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Topic: Alzheimer's disease
Type of work: Abstract
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Alzheimer's disease
The changed demographic situation, accompanied by the "aging" of the population, has put dementia of late age among the most urgent problems of modern psychiatry, which is associated with their steadily increasing frequency and the special severity of the medical and social consequences caused by them.
Alzheimer's disease occupies a relatively small place in the structure of gerontological psychiatric morbidity, but due to the deep breakdown of mental activity and severe disability, patients suffering from it at one or another stage of the course of the disease inevitably end up in psychiatric hospitals or specialized boarding schools for the mentally ill.
Although modern medicine does not yet have the means to cure this mental illness, the use of therapeutic and rehabilitative measures at the early stages of the disease (along with various forms of medical and social assistance to the patient's family) allows the patient to stay in his usual social environment for as long as possible and reduce the period of stay in inpatient psychiatric institutions.
At the same time, as the analysis of scientific publications on this problem and the results of our own research shows, the diagnosis of Alzheimer's disease is usually made only at relatively distant stages of the disease (in most cases - not earlier than 5 years after the onset of the disease).
This is caused by serious diagnostic difficulties in assessing the initial manifestations of the disease, the known difficulty of distinguishing them from both signs of physiological involution and other functional and organic mental disorders of late age.
Of particular importance is their timely differentiation with the manifestations of so called reversible dementias, with states of "pseudo dementia" and a number of neurosurgical diseases, i.e. with those forms of mental pathology that represent potentially curable states.
A detailed analysis of the initial syndromes of the disease, the use of modern methods of neuropsychological, neurophysiological and X ray (computed tomography) studies of patients are a serious help for solving diagnostic issues at relatively early stages of the disease.
In accordance with the concept of Alzheimer's disease adopted in Soviet gerontopsychiatry *( In modern foreign (especially American) literature, there is a tendency to combine Alzheimer's disease and senile dementia of the Alzheimer's type under the general name "Alzheimer's disease" with an early (up to 65 years) and late (after 65 years) onset.), which is part of the general group of Alzheimer's dementia (which also includes senile dementia), is considered as a clinically independent form, differing from dementia depends not only on the age of onset, but also on the qualitative originality of the clinical manifestations of the disease, the sequence of violations of various aspects of mental activity and the depth of the breakdown of mental functions.
Knowledge of the features of clinical manifestations and dynamics of disorders of higher mental functions in Alzheimer's disease is necessary for the correct diagnosis of the disease, especially at relatively early stages of its course.
These guidelines briefly outline the criteria for the clinical diagnosis of Alzheimer's disease; describe the typology of the initial manifestations of the disease and their features depending on the age of onset of the disease; identify those differential diagnostic signs that allow you to distinguish Alzheimer's disease from other forms of mental pathology of late age; provide additional methods (neuropsychological, electrophysiological, X ray) studies that allow you to expand the possibilities of clinical diagnosis of this disease.
Clinical diagnosis
Alzheimer's disease is an atrophic disease of the brain, which is characterized by a progressive breakdown of higher mental functions (speech, praxis, gnosis) and mental activity in general, with an outcome in global dementia.
Alzheimer's disease is characterized by a gradual, hardly noticeable onset, a relatively slower, but steadily progressive course with the gradual development of dementia - from an initial decrease in mental activity to its total collapse.
At different stages of the disease, there is an addition of neurological disorders themselves.
The diagnosis of Alzheimer's disease is established on the basis of studying the mental status of the patient, as well as on the basis of objective anamnestic data confirming the gradual nature of the progression of mental and intellectual disorders and the increase of difficulties in everyday life for a sufficiently long time (at least 6 months).
The diagnosis of Alzheimer's disease can be: established only if the probability of a causal relationship of dementia with any general or cerebral disease is excluded (for example, heart failure, hypothyroidism, hyperparathyroidism, folic acid and vitamin B12 deficiency, intoxication, normotensive hydrocephalus, brain tumor, cerebral vascular disease, etc.).
The pathological anatomical verification of the diagnosis of "Alzheimer's disease" is based on the presence of the following neuromorphological changes: diffuse loss of neurons in the cortex and subcortical nuclei, Alzheimer's degeneration of neuro fibrils, the appearance of senile plaques and granulovacuolar cell degeneration.
alzheimer's disease dementia mental
In the vast majority of cases (from 70 to 80%), Alzheimer's disease begins at the presenile age (from 45 to 65 years), but cases of earlier and later onset of the disease are possible.
Approximately 5-10% of patients become ill at the age of 40-45 years and from 20 to 25% - after 65 years.
The average duration of the disease is 8-10 years, but it is possible both more prolonged (up to 20-25 years) and more catastrophic (up to 4 years) the course of the disease.
