Chapter 12 explores the relationship between cognition and interaction. The longitudinal study, spanning over two years, utilises Conversation Analysis (CA) to investigate the cognitive and interactional abilities of a person with Alzheimer’s disease, ‘May’, through 70 audio recordings of telephone conversations with family members. The chapter acknowledges a close relationship between language and cognition by examining how memory and memory loss are displayed in verbal conduct over time. Furthermore, the chapter sets out to challenge the deficit-focused perspective pervasive in dementia literature, showcasing how May employs sophisticated communicative strategies and transacts routinised practices of interaction even with more advancing dementia. The findings suggest a nuanced understanding of cognitive abilities in dementia, questioning the binary framework of competence versus incompetence in analysing complex cognitive issues and interactional events. The findings contribute to understanding the complexities of Alzheimer’s disease, emphasising the need for tailored communication strategies to enhance the quality of interactions for individuals and their family’s facing dementia. The chapter underscores the significance of using interaction as a window to cognition, offering insights into the degenerative consequences of Alzheimer’s and paving the way for a more nuanced understanding of cognitive decline in the context of family communication.

People with intellectual disability (particularly those with Down syndrome) have a higher risk of developing dementia than the general population. The varied presentation, the course, and available treatments are covered.

Delirium is more common in older adults, especially those with major neurocognitive disorders. Always do a thorough review of medications when considering any mental status changes in older adults. Medications and infections are the most common causes of delirium in older adults. Delirium is a medical emergency and warrants immediate medical evaluation and treatment.

Agitation is a neuropsychiatric syndrome that is commonly seen in those with major neurocognitive disorders. Those demonstrating agitation can show increase in motor activity, restlessness, emotional distress, and physical or verbal aggression. Agitation is the third most common neuropsychiatric symptom in dementia after apathy and depression. Up to 80% of people with dementia experience some degree of agitation at some point during the course of the illness. The pharmacologic management of agitation in those with major neurocognitive disorders is complex and many studies have shed light on the topic.

Biopsychosocial-spiritual distress, also known as agitation, can be experienced by anyone with unmet biological needs, safety needs, need for love and belonging, and need for self-actualization. Signs of potential biopsychosocial-spiritual distress can include: restlessness, aggression, agitation, sundowning, wandering, exit seeking, social withdrawal, repetitive behaviors, and increased anxiety. Common unmet biopsychosocial needs in long-term care can include loneliness, boredom, pain, hunger, toileting issues, difficulty communicating needs, medical interventions, changes in routine, interpersonal conflicts, staff issues, and issues with other residents. Potential signs of psychosis in those with major neurocognitive disorders can include screaming out, picking at the skin, extreme agitation with personal care, talking to oneself, signs of compulsive behaviors, and the presence of paranoia. The presence of psychosis in major neurocognitive disorder may warrant the use of antispsychotic angents.

Alzheimer’s disease is the most common form of major neurocognitive disorder, causing gradual declines in many areas of cognition. Alzheimer’s disease accounts for 60-70% of cases of dementia worldwide. Donepezil is the prototypical cholinesterase inhibitor and was approved for use in 1996. It is FDA approved for the treatment of mild, moderate, or severe Alzheimer’s disease and is considered a symptomatic treatment for Alzheimer’s disease and some other dementias as it does little to alter the course of the disease. The advantages to maintaining patients on cholinesterase inhibitors include continued slowing of the decline in cognition, delaying need for a higher level of care, and potentially delaying the need for medications to address neuropsychiatric symptoms.

This chapter describes basic principles of neuropsychology, patterns of neuropsychological dysfunction, methods of neuropsychological assessment, and neuropsychological approaches to psychopathology. It presents a history of clinical neuropsychology and illustrates the ways in which clinical neuropsychologists perform assessments and help design interventions for patients who experience neurological, cognitive, and/or psychological dysfunction related to conditions stemming from developmental, medical, degenerative, or other kinds of problems. It also highlights their research on both normal and abnormal brain functioning, pointing out that this research has helped shed light on psychological disorders such as depression and schizophrenia, and on neurological disorders such as Alzheimer’s disease or the effects of a concussion. The chapter portrays clinical neuropsychology as a rapidly growing field for which specialized training is required. Its practitioners must understand brain–behavior relationships and develop competence with a variety of assessment and intervention techniques that are unique to the field.

