1. THE AGING BRAIN DEMENTIA, DEPRESSION, AND SUNDOWNERS SYNDROME Teresa Stoddard

2. Annotated Bibliography Beason-Held, L., Dotson, V., Kraut, M.,Resnick, M.(2009). “Longitudinal study of chronic depressive symptoms and regional cerebral blood flow in older men and women". International Journal of Geriatric Psychiatry May 2009 808-819.Academic Search Premier. EBSCO. 15 Jan 2011.www.interscience.wiley.com. This article examines depression and its associations with the alterations that take place in the brain, particularly cerebral blood flow. Sixty one dementia free adults with an eight year follow up were studied. Castel, S., Rewilak, D., Scalo, M., Streiner, D., Van Reekum, R.(2008). “Smell tests predicts performance on delayed recall memory test in elderly with depression.” International Journal of Geriatric Psychiatry Sept. 2008 376-381. Academic Search Premeir.EBSCO. 15 Jan 2011. www.interscience.wiley.com. This article studies the correlation between smell tests and dementia in the elderly. Results suggest smell tests may be used as a screening tool for cognitive impairment among the elderly with depression.

3. Davatzikos, C., Dotson, V., Kraut, M.,Resnick, S.(2009). ”Depressive symptoms and brain volumes in older adults: a longitudinal magnetic resonance imaging study.” Psychiatry Neurosci2009; 34(5):367-75. This study examines the decreased brain volumes in late life depression patients, particularly the frontal and temporal areas. Brain volume reductions with advancing age were associated with the cingulategyrus and orbitofrontal cortex. Hurley, A., Mahoney, E., Volicer, L. Challenging Behaviors in Dementia. Health Professionals Press, Inc., 2000. Print. This book focused on dementia and personality, functional impairment, and mood disorders. The book offers real life case studies and contextual framework for understanding the challenging behaviors of dementia.

4. Annotated Bibliography Continued “Ageing and the brain.” J Pathol 2007; 211: 181-187. Journal of Pathology. www.interscience, wiley.com. This study summarizes the evidence of changes in the brain that go along with ageing. Neuron loss along with the reduced size of dendrites and axons in the ageing brain and the roles of genes and environmental factors are explored. About Sundowners Syndrome. John Lindell. Retrieved 11 Jan. 2011 http://www.ehow.com/about This article defines the phenomenon of Sundowners Syndrome, the causes,treatmentsand what parts of the brain are affected. The article also offers information on how to identify the symptoms, and ways to cope.

5. Dementia, from the Latin word for “apart “and “mind” is the symptom of the deterioration of intellectual faculties such as memory, concentration and judgment. Dementia is among the most frequent diseases of the central nervous system that occurs with age. Dementia disorders can be classified many different ways. The different classifications attempt to group disorders that have particular features in common, such as whether they are progressive, or what parts of the brain are affected. The five most common types of dementia are: cortical dementia, where the brain’s cortex is affected and causes problems with memory, language, thinking and social behavior. Subcortical dementia affects parts of the brain below the cortex and causes changes in emotions and movement along with problems with memory. Progressive dementia gets worse over time, gradually interfering with cognitive abilities. Primary dementia, such as Alzheimer’s disease, does not result from any other disease and secondary dementia, that occurs as a result of a physical disease or injury.(Hurley, Mahoney, Volicer, Challenging Behaviors in Dementia, 2000). As our population is increasingly ageing, problems connected to old age will dominate health care. Depression will take an even more prominent position because depressive symptoms are present in almost one third of the elderly population, especially those with dementia. The study, Longitudinal study of chronic depressive symptoms and regional cerebral blood flow in older men and women,(Beason-Held, et al.,2009) showed the depressive symptoms in older adults are associative with cognitive deficits, and that there were alterations in cerebral blood flow and metabolism in the frontostriatal and limbic regions and the cerebellum.

