Class 7 - Aging & Dementia

(Normal Aging) Language remains intact:

• Slight decline in word-finding abilities

• No change in comprehending everyday discourse (e.g., television newscast)

• Syntactic complexity in discourse declines with aging

(Normal Aging) Sustained attention remains mostly intact:

• Slightly decline in selective attention skills

(Normal Aging) Divided attention skills intact during simple tasks:

• Divided attention begins to break down in complex tasks

Normal Aging Continued:

• Reaction time is slowed

• LTM & procedural memory remain intact

  • STM is reduced

What is Mild Cognitive Impairment?

• Changes that are significant enough to not be within the normal spectrum of changes w/ age, but not severe enough to affect ADLs

• MCI may increase the risk of later progressing to dementia, caused by Alzheimer’s disease or other neurological conditions

• In some people, MCI never gets worse

• And in some other people, MCI eventually gets better

What is the 3 criteria for diagnosing MCI?

1. Self-report of memory problems, w/ corroboration from a family member or caregiver

2. Measurable memory impairment on standardized testing, outside the range expected for age- & education-matched healthy older adults

3. No impairments in reasoning, general thinking skills, or ability to perform ADLs

What are the etiologies of MCI?

• Arises from a lesser degree of the same types of brain changes seen in Alzheimer’s disease or other forms of dementia

• Small strokes or reduced blood flow through brain blood vessels

• Shrinkage of the hippocampus, a brain region important for memory

• Enlargement of the brain’s fluid-filled spaces (ventricles)

What symptoms are included in Mild Cognitive Impairment?

• Decreased sustained attention

• Decreased word-finding abilities

• Decreased STM, episodic memory, semantic memory

• Difficulty w/ executive functions

• Difficulty following detailed heavy conversations/writings

• No functional impairment

• No significant impairment in occupation & social function

What are the 2 types of MCI?

• Amnestic

• Non-amnestic MCI

Amnestic MCI:

• Single-domain: Most common; Majority of client amnestic MCI progress to AD

• Multiple-domain

Non-amnestic MCI:

• Single-domain: Relatively isolated impairment in a single non-memory domain such as EF or visuospatial processing

• Multiple-domain: Slight impairment in multiple non-memory domains, not enough to constitute dementia

(DSM-5 Criteria for Neurocognitive Disorders) Mild Neurocognitive Disorders:

• Mild cognitive impairment or MCI

• Evidence of modest cognitive decline

• Does NOT interfere w/ independent completion of ADLs

(DSM-5 Criteria for Neurocognitive Disorders) Major Neurocognitive Disorders or Dementia:

• Evidence of significant cognitive decline

• Cognitive decline must be severe enough to disrupt independence in ADLs

What are the cognitive domains affected by dementia?

• Memory

• EF

• Attention

• Language

• Visuospatial function

• Instrumental Activities of Daily Living

What are the progressive dementia types?

• Alzheimer’s disease

• Frontotemporal dementia

• Lewy Body dementia

What are the potentially reversible or stoppable dementia types?

• Medication-induced dementia

• Metabolic / endocrine/ nutritional / systemic disorders

• Vascular dementia / hydrocephalus / tumors / hematoma

• Depression

Dementia Image:

Alzheimer’s Disease:

• Single most common cause of dementia

• Currently affects nearly 5.7 million Americans (Alzheimer’s Association, 2018)

• In the U.S., AD affects more women than men

What does neuropathology in AD include the presence of?

• Beta-amyloid plaques: Dense protein deposits that accumulate outside & around neurons

• Neurofibrillary tangles: Twisted fibers of tau protein that build up inside neurons

• General neuronal atrophy-shrinkage of cortex & widening of ventricles

What are the modifiable risk factors of AD?

• Heart-healthy diet

• Social & cognitive engagement

• Regular physical activity

• Controlling cardiovascular risk

• Preventing TBI

What are the nonmodifiable risk factors of AD?

• Older age

• Positive family history of AD (esp in first-degree relatives)

• Carrier status for the e4 allele of APOE gene

Alzheimer’s Disease (AD) Continuum:

What are the earliest symptoms of AD?