Women get Alzheimer's disease 10-12 times (according to the literature - 3-8 times) more often than men.
About 1/3 of cases in the families of patients show secondary cases of dementia related diseases of late age.
The clinical picture of Alzheimer's disease is determined by a combination of progressive memory disorders and mental activity in general with disorders of higher cortical functions, which seem to gradually pass from special manifestations of dementia to distinct cortical focal disorders.
The disintegration of memory and mental activity in general in Alzheimer's disease occurs according to the laws of progressive amnesia, i.e. from the most complex, late acquired and less firmly fixed knowledge and skills to the early acquired, more organized and automated.
In accordance with this, the most complex (creative, abstracting) forms of mental activity suffer first of all.
In Alzheimer's disease, the process of gradual disintegration of mental activity is characterized by a number of features.
Violations of memorization and the possibility of assimilation of new knowledge and experience, combined with the progressive disintegration of previously acquired memory reserves, are the background against which disorders of attention, comprehension and perception of the environment and the initial symptoms of future cortical focal disorders develop.
For example, optical diagnostic disorders gradually "grow" out of memory and optical attention disorders and initially manifest themselves as spatial orientation disorders in an unfamiliar area, later in a familiar area and environment.
Only at the later stages of the disease do they turn into more distinct optical and diagnostic disorders, which reach their maximum expression at the distant stage of the disease in autopsychic disorientation (not recognizing one's own image in the mirror).
Similarly, symptoms of apraxia gradually grow out relatively early manifested breaking the traditional skills of others there is the impression that people have forgotten how to do their work (for example, to carry out plans, sewing, cooking, etc.).
At the initial stage of the disease these disorders usually intermittent and mostly focuses on the most challenging action ("forgotten" sequence of their execution, action Plan, etc.), while the elementary steps and automated activities remain unchanged.
Only later, stupidity, inconsistency, helplessness in performing more complex forms of habitual activity "develops" into a violation of automated, elementary actions, and at the final stage of the disease reaches the degree of total apraxia.
At the same time, there may be a state of "apractic immobility" (when patients lose the ability to walk, stand, sit down, give a hand, stick out their tongue, etc.) or general "motor confusion", in which purposeful activity is replaced by disorderly motor activity, aimless fussiness and stereotypical, rhythmically repetitive monotonous movements.
In some cases, however, violations in the performance of elementary actions in the form of motor awkwardness are detected already at the initial stage.
Speech disorders in Alzheimer's disease also in most cases develop in a certain sequence - amnesic afatic symptoms seem to gradually "grow" out of a clearly pronounced amnesic syndrome.
This applies not only to the naming of certain objects (amnesic aphasia), but also to the initial sensory aphasic symptoms and even violations of expressive speech.
At the early stages of the development of the disease, patients seem to "forget" the meaning of a word or concept or its pronunciation.
The development of sensory aphasia also occurs through the stage of limited semantic understanding of speech (with relative preservation of phonemic understanding and repeated speech) to total sensory aphasia.
The disintegration of expressive speech, in turn, occurs through a number of stages of increasing impoverishment of speech, impoverishment of vocabulary, simplification of the gammatic and semantic construction of speech and difficulties in pronouncing individual words and syllables ("stumbling speech") to typical violations of word formation, speech automatism (locoglonia) and echolalic forms of speech.
These violations of speech function are more often accompanied by an increase in speech activity, up to speech arousal (forced speaking in the later stages of the disease) or - less often - speech spontaneity.
The described sequence of the decay of the speech function is not the only possible one.
In some cases, violations of expressive speech may outpace violations of impressive speech.
Disorders - reading, writing, counting, reaching a total violation of the corresponding functions (alexia, agraphy, acalculia) at the remote stages of the disease, can be detected already at the initial stage, often ahead of the breakdown of oral speech.
These disorders, however, can not always be detected by anamnestic data, although the corresponding experimental psychological study allows them to be detected already at the 1st stage of initial disorders (see the corresponding section)
Knowledge of the described sequence of the breakdown of higher mental functions and mental activity in general and taking into account the combination of clinical manifestations characteristic of the course of Alzheimer's disease can provide early diagnosis of the disease and correct assessment of cortical function disorders already at the initial stage of the disease.
As the research results have shown, the psychopathological structure of the initial manifestations of Alzheimer's disease can detect a certain variability, which, in turn, correlates with the age of onset and the progrediency of the painful process.
The clinical typology of the initial stage of the course of Alzheimer's disease includes four main variants, differing in different representation in the structure of initial psychopathological disorders of disorders of higher cortical functions, mnestic intellectual disorders and symptoms of personal transformation.
These structural components of the syndrome of initial psycho organic decline vary both in severity and in relation to each other.
