Week 7 (Cognitive impairments)

Definition of cognition

Mental activities & processes, and their use in perceiving, remembering, thinking & understanding

- Communication

- Memory

- Alertness

- Attention

- Executive function

- Emotional state

Definition of cognitive impairments

Disorders in one of the components of cognition due to e.g. drugs, stroke, MS or CP, e.g.:

- Trouble remembering

- Delays in processing and task execution

- Difficulty learning new things

- Issues with concentrating or making decisions

Definition of dementia

- progressive deterioration of intellect, behaviour and personality due to diffuse disease of the cerebral hemispheres, maximally affecting the cerebral cortex and hippocampus

- Causes substantial cognitive decline (more than expected from ageing) that interferes with independence

- One or more of complex attention, executive ability, learning & memory, language, perception or social cognition

- May be accompanied by changes in mood, emotional control, behaviour, or motivation

Types of dementia

- Alzheimer's disease

- Vascular dementia (due to multiple small infarcts)

- Fronto-temporal dementia (causes personality & mood changes)

- Dementia with Lewy bodies (mimicking PD)

- neurodegenerative

- normal pressure hydrocephalus

Classification of dementia

- Based on location (anterior, posterior or subcortical)

- Based on cause (infectious, nutritional, metabolic, trauma, medical)

Diagnosis of dementia

- Clinical diagnosis (with detailed history)

- Exclusion of potentially treatable causes

- Differential diagnosis (as may have dementia, delirium and depression)

Features of different stages of dementia

Early stage:

- Losing track of time

- Short term memory loss

- Forgetfulness

Middle stage:

- Forgetful of recent events / people's names

- Needs help with personal care

- Behaviour change (wandering, repeated questioning)

Late stage:

- Unaware of time & place

- Unable to recognise family / friends

- Behaviour changes (e.g. aggression)

- ↑ need for assisted self-care

Pathophysiology of Alzheimer's disease

- Degenerative changes to neurons (atrophy)

- Formation of neuritic plaques and neurofibrillary tangles

- Neurotransmitter changes (↑ glutamate & ↓ acetylcholine)

Types of vascular dementias

- Multi-infarct dementia: by a number of smaller strokes

- Subcortical vascular dementia: hypertension causing thickening of blood vessels and inadequate blood flow

- Strategic infarct dementia: single large stroke

Symptoms of vascular dementia

- Depending on area of brain affected

- Executive functions, spatial processing & attention impaired

- Walking impairments & balance

- Less of memory loss

Diagnosis of vascular dementia

- Clinical diagnosis based on presence of cognitive impairment and vascular disease

- Medical Hx (stroke / heart issues)

- Blood tests (exclude infective causes)

- Brain imaging to identify type & location of vascular brain damage

- Neuropsychological tests to assess executive & subcortical brain functions

Definition of delirium

- Concurrent disturbance of consciousness & attention, perception, thinking, memory, etc.

- Variable duration and severity of symptoms (mild - severe)

- "Clouding of consciousness"

Subtypes of delirium

- Hyperactive: agitated, restless

- Hypoactive: drowsy, inattentive

- Mixed

Common causes of delirium

- Medications

- Infection (UTI)

- Metabolic disturbance

- Intoxication with ethanol (ETOH)

- Constipation

- Surgical procedure (e.g. DHS for #NOF)

Differential diagnosis between delirium & dementia

Delirium:

- Sudden onset

- Lasts for hours to days, worse at night

- Alertness fluctuates through the day

- Emotions fluctuates (outbursts, anger, fearful, crying)

Dementia:

- Gradual decline

- Lasts months to years, stable through the day

- Attention mostly normal

- Emotions flat (depressed, apathetic or disinterested)

Screening tools for dementia & delirium

Delirium:

- Confusion assessment method

Dementia:

- Mini-mental state examination

- Clock drawing test

- Rowland Universal Dementia Assessment Scale

Gait changes with cognitive changes

- Reduced gait speed & cadence

- Inability to dual task

- Reduced trunk stability

complications of dementia

• behavioural and psychological symptoms (disturbed perception, thought content, mood, behaviour)

• falls (2x more likely)

• motor problems (dyspraxia and apraxia)

Medical management of dementia

- Acetylcholinesterase inhibitors

- Blocking of excessive glutamate

- Tranquilisers to manage agitation & aggression

- Reminiscence therapy: inconclusive evidence

- Companion animals

MDT management of dementia

- Geriatricians, allied health staff, nursing & pharmacy

- Cognitive, dementia & memory services: education support, information and links to other service providers

- Aged care programs (home care packages): services to meet old people needs

- Legal services: power of attorney

- Community organisations (dementia support australia)

Physiotherapy for cognitive impairments

- Multimodal exercise (aerobic, balance, resistance, etc.): can ↓ risk & pathological features of Alzheimer's

- 1 hour twice weekly for at least 4 months

- Education of patient & carer

- Pain management

- Mobility assessment & management

- Falls prevention

- Carer education re: transfers & mobility skills

How to optimise physiotherapy interventions in cognitive impairments

- Consider the environment when working with the client

- Validating the person's fears and concerns

- Writing instructions & displaying them in an obvious place

- Developing a good communication plan

- Minimising complex techniques & equipment

- Avoiding "dual task" activities

- Educating carers

- Modifying environment if client cannot alter motor performance

Managing cognitive deficits when managing dementia

Memory:

- Writing it down, habits & reminders

- Spaced repetition, frequent feedback

Attention: short & frequent sessions

Executive function: greater attention to safety & assistance with planning exercises

Visuospatial function: contrasting colours & visual cues

Motivation: Performing enjoyable activities, habit formation, fitting into daily routine, or joining a group