NEUROBEHAVIOR

(BEHAVIORAL NEUROLOGY)

Divisi Neurology Kognitif dan Behavioral Neurology :

pendekatan komprehensif multidiscipliner untui diagnosis
dan management pasien dengan memory, fungsi
eksekutif, atensi, bahasa, emosi, atau tingkah laku
akibat penyakit, cedera atau gangguan
perkembangan pada SSP.

Asesmen dan tatalaksana pada :

- Dementia (e.g., Alzheimers disease dan kelainan
degeneratif lain, vascular dementia, frontotemporal
dementia, dementia dengan parkinsonism)
- Gangguan kognitif, emosi atau tingkah laku akibat
bermacam sebab (epilepsy, multiple sclerosis, stroke,
traumatic brain injury, brain tumor, kelainan sistemik
dengan manifestasi SSP)
- Gangguan perkembangan pada dewasa (Attention
deficit
disorder,
gangguan
belajar,
mental
retardation,autism).

Basic brain biology

Otak manusia terdiri atas:
- Brain stem, hind brain, mid brain, cerebellum:
organ yg paling awal, terhubung dg medula
spinalis mengatur pergerakan, pernafasan dan
jantung.
- Limbic system
Hypothalamus, hippocampus fungsi memori
dan respon emosi.
- Cerebral cortex
the distinguishing feature of human brains

Tahap pembentukan otak

1. Neural tube
2. Proliferasi
3. Migrasi
4. Mielinisasi
5. Sinaptogenesis

4 weeks

7 weeks

2 years

3 weeks

3 months

6 months

 Occipital - visual
Parietal pergerakan,
orientasi, kalkulasi,
pengenalan
Temporal suara dan
bicara, aspek memori
Frontal berfikir,
konseptualisasi,
rencana.

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

Macam-macam ggn perkembangan :

1. Disfasia
2. Disleksia
3. Diskalkulia
4. Disgrafia
5. Dispraksia
6. GPPH
7. Autisme
1-6 Disebut sebagai Learning disability

Disfasia:
Tidak / terlambat bicara
12 bln ; ma., pa.
18 bln ; mama, papa
24 bln ; mama makan

DISLEKSIA : kesulitan membaca

VISUAL DYSLEXIA

- ggn memori berat

- tdk dpt membaca huruf atau baca huruf demi
huruf
- terbalik huruf yang mirip : b d, p q.

DISCONNECTION DYSLEXIA
- peralihan huruf atau kombinasi huruf ke bahasa,

buta
huruf atau buta kata.

DISPHONEMIC DYSLEXIA
- ggn persepsi bunyi, krn ada huruf yg hilang
VERBAL DYSLEXIA
- bicara tdk lancar

DISKALKULIA : kesulitan berhitung

1. Ideognostic dyscalculia
ggn pemahaman abstraksi angka
7 berarti mewakili sesuatu berjumlah tujuh

2. Verbal dyscalculia
ggn mengerjakan soal hitungan dengan kalimat

3. Dysortographic dyscalculia
ggn pemahaman tanda aritmatika, tanda + , - , :
,x

4. Operational dyscalculia
pemahaman aritmatika baik tapi ggn
penghitungan yg kompleks

Disgraphia
Gangguan menulis
Gangguan menggambar

DISPRAKSIA
1. Dyspraxia Ideomotoric
ggn praksis sederhana, kurang luwes; gsk gigi, makan pakai
sendok, menggunting dll
2.

Dyspraxia Ideasional

ggn dlm urut-urutan melakukan gerakan, bingung untuk mengawali

suatu aktifitas

3. Dyspraxia Konstructional
ggn gerakan kompleks yg berkaitan dgn bentuk, nyusun balok,
menggambar dll.
4. Dyspraxia oral
ggn gerakan motorik di mulut; ggn berbicara ( disartria)

GPPH / ADHD
Perhatian : tidak bs konsentrasi, mudah
terpecah perhatiannya, bosan.
Hiperaktif : tidak bisa diam, lari kesana
kemari,

DSM III mendefinisikan GPPH dengan 3

gejala utama :

Inatensi
Impulsifitas
Hiperaktif

2 jenis GPPH :
1. defisit atensi dan hiperaktifitas, ketiga
gejala ada.
2. defisit atensi dan impulsifitas tanpa
hiperaktif

Atensi : kemampuan untuk memfokus

perhatian pada masalah yg dihadapi
atensi ada 2 aspek ;
1. seleksi : lob. Frontal dan sirkit limbik
2. sadar : R.A.S , talamik dan cortek

DEMENTIA
Sekumpulan gejala yg bisa disebabkan oleh
60-70 penyakit.
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
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
4,000,000 orang di U.S.
Perubahan pada Alzheimers Disease:
Diminished blood flow
Neurofibrillary Tangles
Neuritic Plaques
Degeneration of hippocampus, cerebral
cortex, hypothalamus, and brain stem

Neurofibrillary Tangles
Intracellular inclusion bodies: filamen
helical berpasangan double-helix.
Hyperphosphorylated microtubule yg
berhub,. Dg protein, disebut tau.
Kerusakan neuronal microtubules.
Amyloid Plaques
Struktur extracellular di hippocampus dan
neocortex.
Padat dan insoluble structures.
Inti beta-amyloid protein yg dikelilingi
axons dan dendrit abnormal.

Teori Etiologi Alzheimer's

Perubahan Neurotransmitter: Acetycholine ,penting
untk fungsi kognitif.
Perubahan Sintesis Protein: Beta amyloid
(penyebab plaque), Tau(neurofibrillary tangles).
Teori Genetik: ApoE4 pd chromosone 19: lateonset, Chromosome 21: early-onset.
Teori Metabolik: Berkurangnya metabolisme
glukosa scr dramatis.
Teori Calcium: terlalu banyak kalsium
membunuh sel neuron mati

Theories Regarding Causes of

Alzheimer's
Environmental: Aluminum, Zincpada otak
saat autopsi.
Viral
Trauma Kepala: meningkatkan konsentrasi B-amyloid
protein

Edukasi Rendah kurang mampu mengkompensasi

defisit kognitif
Defisiensi Estrogen
Early Life Experience---kehilangan ortu sebelum 16
tahun

Gauthier at all, 1997

Diagnosis Alzheimers Dementia

Memory Impairment
Multiple cognitive deficits :
Aphasia:
Expressivetidak mampu mengucapkan kata2
Receptivetidak memahami bahasa lisan maupun tulisan

Apraxiatidak mampu melakukan gerakan

kompleks, atau tidak mampu melakukan aktivitas
dibawah perintah.
Agnosia---tidak mampu mengenali objek dengan
melihat, menyentuh, merasa, mencium atau
mendengar

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