In the" amnesic " type of onset, memory disorders and personality changes prevail over disorders of higher cortical functions.
This type of onset of Alzheimer's disease can be accompanied by heterogeneous changes in the personal structure: a distinct sharpening of personal characteristics and a psychopathic restructuring of the personality structure or leveling of individual personal characteristics against the background of increasing aspontality.
Depending on the quality of personal transformation, two variants of the "amnesic" type of the onset of Alzheimer's disease are distinguished: 1) with psychopathic disorders and 2) with spontaneity.
Both variants of the amnesic type of onset differ in the minimal representation of disorders of higher cortical functions at the initial stage and the absence of their" neurologization " (i.e., the collapse of the corresponding cortical function to the degree of neurological disorders) at the stage of advanced dementia.
Cortical focal disorders begin to increase only at the stage of clinically pronounced dementia, against the background of deep memory disorders accompanied by violations of social adaptation.
In these cases, the decay of the higher cortical functions seems to lag behind for a rather long period (from 5 to 13 years) from the decay of memory and intelligence in general.
Patients with distinct initial psychopathic disorders at various stages of the disease often have psychotic episodes in the form of fragmentary delusions of damage, petty persecution or jealousy, and in some cases - more protracted paranoid states, usually developing against the background of very slowly progressing mnestic disorders.
Much more often (more than two thirds of patients) in the structure of the syndrome of initial psycho organic decline, initial disorders of higher cortical functions are clearly represented.
Depending on the violation of one or more higher cortical functions, "monocal" and "polyocal" types of the onset of Alzheimer's disease are distinguished.
In these cases, the initial manifestations of future cortical focal disorders occur shortly after the appearance of initial mnestic intellectual disorders, and the rate of their progression often outstrips the disintegration of mnestic intellectual functions.
Most often, violations of the higher cortical function (for example, speech or praxis), most affected at the initial stage, outstrip the collapse of other cortical functions at the stage of expanded dementia and, as a rule, reach the maximum degree of severity, up to the total collapse of the corresponding function.
Relatively less often, in the subsequent stages of the disease, the decay of previously preserved cortical functions is observed ahead of the rate of progression.
With the " monocal "and less often with the" polyocal " type of onset, the main personal characteristics, emotional forms of reaction and kinship attachments remain preserved for a long time.
It is these patients who at the beginning of the disease show a kind of confusion, complain about memory disorders, decreased performance, difficulty concentrating attention, and also give affective reactions (sometimes in the form of more defined depressive or anxiety depressive states) to their insolvency.
Even in a state of deep dementia with pronounced focal changes, such patients can detect a sense of their own change and inferiority (complaints that "there is no memory", "the head does not work", etc.) and an adequate emotional reaction to their failure.
The different types of onset of Alzheimer's disease show a certain relationship with the age of its debut.
For example ,the "amnesic" type of the initial stage, accompanied by psychopath like disorders, is more common in patients with a relatively early onset (average age 46.7 years), and the "poly focal" type of initial disorders is more often observed at the onset of the disease about 60 years or later (average age of onset -63.4 years).
The "amnesic" variant with signs of aspiration, as well as the "monocal" type of initial disorders, is more often "tied" to the classical presenile age of onset (the average age of onset is 53.1 and 55.1 years, respectively).
The type of initial disorders also reveals certain correlations with the subsequent progrediency of the painful process.
The course of Alzheimer's disease with the "amnesic" type of initial disorders and distinct psychopathic like changes at the initial stage is characterized by the lowest rate of progression.
It is associated with a special duration of the initial stage and the disease as a whole.
On the contrary ,the "multi focal" type of initial disorders correlates with the greatest progrediency of the disease, the brevity of the initial stage and the shortest duration of the disease as a whole.
The "monocal" type of initial disorders and the "amnesic with spontaneity" occupy an intermediate position between these two extreme variants in terms of the rate of mental disintegration.
The correct qualification of the type of onset of the disease allows, thus, to predict the further course of the disease, to properly plan rehabilitation measures and the need for medical and social assistance to various categories of patients.
Differential diagnosis
Diagnosis of Alzheimer's disease, especially at relatively early stages of its course, often meets with serious difficulties and requires differentiation with other forms of mental pathology, accompanied by violations of various aspects of cognitive activity, behavior and social adaptation of the patient.
The task of timely distinguishing Alzheimer's disease from a number of neurosurgical diseases (volumetric cerebral processes, normotensive hydrocephalus) is especially urgent, because the erroneous diagnosis of Alzheimer's disease in these cases does not allow timely use of the only surgical method of treatment possible to save the patient.