Shortly after microRNAs were discovered in humans they were found to be present in blood samples. This led to another branch of microRNA research with the potential to transform medicine, answering the question healthcare professionals ask every day. What’s wrong with my patient? This chapter introduces circulating microRNAs as biomarkers and their emergence as potential diagnostic tools. Core arguments in their favour as indicators of health and disease include tissue specificity, their known locations in the body enabling doctors to zero in on where a problem lies. It looks at what shelters microRNAs as they circulate in the bloodstream and the disruptive thinking that has interpreted such findings as evidence that extracellular microRNAs are conveyors of information between distant tissues in the body. It moves to efforts to probe ever-smaller volumes of biofluids to find the least-invasive source of microRNA biomarkers and the diseases for which microRNA-based diagnostic tests already exist or may emerge in the future. Finally, it looks at developments in RNA detection technology that might allow point-of-care testing and perhaps microRNA-based health monitoring at home.

In this chapter, readers are provided with 80 case examples of typical Alzheimer’s disease. Each case comes with a summary of cognitive and functional assessment results, complaints by informants, clinical history, laboratory examinations indicated, diagnosis, and management, followed by insights from both medical and psychosocial perspectives. These are organised around several themes: cases illustrative of pathognomonic features of Alzheimer’s disease; cases that are relevant for understanding cognitive, functioning, and clinical assessment findings; cases highlighting indications for further investigations; cases presenting with carers’ complaints about challenging behaviours; and cases in which the line between normal ageing, mild cognitive impairment, and mild dementia seems unclear.

We all have to eat, and what we eat has been established by numerous cultural forces. When we begin to view food as fuel for our brain, we may have to confront our dietary eating patterns in order to enhance brain health and mental strength. The consumption of hyperpalatable foods, often ultra-processed with excess sugar and fat, can lead to self-medication with food and to compromised brain health. The motivation and reward system in our brain that facilitates our habits includes the overconsumption of unhealthy food. This chapter covers the critical neurodestructive conditions that are impacted by our diet (dementia, Alzheimer’s disease, inflammation, oxidation, elevated blood sugar, malfunctioning gut microbiome); argues that ultra-processed foods and comfort foods with high concentrations of sugar and fat are bad for the brain, highly addictive, and targets for self-medication; and concludes with foods to avoid and foods to consume to optimize brain health and mental strength.

The brain has two superpowers: continuous development, which is the capacity to rewire itself with everything you think, learn, and do, called neuroplasticity; and neurogenesis, which is the birth of new brain cells in our memory-processing hippocampus. The brain has three functional areas: the primitive brain, the emotional brain, and the thinking brain. The emotional and thinking brains work together to help us learn and think and to develop our habits. Information flows throughout the brain, and from the brain to the body, via brain cells called neurons. Each lawyer’s brain has a unique network of brain cells because each of us leads different lives. Information is transmitted as an electrical impulse within the neuron, which shifts to a chemical messenger, called a neurotransmitter, to jump from neuron to neuron. The architecture of the thinking brain’s neural networks is called the connectome, and each brain is a work in progress for the entire lifespan. We can make choices that empower our brain, or decisions that harm our brain. With the right information, a lawyer can self-hack the brain to change its structure and function, improving its capabilities.

Advances in biomarker science are transforming the treatment of Alzheimer’s disease. First, clinicians can now identify Alzheimer’s disease neuropathology in situ, years, or even decades, before the onset of cognitive and functional impairment using biomarkers, particularly measures of amyloid, tau, and neurodegeneration. Second, there is growing evidence that other digital markers – for instance, changes in banking and driving patterns – can be used to identify older adults at increased risk of cognitive decline. As a result of these two advances, there is growing interest in monitoring older adults for incipient changes in cognition that might affect their wellbeing. This monitoring can be no-tech, such as when an older adult asks a friend or family member to let them know if they start repeating questions or retelling stories. Or it can be high-tech, such as installing a device in one’s car that tracks sudden accelerations and decelerations and the distance traveled from home. While there is great enthusiasm for this kind of monitoring among clinicians and researchers, and even, as our own research shows, among some older adults and their family members, other older adults deem monitoring to be an unwanted intrusion on their privacy. This chapter discusses the changing understanding of Alzheimer’s disease risk; presents data on the desire for monitoring, highlighting the potential for intrafamilial conflict; considers the ethical obligations of non-health businesses to collect or disclose information about Alzheimer’s disease risk; and, finally, identifies potential ethical and legal challenges – such as privacy, stigma, and discrimination – with possible solutions.