6. The study was done by obtaining PET scans and revealed the relationship between depression and patterns of brain activity. The scans revealed the associations were primarily in frontal and temporal regions. The study did an eight year follow up showing both men and women had unique associations between depressive symptoms and cerebral blood flow that was not evident at baseline. The key learning was older adults with depressive symptoms show a pattern of cerebral blood flow abnormalities similar to that observed in late life depression. The study , Smell test predicts performance on delayed recall memory test in elderly with depression, (Castel, et al.,2008)suggests elderly with depression are at an increased risk for cognitive dysfunction and dementia. Dementia and depression are seemingly connected, does depression cause dementia, or does dementia cause depression? We may never know. This study was able to identify that odors involve the medical temporal lobe structures and is affected early in the progression of Alzheimer's Disease. The participants did a scratch and sniff test that confirmed olfactory dysfunction is associated with higher risk of cognitive decline. More than half of the patients without cognitive impairment had late-onset depression, and the group with cognitive impairment had worse performance on all tests. The key learning of this study were smell test may potentially be used as initial screening for cognitive impairment in assessing elderly people with depression to select who should be referred for further neuropsychological assessment. The following chart shows the decline in memory recall according to age, when identifying smells.

7. Late life depression is associated with decreased brain volumes, particularly in the frontal and temporal areas, and are also associated with brain atrophy in these regions. According to the article, Ageing and the brain,( Journal of Pathology(2007);211:181-187, brain volume reductions increase from about “0.1%-0.2%/year at age 30-50 years to 0.3%-0.5%/year over the age of 70 years." The frontal and parietal cortex are affected more than the occipital cortex. The similarities of the brain volume of the ageing brain and the brain of those with late life depression are strikingly similar. Dementia may be caused by more than one mechanism in the same person. It is recognized that memory becomes somewhat impaired during normal aging, and this is called benign senile forgetfulness.

8. The difference between this normal forgetfulness and dementia is, with dementia the continued decline of memory becomes steadily worse, often ending up with Alzheimer’s Disease .Clinical diagnosis of progressive dementias is supported by neuropathological examination of the brain. One theory suggests gene mutation while others suggest neuritic plaques and neurofibrillary tangles. Head trauma, estrogen deficiency, and environmental toxins have also been thought to be causes. The research paper titled “Depressive symptoms and brain volumes in older adults” (Dacatzikos, et al., 2009) examined participants over a nine year period during which structural MRI’s were acquired and depressive symptoms were measured. The results of this study showed depressive symptoms were associated with grey matter volume reduction in the left temporal lobe, and were also associated with brain volume reductions with advancing age in the cingulategyrus and orbitofrontal cortex. Given the extensive literature linking late life depression to dementia and implicating the atrophying of the brain, it seems there is some connection associated with brain volumes. The cognitive deficits in dementia occur in several spheres including memory and a disturbance in executive function. As dementia progresses, cognitive skills decline, with complex functions ,such as problem solving, being affected first. The decline may continue to include more simple aspects such as sensory reception.

9. Some medications may delay the clinical symptoms, but no medication stops the pathological changes or their clinical consequences. Successful management of the challenging behaviors of dementia patients becomes critical for their well-being.These challenging behaviors vary and can go from mild and moderate, to severe and terminal. The mild stage of dementia may mean memory loss and personality change, while the severe and terminal stages may mean resistiveness, incontinence and finally bed ridden and mute. The true cause of dementia and Alzheimer’s is still a mystery, and that is true also for yet another type of dementia called Sundowner’s Syndrome. Sundowner's Syndrome refers to a symptom often associated with the early stages of dementia, including Alzheimer’s, and is considered a mood disorder (Lindell, 2011). Sufferers experience periods of extreme agitation and confusion especially during the late afternoon and early evening hours. Research to date suggests this illness is a result of the degradation of certain areas of the brain. Cells is the rhinal area of the cerebral cortex ( a part of the brain that stores memory) seem to be the first to be affected, followed by the hippocampus(area of spatial awareness) and the temporal and parietal lobes(areas that deal with words and memory) .These area are the same areas affected with dementia.

10. Symptoms of Sundowner’s include mood changes, anger, crying, pacing ,fear, paranoia, hallucinations; again, many of the same symptoms of dementia. Health experts feel darkness is a key factor because symptoms decrease during day light hours. Reducing stress, regular daily routine and sleep routine seem to help in decreasing the severity of symptoms. The cause of these forms of dementia may never be fully understood, the symptoms are believed to be a result of neurons in the brain that stop working. Strokes and such diseases as Parkinson’s put people at more risk, but the end result is dementia, of any type, is a cruel phenomenon. On a personal note, I have just started this long dementia journey with my own Mother, and perhaps the best advice I have been given by her nurse was, don’t ever ask her, “do you know who I am, Mom?” This immediately puts her mind into a state of confusion. Instead just identify myself right away, and then put myself in the time and place of wherever her mind might be at the time!