No less important is the correct diagnostic qualification of cases of secondary, i.e. caused by other general somatic (infectious, intoxicating, metabolic, endocrine) or cerebral processes (encephalitis, brain injury, subdural hematoma, etc.), dementia, which, with the right therapeutic tactics, can be partially or completely reversible.
It is also significant to distinguish the initial manifestations of Alzheimer's disease (especially in patients with depressive or anxiety depressive reactions to the disease) from depressive states that are not rare at a late age, accompanied by a picture of apparent dementia ("pseudodementia").
The doctor also faces frequent diagnostic difficulties when it is necessary to differentiate Alzheimer's disease from vascular (multiinfarction) dementia and other atrophic processes of late age (senile dementia, Pick's disease, etc.).
The need to distinguish Alzheimer's disease from a brain tumor usually arises if certain cortical disorders predominate in the early stages of the disease, which are ahead of the rate of progrediency of violations of mnestico intellectual functions.
For example, in those cases where, with relatively shallow dementia, speech disorders (at a certain stage of the course of the disease) reach the degree of pronounced decay, and violations of other higher cortical functions significantly lag behind them in progrediency and are detected only with a special neuropsychological study.
Or, on the contrary, with mild speech disorders and a moderate psycho organic decrease, there are distinct violations of writing, counting, reading and agnostic symptoms (i.e., we are talking about a predominant lesion of the parietal occipital regions).
The correct diagnostic qualification in these cases is helped by the absence of general brain disorders (headache, vomiting, dizziness, etc.) and local neurological symptoms.
The appearance of local neurological symptoms and epileptic seizures at the stage preceding the development of dementia, or general brain symptoms, calls into question the diagnosis of Alzheimer's disease and requires mandatory fundus examination, electrophysiological examination, echography, X ray examination, etc.to exclude volume formation.
Hydrocephalic dementia or normotensive hydrocephalus is the most well known curable dementia (timely bypass surgery gives a high therapeutic effect and almost half of the cases eliminates the symptoms of dementia), is characterized by a triad of disorders - gradually progressive dementia, gait disorders and urinary incontinence, which, unlike Alzheimer's disease, appear at relatively early stages of the disease.
In some cases, however, not all the structural components of the "triad" are represented evenly.
Mnestico intellectual disorders in normotensive hydrocephalus are usually determined by a violation of memorization and memory for recent events and orientation disorders, whereas in Alzheimer's disease, memory disorders are usually more total in nature, not only memorization and memory for recent events are violated, but also past knowledge and experience.
In contrast to the emotional safety of patients suffering from Alzheimer's disease, patients with normotensive hydrocephalus are characterized by indifference, emotional stupidity or disinhibition.
Patients with normotensive hydrocephalus usually do not detect violations of praxis and speech, and gait disorders are peculiar (slow, on stiff, widely spaced legs).
The need to differentiate Alzheimer's disease with endogenous depression usually occurs mainly at a relatively early stage of the disease with a still shallow degree of disintegration of mental and intellectual functions and emotional safety of patients, when patients give reactions of anxiety and confusion to changes occurring with them or express general complaints about fatigue, difficulties in work, difficulties in concentration, decreased activity.
Especially often pronounced depressive reactions occur in the so - called "monocal" type of onset of Alzheimer's disease and somewhat less often in "polyocal" and "amnesic" with psychopathic changes at the initial stage.
The distinction between Alzheimer's disease and "pseudodementia" in endogenous depression in elderly patients is based on a thorough clarification of anamnestic data and a comprehensive assessment of the patient's mental state and features of its dynamics.
In the anamnesis of patients with endogenous depression, previous subdepressive episodes or unexplained periods of "poor health"are often clarified.
In addition, patients with depression can usually indicate a chronological period or even the date of the onset of the disease, and with Alzheimer's disease, initial symptoms increase so slowly and little noticeably that patients find it difficult to date their onset.
The reduced affect in "pseudodementia" in depressive patients is usually stable, while the severity of memory and intellectual activity disorders can vary in intensity not only for a more or less long time interval (a week, a month), but even for one day.
In contrast, in Alzheimer's disease, depressive disorders are usually unstable and changeable, and cognitive disorders are stable and tend to progress slowly.
The attitude of patients to their intellectual disorders also differs.
If depressive patients are worried about this, are prone to self reproach and increase (according to self assessment) the severity of their intellectual disabilities and their own insolvency, then patients with Alzheimer's disease hide or downplay them.
A special study of memory and higher cortical functions using simple neuropsychological tests (see the corresponding section) allows us to detect in patients with Alzheimer's disease, even at an early stage of the disease, the memory disorders described above (with "pseudodementia", memory disorders relate mainly to recent events), as well as visual spatial activity disorders, elements of afatic or apractic disorders.
