and mental health outcomes, including increased risk for suicide. Homeless older adults are at increased risk for developing depression. The clinical presentation of depression in older adults and younger adults often differs. Having an appreciation for these differences allows clinicians to better diagnose and treat this vulnerable population. This chapter provides case example highlighting the common themes of the presentation, diagnosis, and treatment of depression in the homeless older adult population. Research and advocacy are warranted to ensure that older homeless individuals with a major depressive disorder receive optimal assessment and treatment of their depression. The chapter discusses barriers to adequate detection and treatment of depression in older homeless adults, as well as assessment and treatment strategies. It covers identification and treatment of grief. The chapter reviews promising directions for future strategies to decrease depression among older homeless adults.