NEUROBEHAVIOR

(BEHAVIORAL NEUROLOGY)

The Division of Cognitive and Behavioral Neurology :

provides a comprehensive, multidisciplinary approach to
the diagnosis and management of patients who have
problems with memory, executive functions, attention,
language, emotion, or behavior due to disease, injury,
or developmental disorders of the central nervous
system. Patients receive the highest standard of
neurologic, psychiatric, and social work care for the
treatment of their conditions.

in the assessment and treatment of diverse clinical

problems including:
- Dementia (e.g., Alzheimers disease and related
degenerative
disorders,
vascular
dementia,
frontotemporal
dementia,
dementia
with
parkinsonism)
- Cognitive, Emotional, or Behavioral Problems due
to Diverse Conditions (e.g., epilepsy, multiple
sclerosis, stroke, traumatic brain injury, brain tumor,
systemic diseases with central nervous system
manifestations)
- Developmental Disorders in Adults (e.g., Attention
deficit disorder, learning disabilities, mental
retardation,autism)

Basic brain biology

A simplified model of the human brain consists of
many parts:
- Brain stem, hind brain, mid brain & cerebellum the most ancient parts, connected to the
spine, controls movement, breathing and
heartbeats.
- Limbic system - consisting of many specialist
organs including the Hypothalamus,
hippocampus -developed in mammals. Some
memory functions and generation of
emotional
responses.
- Cerebral cortex - the distinguishing feature of
human brains

 Each hemisphere of the

cortex can further be
divided into four lobes:
Occipital - visual
processing
Parietal - movement,
orientation, calculation,
recognition
Temporal - sound and
speech processing,
aspects of memory
Frontal - thinking,
conceptualisation,
planning.

Some specific differences between the two hemispheres resulted from this and
subsequent research. The right-brain is better at:
Right Hemisphere

Specialities

Shared

Copying of designs,
Discrimination of shapes e.g. picking out a
camouflaged object,
Understanding geometric properties,
Reading faces,
Music,
Global holistic processing,
Understanding of metaphors,
Expressing emotions,
Reading emotions.

Left Hemisphere
Language skills,
Skilled movement,
Analytical time sequence
processing.

Sensations on both side of face,

Sound perceived by both ears,
Pain,
Hunger,
Position.

Emotions

Negative emotions (fearful mournful feelings),

Positive emotions

neurotransmitters

Higher levels of norepinephrine

Higher levels of dopamine

Grey Matter White

Maatter ratio

More white-matter (longer axons) on right

more grey-matter (cell bodies)

on the left

SIRKUIT AMIGDALA

Hipokampus

( LINTASAN EMOSI )
dengan bagian Otak lain

Striatum ventral,
nukleus dorsomedial
thalamus

PATOGENESIS

RESPON TERHADAP EMOSI

DARI BAGIAN-BAGIAN OTAK
AKIBAT STIMULUS NUKLEUS
SENTRALIS AMIGDALA

GAMBARAN fMRI pasien depresi :

penurunan aktifitas metabolik daerah prefrontal

GAMBARAN PET Scan : Peningkatan aktifitas amigdala pada orang

yang melihat kata-kata ancaman

DEMENTIA
DEFINITION:
Group of symptoms that can be caused by
over 60-70 disorders.
Syndrome which refers to progressive
decline in intellectual functioning severe
enough to interfere with persons normal daily
activities and social relationships. (National
Institute on Aging-1995 No. 95-3782)

Dementia
Marked by progressive, irreversible
declines in
memory.
visual-spatial relationships
performance of routine tasks
language and communication skills
abstract thinking
ability to learn and carry out mathematical
calculations.

Dementia
Two Types:
Reversible
Irreversible

Individuals must have intensive medical

physical to rule out reversible types of
dementia.