The need to distinguish Alzheimer's disease from vascular (multi infarct) dementia occurs mainly in the so called pseudo Alzheimer's forms of vascular dementia, accompanied by disorders of higher cortical functions (afato apracto agnostic disorders).
The correct diagnostic assessment in these cases is helped by the analysis of objective anamnestic data.
Information about the acute onset of the disease, about transient disorders of cerebral circulation with the appearance of transient neurological disorders or short term episodes of confusion, as well as information about a step like increase in dementia indicate a probable vascular genesis of the disease.
The detection of focal neurological symptoms increases the likelihood of this diagnosis.
To recognize vascular (multiinfarction) dementia accompanied by cortical focal disorders and distinguish it from Alzheimer's disease, it is useful to use the appropriate scales developed by foreign researchers and widely used abroad - the Khachinsky ischemic scale and the evaluation scale for the diagnosis of Alzheimer's disease developed by Gustafson and Nilson (see appendix).
A score of more than 8 points on the Hachinsky scale indicates a high probability of vascular etiology of dementia.
A score of more than 5 points and especially 8 points (depending on the duration of dementia) on the Gustafson and Nielson scale speaks in favor of the diagnosis of Alzheimer's disease.
But the most significant help in the diagnosis of the pseudo Alzheimer's form of vascular (multi infarct) dementia is provided by the study of the patient using computed tomography (multi infarct dementia is characterized by a combination of focal changes in the density of the brain substance and an indistinct diffuse expansion of both the ventricles and subarachnoid spaces).
The need to distinguish Alzheimer's disease with other atrophic processes of late age most often arises in relation to senile dementia and Pick's disease.
About some of the differences in the clinical picture of Alzheimer's disease and dementia stilnoe mentioned above (pronounced dissociation between amnesia and long term preservation of the basic properties of the personality and the emotional sphere, no characteristic pattern of dementia stilnoe phenomenon of "displacement situations in the past" and "past life").
Along with the above clinical features of differential diagnostic criteria to distinguish Alzheimer's disease from dementia stilnoe is the emergence of symptoms of higher cortical functions (dysphasia, there is disgnose) already in the early stages of the disease; when stilnoe dementia these phenomena arise, as a rule, only at the stage with advanced dementia and usually does not reach the degree of heavy disruption (neurological) cortical functions characteristic of Alzheimer's disease.
The disintegration of speech in senile dementia is usually limited to amnesic and sensory aphasia, there is no disintegration of motor speech and speech automatisms.
Senile dementia is also not characterized by a gross breakdown of motor praxis and the appearance of a number of neurological disorders characteristic of the final stages of Alzheimer's disease (a sharp increase in muscle tone, oral and grasping reflexes, myoclonia, epileptic seizures, etc.).
The differentiation of Alzheimer's disease from Peak's disease, which is also accompanied by disorders of higher cortical functions and the development of total dementia, is based on certain qualitative differences in the structure of dementia and the dynamics of its development.
Unlike Alzheimer's disease, in Peak's disease, deep personal changes occur already at the early stages with spontaneity and impoverishment of speech and motor activity, or with foolishness and disinhibition, stereotypical forms of activity.
At the same time, the instrumental functions of the intellect (memory, attention, orientation, counting, etc.) remain preserved for a long time, although the most complex aspects of mental activity (generalization, abstraction, criticism) are violated already at the initial stage of the development of the disease.
Cortical focal disorders also have certain features.
Speech disorders prevail, which are not only mandatory, but also early manifestations of the disease.
There is a gradual impoverishment of speech, a decrease in speech activity to "apparent dumbness" and the appearance of speech stereotypes, "standing turns", which at the later stages of the disease represent the only form of speech activity.
The late stages of Peak's disease are characterized by complete destruction of speech function (total aphasia), while the symptoms of apraxia appear quite late and usually do not reach the degree of severe decay characteristic of Alzheimer's disease.
Neurological symptoms (with the exception of amymia and mutism) are usually absent even at the remote stage of Peak's disease.
A differential diagnosis with Huntington's chorea has to be carried out if there are choroid like hyperkineses in the clinical picture of dementia.
However, in Alzheimer's disease, hyperkinesis occurs only at remote stages of the course against the background of far reaching dementia and pronounced cortical focal disorders, which is not typical for Huntington's chorea.
Additional research methods
Neuropsychological examination
The use of a complex of neuropsychological techniques allows us to significantly expand the possibilities of detecting and evaluating violations of higher cortical functions, memory and mental activity in patients at relatively early stages of the disease.
The following is a description of simple neuropsychological techniques that allow us to identify the disorders of praxis and gnosis characteristic of Alzheimer's disease.
opto spatial activity, speech, reading, writing, counting, memory and evaluate the possibilities of performing intellectual operations.
