Dementia

Types of Attention

Orientation, Sustained, Selective, Alternating, Divided

Orientation Attention

Directing cognitive and visual resources to external stimuli

Ex: What city are we in right now?

Sustained Attention

Ability to maintain attentional resources on a stimulus for prolonged periods of time

Ex: Reading a book for 30+ minutes straight.

Selective Attention

Attending to a stimulus in favor of another

Ex: Watching TV while ignoring family conversation.

Alternating Attention

Ability to switch attentional resources from one stimulus to another

Ex: Driving and talking on hands-free phone (task-switch).

Divided Attention

Distribution of attentional resources to more than 1 stimulus at the same time.

Ex: Walking the dog while texting.

Types of memory

Sensory, STM, LTM, Working, prospective and emotional

Sensory memory

Pre-attentive memory system that briefly stores sensory information

Ex: Echo of someone's last word after they stop speaking.

STM

Brief storage of info w/o rehearsal

Ex: Remembering a phone number long enough to dial it.

Working Memory

Storage, maintenance and manipulation of information

Ex: Following multistep directions w/o writing them down

LTM

Episodic, semantic and Procedural memories

Episodic: Autobiographical and learning event memories (last birthday celebration)

Semantic: General Factual knowledge (Paris is capital of France)

Procedural: Motor based and behavioral memory (riding a bike)

Prospective Memory

Remembering of time or event based actions in the future

Ex: Stopping at store on way home from work.

Emotional Memory

Memories that emotionally charged or relevant

Ex: Flashback to smell of grandma's kitchen → warm feeling

Implicit Learning Process

Use of unconscious and automatic processing for learning and retrieving information

Ex: Gradually improving gait pattern through repeated walking practice without conscious rules.

Explicit Learning Processes

Use of conscious and effortful processing for learning and retrieving information. Can be considered intentional learning/retrieval

Ex: emorizing list of precautions after total hip replacement

Sensory memory usually lasts how long, and how does it encode?

Usually <1 sec or so. Encodes info from external sensory events

If you want to remember sensory memory, what attention should you use?

Selective attention.

After selectively being attentive to the sensory, what occurs?

STM, which unrehearsed info is lost in about 15-30 seconds.

How to convert STM to LTM?

It must be rehearsed, consolidated for information to be retained indefinitely, although some info may be difficult to retrieve.

Executive Function

Higher Order Cognitive Processes

Ex: Deciding what to wear based on weather and schedule

Everyday Cognition

Use of cognitive processes in real-world contexts

Ex: Estimating how long commute will take in traffic.

Wisdom

Deeper knowledge and understanding based on life expertise

Ex: Knowing when to give advice vs. stay silent.

Expertise

High level of skill in a particular area

Ex: Mechanic diagnosing car issue by sound alone.

Dementia Classification

Not a specific disease, but classifies range of sx. Sx must be severe enough to interfere with daily activities and serious mental decline is NOT part of normal aging

Signs of dementia

Poor judgment and decision making

Inability to manage a budget

Losing track of the date or the season

Difficulty having a convo

Misplacing things and being unable to retrace steps to find them

Typical Age related changes

Making an occasional bad decision

Missing a monthly payment

Forgetting which day it is and remembering later

Sometimes forgetting which word to use

Losing things from time to time

Reversible Causes of Dementia

Depression, delirium, NPH and brain tumor

Irreversible Causes of Dementia (ranked)

1. Alz

2. Vascular Dementia

3. Lewy body dementia

4. Mixed Dementia

5. PD

6. Creutzfeldt-jacob Disease

7. HD

8. Wernicke-Korsakoff Syndrome

>65 Most common causes of Dementia

1. Alz (54%)

2. Other dementias (30%)

3. Vascular Dementia (16%)

<65 Most common causes of Dementia

1. Alz (34%)

2. Vascular Dementia (18%)

3. Other dementias (14%)

4. Frontotemporal Dementia

5. Alc related dementia (10%)

6. Dementia with Lewy bodies (7%)

7. HD (5%)

Alzheimer's Disease

Progressive, neurodegenerative disease that leads to memory, thinking and cognitive decline

Alzheimer's Epidemiology

Prevalence: 5.5 million Americans with AD, expected to reach 14 million by 2050

Gender: More common women (2:1)

Age: Americans >65 = 1 in 8 has Alz. 50% of people aged 85 and older have the disease

Alzheimer's Disease Pathophysiology

Harmful deposition of extracellular amyloid plaques and intracellular tau-protein tangles in.....