Dementia
Reversible:
D=
E=
M=
E=
N=
T=
I=
A

Drugs, Delirium
Emotions (such as depression) and
Endocrine Disorders
Metabolic Disturbances
Eye and Ear Impairments
Nutritional Disorders
Tumors, Toxicity, Trauma to Head
Infectious Disorders
Alcohol, Arteriosclerosis (Dick-Mulheke- Overview of

Alzheimer's Disease)

Dementia
Irreversible:

Alzheimers
Lewy Body Dementia
Picks Disease (Frontotemperal Dementia)
Parkinsons
Heady Injury
Huntingtons Disease
Jacob-Cruzefeldt Disease

ETIOLOGI
Penyakit Alzheimer
Demensia Vaskuler
Pseudodemensia 8%
Demensia alkoholik
Tumor intrakranial 5%
NPH 5%
Intoksikasi 3%
Huntington 2%
Penyakit lain
10%

50%
10%
7%

Adams RD, 1997

Baldereschi et al., 1998

Progression of normal aging to dementia

Brain Aging

Normal
Cognition

Prodromal
Dementia

Dementia

revers

other
other
dementia

dementia

Golomb J,Kluger A,Ferris SH, 1999

MCIMCI
/ VCI

Alzheimer
Alzheimers
dementia
disease

stableor
or
stable
reversible
reversible
impairment
impairment

vascular
vascular
dementia

dementia

Alzheimer's Disease
Estimated that 4,000,000 people in U.S.
have Alzheimer's disease.
Estimated that 25-35% of people over age
85 have some time of dementia.
After age 65 the percentage of affected
people, doubles with every decade of life.
Caring for patient with Alzheimer's disease
can cost $47,000 per year (NIH).

Changes Caused by
Alzheimer's
Diminished blood flow
Neurofibrillary Tangles
Neuritic Plaques
Degeneration of hippocampus, cerebral
cortex, hypothalamus, and brain stem

Theories Regarding Causes of

Alzheimer's
Changes in Neurotransmitters
Acetycholine is decreased--necessary for
cognitive functioning.

Changes in Protein Synthesis

Beta amyloid--may be responsible for forming
plaques.
Tau--major component of neurofibrillary tangles.

Genetic Theories
ApoE4 on chromosone 19 linked to late-onset
Alzheimers Disease.

Theories Regarding Causes of

Alzheimer's
Genetic Theories
Chromosome 21 --Responsible for early-onset
Alzheimers Disease.

Metabolic Theories
Glucose metabolism declines dramatically in
Alzheimers patients.

Calcium Theories
Too much calcium can kill cells. Suspect that it
may reason why neurons die in Alzheimer's
patients.

Theories Regarding Causes of

Alzheimer's
Environmental
Aluminum--Traces of metal found in brain.
Zinc--found in brains on autopsies.
Food borne poisons--amino acids found in
legumes in Africa and India my cause neurological
damage.

Viral
May be hidden in body and attack brain cells years
later. (NIH-1995)

Theories Regarding Causes of

Alzheimer's
Head Trauma
Head trauma increase the concentration of B-amyloid
protein

Low Level of Education

Individuals with low level of education less able to
compensate for cognitive deficits

Estrogen Deficiency
Early Life Experience---have lost parent before
age 16

The Cholinergic Hypothesis

Acetylcholine is as important
neurotransmitter in areas of the brain
involved in memory formation the
hippocampus, cerebral cortex, and amygdala.
Concentrations of acetylcholine are markedly
decreased in Alzheimers disease.
Enhancement or restoration of cholinergic
function may significantly reduce the severity
of cognitive loss.
Depletion is limited to the basal forebrain
projection system.

Gauthier at all, 1997

Neuronal Degeneration
The pathobiology of Alzheimers
disease is characterized by:
Amyloid plaques
Neurofibrillary tangles

Neurofibrillary Tangles
Intracellular inclusion bodies consisting of
paired helical filaments that appear in a
characteristic double-helix shape.
Filaments appear to be composed of a
hyperphosphorylated microtubuleassociated protein called tau.
Remains of damaged neuronal
microtubules.