The study of praxis is aimed at identifying the defect of both the kinesthetic (praxis of the pose) and the kinetic (dynamic praxis) basis of the motor act.
The praxis of the pose is examined alternately on the right and left hands and includes sequential reproduction by patients of the following finger positions according to a visual sample: 1) connect the thumb alternately with the index, middle, little finger;
2) squeeze your hand into a fist, leaving the index and middle (little finger) fingers free.
Dynamic praxis is also studied alternately on both hands and includes the reproduction of a three stage program by the patient according to a visual sample: the hand is alternately clenched into a fist, placed on the table with the edge of the palm and placed palm down.
In the praxis of the pose, the main difficulties in patients with Alzheimer's disease are switching from one pose to another, as well as performing the most difficult poses - connecting the thumb and little finger, contrasting the little finger and index finger.
In dynamic praxis, patients skip the middle link of the program, reducing it to a two stage one.
Optical gnosis is studied under the conditions of sequential presentation of real objects to the patient (a coil, a pencil, a key, a watch, etc.); color object images (an apple, a rooster, scissors, a watch, a phone, a bucket, glasses, a bicycle); contours of objects crossed out by lines of various configurations; superimposed contours of objects.
In Alzheimer's disease, specific paragnosities are detected when recognizing object images (patients take a phone for a watch, a bicycle for glasses).
At the same time, there is no criticism of errors.
Recognition of crossed out images is usually unavailable due to the fact that it is difficult for the patient to distinguish the figure from the background.
From the superimposed images, patients recognize objects located in the background worse.
When studying opto spatial activity, the assessment of its constructive component is of the greatest importance for patients to perform the task of drawing simple geometric shapes, images of a house, a table, a cube, a human figure on their own and on a sample; as well as folding various constructions of increasing complexity from matches.
The performance of these tasks causes distinct difficulties in patients, even at the initial stage of the disease.
The worst patients cope with drawing spatially oriented shapes (cube, table), the presence of a sample slightly improves the performance of the task.
The study of speech consists of a sequential repetition of the following tasks for the doctor: 1) separate vowel and consonant letters;
2) syllables that include deaf and voiced consonants, as well as sounds with different articulatory bases (ba pa, da ta, za sa, ra la, ta ka, ba ma pa, da la na);
3) compound words (electrician, steam locomotive, shipwreck, etc.);
4) placed at a normal pace tongue twisters ("whey from the curd from the clatter of hooves dust flying across the field", "Sasha was walking on the highway...", etc.).
In addition, fixed defects spontaneous speech of the patient and the naming of objects and object images.
Repeated speech of patients with Alzheimer's disease may suffer already at the level of repetition of individual syllables, but a particularly distinct defect is observed when reproducing complex words and tongue twisters, and the first part of them is reproduced well, and the second - with paraphasias or illegible.
In spontaneous speech, there are difficulties associated with the forced repetition of the beginning of a word (logoclonic "stumbles"), paraphasias (more often literal) and amnesic entanglements.
When naming objects, an amnesic aphasia is revealed.
The study of the letter should include writing several short phrases under dictation, not limited to the task of writing your last name, first name, patronymic.
Writing a surname, first name, patronymic, as an autochmatized action, is better for patients than writing under dictation, in which the most frequent omissions of letters (more often consonants), incomplete spelling of the endings of words, extra strokes in the letters.
When studying reading, individual words of varying degrees of complexity and the text of a short story (preferably written in large font) are used.
In the early stages of the disease, reading individual, especially common words does not cause difficulties for patients.
When reading the text, it is possible to lose a line, distort the endings of words, skip the end of the line.
The study of memory involves the reproduction of a series of 5 words (directly and sequentially during 5 presentations) that do not contain an associative connection with each other, and a short story consisting of 5-10 phrases.
When studying memory, the failure of patients with direct reproduction of a number of 5 words, the unproductivity of memorization, a significant decrease in the volume of reproduction (or even the inability to reproduce) after the inclusion of side activities (for example, counting) in the task is revealed quite early.
The elements of the first part of the story are usually reproduced in the story.
It is advisable to include the study of counting in the study of memory, asking the patient to reproduce the words he learned after 5 repetitions after several counting operations.
Counting operations are usually available within the automated actions of the multiplication table and individual operations for addition and subtraction within no more than two dozen.
As a rule, tasks in the form of arithmetic problems (even elementary ones) are performed by patients much worse than the counting operations themselves included in their solution.
The study of intellectual operations includes drawing up a plot story based on a picture and checking the understanding of the figurative meaning of proverbs and metaphors.
When composing a story based on a plot picture, fragmentary perception is usually noted (patients describe individual characters and details of the drawing, not being able to assess the situation as a whole).