Lateral parietotemporal area, hippocampus, and frontal association areas

Alz Etiology

Unknown (genetic or environment)

Alz RF

Age (#1), low education, genetic (APOe4), lifestyle and gender

Protective factors of Alz

Cognitive reserve, mild-moderate alcohol consumption, mediterranean diet, regular physical activity and social support

Alzheimer's Disease Stages

preclinical, MCI and Dementia

Alz Preclinical Stage

Detectable biomarker changes prior to cognitive sx

Alz MCI stage

Mild memory and cognitive changes that are detectable on mini mental state exam and MoCa. Changes do not disrupt daily life

Alz Dementia Stage

Memory, thinking and behavioral changes that impair a person's ability to function independently

Alzheimer's Treatment Pharmacology and Supportive Interventions

Cholinesterase Inhibitors, NMDA and Monoclonal Antibody Treatments

PT/OT/ST

Cholinesterase Inhibitors

Donepezil (Aricept)

Galantamine (Ranzadyne)

Rivastigmine (Exelon)

Tacrine (Cognex d/c)

Increase acetylcholine to aid memory/thinking.

NMDA Receptor Antagonists

Memantine (Namenda)

Regulates glutamate to reduce excitotoxicity.

Monoclonal Antibody Treatments

Lacanemab (Laqembi) and Aducanumab (Aduhelm)

Slow progression by clearing amyloid;

Alz Life Expectancy

6-15 years after dx

Alz Cincinal Presentation of Cognitive Deficits

Very early STM deficits, problem solving difficulty, contextual orientation is compromised early, prospective memory deteriorates early

Alz Motor Deficits

Gait dysfunction, impaired balance and decreased dexterity

What is preserved in Alz?

Focused attention, procedural (implicit memory), reading and aspects of language remain intact until late in disease, L/R orientation, unless it requires mental rotation and emotional memory

GDS

Global Deterioration Scale. Contains 7 stages

Stage 1-3 of GDS is?

Pre-Dementia

Stages 4-6 of GDS is?

Dementia.

Stages 5-7 require what in GDS?

Assist

Stage 1 of GDS

Normal, 25+ MMSE

Sx: STM Problems and variable with stress

Stage ll of GDS

Aging Adult/MCI, MMSE 18-24

SX: Use of compensatory strategies masks deficits

Stage lll of GDS

MCI/Early dementia, MMSE 12-17

Sx: Indiv recognizes as compensatory strategies fail

Stage IV of GDS

Early Moderate Dementia, MMSE 8-12

Sx: Others become aware of problems

Stage V of GDS

Moderate Dementia, MMSE 5-7

Sx: No longer aware of decline, over mobility deficits

Stage Vl of GDS

Severe dementia, MMSE 2-5

Sx: Self care affected, greater physical decline

Stage Vll of GDS

Severe/end stage dementia, MMSE 0-2

Sx: dominated by senses, unable to communicate verbally

Rehab Strategies for GDS stage 3/4

Education & Physical Activity

Teach disease process & progression

CDC fitness: 150 min moderate aerobic + 2× strength/week + balance

Future planning: advance directives, POA, care options

Caregivers & Compensatory Strategies

External reminders: calendars, pill boxes, alarms, voice assistants

Environmental set-up: labels, declutter, consistent placement, lighting

Routines/schedules: fixed daily structure

Mental Stimulation

Puzzles: crosswords, jigsaws (match level)

Socializing: groups, family, senior centers, calls

Everyday tasks: folding laundry, setting table, watering plants → maintain independence

Rehab Strategies for GDS 4

Safety: Household and community

Routines: Avoid distressing patient and participate in social events and ADLs as able to

Physical Therapy: Mobility, balance, strength and AD

Rehab Strategies for GDS Stages 5-6

Safety w/ Assistance: How to assist pt, supporting caregivers, LTC/home modification

Physical Therapy: Obtaining equipment, positioning, mobility and social engagement

Effective Communication Examples

Patience: Wait for response without interrupting

Brevity: "Stand up" (not long explanations)

Modeling: Demonstrate putting on jacket first

Narrowing choices: "Tea or coffee?" (not open menu)

Errorless Learning Examples

Prevent mistakes

Avoid trial-and-error practice

High reps

Ex: Hand-over-hand guide tying shoes correctly every time

Spaced-retrieval examples

Leverages implicit memory

Repeat target info at increasing intervals

External memory aide examples

Large calendar with doctor appointments

Labeled drawers ("socks", "shirts")

Pill organizer with days/times

Alarm clock for meals/meds

Who is affected most with these patients?

Caregivers undergo depression, anxiety and financial issues (57.8% undergo levels of burden)

PT reduced burden