Amyloid Plaques
Plaques are extracellular structures that are
more prevalent in the Alzheimers patients
brain, particularly in the hippocampus and
neocortex.
Amyloid (neuritic) plaques in Alzheimers
disease are dense and insoluble structures.
Plaques consist of a central core of betaamyloid protein surrounded by abnormal
axons and dendrites.

Diagnosis of Dementia Due to

Alzheimers
Memory Impairment
Multiple cognitive deficits with at least one
disturbance in the following areas:
Aphasialoss of the ability to use symbols to
communicate orally or in writing
Two Types:
Expressiveinability to form words
Receptivedecreased ability to understand spoken or written
language

Apraxiainability to initiate complex learned motor

movement or unable to perform activity on command
Agnosia---inability to recognize familiar objects by
sight, touch, taste, smell or sound

Diagnostic Tests
Neurological Exam
Brain Imagingshrinkage, atrophy of
brain (CT or MRI)
Blood Work

Median Scores on Mini-Mental State Examination

by Age and Educational Level
Age (years)

Educational level
4th grade

8th grade

High school

College

18 to 24

22

27

29

29

25 to 29

25

27

29

29

30 to 34

25

26

29

29

35 to 39

23

26

28

29

40 to 44

23

27

28

29

45 to 49

23

26

28

29

50 to 54

23

27

28

29

55 to 59

23

26

28

29

60 to 64

23

26

28

29

65 to 69

22

26

28

29

70 to 74

22

25

27

28

75 to 79

21

25

27

28

80 to 84

20

25

25

27

84

19

23

26

27

Reprinted with permisssion from Crum RM, Anthony JC, Basset SS, Folstein MF. Population-based norms for
the mini-mental state examination by age and educational level. JAMA 1993 ; 18 : 2386-91

Stages of Alzheimers Disease

Mild Stage
Memory Loss
Symptoms:
Confusion About Place
Loss of Spontaneity
Loss of Initiative
Mood/Personality Changes
Poor Judgment
Takes Longer to Perform Routine chores
Trouble Handling Money, Paying Bills

Stages of Alzheimers Disease

Moderate Stage
Impairments in:
language
motor ability
object recognition
increasing memory loss and confusion

Stages of Alzheimers Disease

Moderate Stage

Symptoms:
Problems recognizing family members, close friends.
Repetitive statements and/or movements.
Restless, especially in late afternoon and at night.
Occasional muscle twitches or jerking.
Perceptual motor problems.
Problems organizing thoughts, thinking logically.
Cant find right words, makes up stories.
Problems reading and writing.
May be suspicious, irritable, fidgety, teary or silly.

Stages of Alzheimers Disease

Severe Stage
Symptoms:
Loses weight even with good diet.
Little capacity for self-care.
Cant communicate with words.
May put everything in mouth or touch everything.
Cant control bladder or bowel.
May have difficult with seizures, swallowing, skin
breakdown, infections.

Stages of Alzheimers Disease

Terminal Stage
Symptoms:
Loss of ability to ambulate.
Loss of ability to sit.
Loss of ability to smile.
Loss of ability to hold up head.
Loss of ability to swallow.

Stages of Alzheimers Disease

Stage IV--Terminal Stage
Symptoms:
Loss of ability to ambulate.
Loss of ability to sit.
Loss of ability to smile.
Loss of ability to hold up head.
Loss of ability to swallow.
Management of Challenging Behaviors in DementiaMahoney, Volicer, Hurley.

Health Professionals Press:2000. Baltimore, Md

Potential agents that can be of

benefit for Alzheimers disease
Reversible inhibitors of the enzyme
acetylcholinesterase (donepezil, tacrine,
rivastigmine)
?Vitamin E 2000 IU units per day - 6
month delay in disease progression
?Selegiline 5 mg twice a day - 4 month
delay in disease progression
?Gingko biloba 40 mg tid