The understanding of the figurative meaning of proverbs is violated already at the early stages of the disease.
Patients, as a rule, operate with specific categories.
The evaluation of metaphors remains fully or partially preserved until the stage of severe dementia.
When evaluating the results of a neuropsychological examination, it should be taken into account that the syndrome of violation of higher mental functions in Alzheimer's disease is characterized by a combination of all three of its components - memory disorders, intellectual operations and certain disorders of higher cortical functions (speech, praxis, gnosis, etc.).
As already mentioned, the degree of severity of the latter and;: the initial stage of the disease .it may vary depending on the structure of the initial syndrome.
It should be noted that the described disorders at the more distant stages of the disease are combined with changes in the general background of the deployment of mental processes: gross inertia, narrowing of the volume of all types of activities, difficulties of inclusion in the task, low productivity even in conditions of stimulation.
At the stage of severe dementia, the breakdown of higher mental functions reaches such an extent that patients do not follow even the simplest instructions.
Electrophysiological examination
For diagnostic purposes and monitoring of the functional state of the central nervous system in Alzheimer's disease, the following electrophysiological methods are used: electroencephalography (EEG), analysis of evoked potentials (VP) and the level of constant potential (UPP) of the brain.
EEG examination
EEG is a method for analyzing the total vibrational electrical activity of the brain.
In Alzheimer's disease, EEG allows you to identify the presence of brain damage and its localization, to assess the degree of violation of the functional activity of the nervous tissue.
EEG changes are observed in 94% of patients with Alzheimer's disease and indicate the presence of diffuse brain damage.
There is a progressive reduction of normal EEG rhythmics: the frequency of alpha activity and its amplitude decreases, alpha and beta indices decrease.
Disappearing normal rhythms replace pathological fluctuations - diffuse, often low amplitude theta and, to a lesser extent, delta activity.
EEG disorders are characteristic, indicating damage to the median structures of the brain: discharges of bilaterally synchronous theta and delta waves.
Sometimes epileptic activity is detected: peaks, acute waves, peak wave complexes and acute wave slow wave.
The reaction of rhythm assimilation during photostimulation is disturbed.
The severity of pathological changes (slowing of the EEG rhythm) correlates with the degree of dementia.
Although EEG disorders in patients have a certain similarity with the changes observed in normal aging, an earlier age of the appearance of pathological activity in Alzheimer's disease (in healthy subjects, changes occur after 60 years) and a greater degree of violations allow us to distinguish EEG in Alzheimer's disease from the norm.
EEG changes in Alzheimer's disease are nosologically non specific.
However, a number of features of the EEG in different types of dementia give rise to a presumptive judgment about the nature of the weakening process.
In Peak disease, the EEG remains intact for a long time and its changes lag behind the severity of clinical disorders.
With tumors of the cerebral hemispheres, as a rule, pronounced focal changes in the EEG are observed.
In tumors of the median structures of the brain located supratentorially, discharges of bilaterally synchronous theta and delta waves are recorded, which can also be detected in Alzheimer's disease.
The differences, not always obvious, are in the greater amplitude or asymmetry of these waves in tumors.
In multiinfarction dementia, changes of a focal nature are noted in the EEG.
In Huntington's chorea, a low amplitude (up to 10 mv) EEG is recorded.
VP Research
To study the VP the brain's responses to external stimuli the method of multiple summation of EEG sections following the stimulus is used using computers or specialized averaging devices.
Changes in visual VP in response to a flash of light are detected in 83% of patients.
There is an increase in the latency period of the intermediate and late components of the VP, in particular the P100 wave; an increase in the amplitude of the intermediate components of the VP, a reduction of the late components.
A positive wave of Ree occurs when recognizing unexpectedly occurring signal stimuli.
Its latency is increased in 80% of patients.
This technique is applicable only for mild degrees of dementia due to the need for active participation of patients in the examination procedure.
SCP research
SCP is a stable potential difference in the millivolt range that exists between brain regions and integratively reflects the value of the membrane potential of nerve and glial cells.
In Alzheimer's disease, there is a violation of the normal regional differences of the SCP.
Deviations from the norm are more pronounced in the temporal regions.
Examination by methods of neurointroscopy (computed tomography)
Among the modern methods of instrumental imaging of brain structures, the methods of lifetime neurointroscopy, which have become widespread in recent years, based on a fundamentally new technology, referred to as computed tomography, are of particular value.
Initially, the term "computed tomography" (CT) referred to a method for obtaining an image of the cross - section of an organ or system under study using X rays (X ray CT, or currently simply CT).With the advent of other technological methods for obtaining images of cerebral formations, in which the CT method was also used, the term "computed tomography" began to define only the principle of obtaining an image, regardless of the physical basis of the method.
This approach has been applied in tomography based on the effect of nuclear magnetic resonance (NMR tomography), in the study of metabolism in nervous tissue, cerebral blood flow and perfusion by recording in the form of sections of the distribution of the intensity of radioactive radiation after the introduction of an isotonic label into the body.
The latter methods include single photon and positron emission tomography (PET and PET).
Each of these methods has its advantages and disadvantages in comparison with others, and none of them can completely replace the other.
X ray CT, which has been intensively developing in the USSR over the past decade, has proved to be particularly promising for the diagnosis of late age dementia processes, in which it is possible to assess not only the degree of deviation from the norm of the liquor system, but also to identify local and widespread damage to the brain matter.
The methodology of the analysis of computed tomograms obtained in patients with various forms of atrophic processes, including Alzheimer's disease, has some features.
Taking into account that macroscopic changes in these patients are characterized, as a rule, by cerebral atrophy of varying degrees of prevalence and varying severity in different anatomical regions of the brain, the quantitative parameters of the ventricular system and subarachnoid space are studied first of all.
The measurement of absorption coefficients (KP), whose deviations from normal values reflect the presence of pathology in the nervous tissue itself, should be carried out in different areas of the brain, and separately in the hemispheres of the cerebrum and cerebellum, as well as in gray and white matter.
Quantitative assessment of the size of the ventricles of the brain is carried out using the following methods: 1) methods of measuring linear dimensions (ventricular indices and absolute transverse dimensions of all parts of the ventricular system);
2) planimetric methods or methods for measuring the areas of the ventricles and the brain on one of the selected sections, which also allow obtaining ventriculocerebral relations;
3) methods for calculating the volume of the lateral ventricles; indicators, the ratio of the volume of the lateral ventricles to the volume of the large hemispheres allow you to accurately determine the degree of cerebral atrophy.
In order to get an idea of the state of the subarachnoid space of the large hemispheres, the following methods are used: 1) determination of the maximum width of the sylvian slits and the interhemispheric gap in its anterior sections;
2) counting the number of hemispheric furrows visible on tomograms on sections above the bodies of the lateral ventricles and the maximum width of one of them;
3) calculation of the volume of the subarachnoid space.
Alzheimer's disease is characterized by a combination of the following tomographic parameters:
) diffuse expansion of the ventricles and subarachnoid spaces of the cerebral hemispheres;
) the maximum severity of the indicators characterizing "central atrophy", i.e. an increase in the ventricular indices of the anterior horns, the central parts of the ventricles and the third ventricle, as well as the transverse dimensions of various parts of the ventricular system (the width of the right and left anterior horns at the level of the middle of the caudate nucleus head, the width of the central part of the right and left lateral ventricles at the level of the medial depression, the width of the third ventricle);
) relatively less pronounced indicators characterizing "cortical atrophy", i.e. an increase in the size of the hemispheric furrows (the width of the posterior sections of the sylvian furrow at the level of the epiphysis, the maximum width of the anterior sections of the interhemispheric fissure, the maximum width of one of the largest furrows) and the number of furrows along the periphery of two adjacent sections located immediately above the section with the image of the ventricles;
) changes in the parameters of the brain substance density - a decrease in the absorption coefficients of gray matter (in the area of the lenticular nucleus) and white matter (in the area of the semioval center).
Alzheimer's disease was first described by Professor Alois Alzheimer in Germany in 1907 in a 55 year old woman.
At first, it was considered a relatively rare form of presenile dementia.
However, over time it turned out that Alzheimer's disease can ...
Alzheimer's disease: symptomatology and therapy However, already at the first description of Alzheimer's disease (AD), A.
Alzheimer noted the presence of the patient not only signs of afato apracto diagnostic dementia, but also auditory hallucinations and delusional ideas of jealousy.
Alzheimer's disease: etiology, behavioral disorders, treatment Alzheimer's disease (presenile dementia of the Alzheimer's type) F00.
0 Started mainly at the presenile age, the slow development of the disease at the initial stages and rapid progression at the stage of clinically pronounced dementia.
Pharmacotherapy of Alzheimer's disease Alzheimer's disease (synonym: Alzheimer's type dementia), according to the experts of the World Health Organization, is recognized as the most common cause of dementia developing in the elderly and senile age.
Alzheimer's disease ...which allow us to distinguish Alzheimer's disease from other forms of mental pathology of late age; additional methods (neuropsychological, electrophysiological, X ray) studies are given, which allow us to expand...
Cognitive impairment in dementias of various etiologies It is believed that Alzheimer's disease can be inherited in the form of genes that are conducive to its development.
According to some data, the risk of developing Alzheimer's disease in close relatives of the patient is 4 times higher than normal.
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