• Episodic memory deficits

• Working memory deficits

• Attention & EF impairments

• Language & communication impairments adversely affecting lexical retrieval & discourse

AD Middle Stage:

• Negative impact on ADLs & reliance on others

• More severe memory loss, attention deficits, dramatic personality changes, visuospatial & visuo-constructive deficits, & expressive language deficits

• May experience wanderlust, sundowner syndrome, disorientation, & confusion

AD Late Stage:

• Loss of motor function

• May become non-ambulatory, bedridden, incontinent, & unresponsive

• Memory, cognition, & expressive language deficits are profound

• May cause muteness & dysphagia

Vascular Dementia (VaD):

• Considered the second most common cause of dementia

• Caused by ischemic or hemorrhagic cerebrovascular disease, cardiovascular disease, or circulatory disturbances that damage brain areas vital for memory & cognitive functions

• Risk factors are similar to AD

• On average, people w/ vascular dementia may progress faster than those w/ AD

Vascular Dementia (VaD):

• Sudden onset of any of the following symptoms

  • Confusion & episodic memory impairments

  • Slowed processing

  • Wandering or getting lost in familiar places

  • Rapid, shuffling gait (history of unsteadiness &/or falling)

  • Loss of bowel or bladder control

  • Emotional lability

  • Difficulty following instructions

  • Problems handling money

A Diagnosis of VAD Requires:

• Objective evidence of cardiac &/or systemic vascular conditions

• Evidence of cerebrovascular disease etiologically tied to onset of dementia symptoms

• Focal neurological s/s (e.g., difficulties in movement, sensation, or speech-language)

• Brain imaging evidence for ischemic, hemorrhagic, or white matter lesions on CT or MRI scans

What is frontotemporal lobar degeneration (FTD or FTLD)?

• FTD is a heterogeneous group of rare neurodegenerative disorders that result in significant impairments of behavior, personality, & distinct types of language impairment

• Most FTDs are diagnosed before the age of 65 years, usually between the age of 35-75 years

• Rapidly progressive; has a 2 to 10 year disease course

• Strong genetic component; positive family history in 20-40% of cases

• Hallmark symptom: Progressive decline in behavior &/or language

FTD → Neuropathology:

• FTDs are characterized by:

  • Progressive, focal atrophy of the frontal & anterior temporal brain regions

  • Spongiform changes in the cortex

  • Abnormal tau protein inclusions

What is Primary Progressive Aphasia (PPA)?

• _____ is a specific type of a more general frontotemporal dementia

• It is also an unusual dementia since episodic memory functions remain largely preserved for many years

• The language impairment constitutes the most salient symptom that impacts the ADLs in the initial stages

• The cognitive decline follows the language symptoms

• In contrast to Alzheimer’s dementia, where patients tend to lose interest in recreational & social activities, some patients w/ PPA maintain & even intensify involvement in complex hobbies such as gardening, carpentry, sculpting & painting

What is the diagnostic criteria for PPA?

• Gradual onset of language problems, isolated in initial stages of disease

• Impaired ADL related to language deficit

• No initial prominent visuospatial or episodic memory deficits

• No initial behavioral disturbances

• Impairment NOT explained by stroke, tumor, TBI, or other neurological or psychiatric condition

PPA Subtypes:

• Diagnosis of PPA subtype should follow PPA diagnosis:

  • Semantic variant

  • Logopenic variant

  • Nonfluent variant

• Consensus criteria for diagnosis of PPA subtypes developed by international panel of experts

What is semantic PPA?

• loss of semantic knowledge d/t anterior temporal lobe atrophy, greater in the language dominant

What are the core clinical features of semantic PPA?

1. Picture naming deficit

2. Single-word comprehension deficit

What are the supporting features of semantic PPA?

• At least 3 of the following:

1. Loss of object knowledge

2. Surface dyslexia/dysgraphia

3. Relatively preserved repetition

4. Intact grammar & motor speech

What is the disease progression of semantic PPA?

• Atrophy spreads throughout semantic network, eventually affecting frontal & parietal lobes as well

• Progressively empty speech

• Behavioral symptoms may emerge

  • Compulsions

  • Disinhibition

  • Personality changes

  • Altered eating preferences

• Worsening dysexecutive symptoms

What is logopenic PPA?

• Impaired phonological processing d/t temporoparietal atrophy, greater in language dominant hemisphere

What are the core clinical features of logopenic PPA?

• Both of the following:

1. Difficulty w/ single-word retrieval in spontaneous speech & picture naming

2. Phrase & sentence repetition deficit (b/c of phonemic paraphasias!)

What are the supporting features of logopenic PPA?

• At least 3 of the following:

1. Phonemic paraphasias in spontaneous speech & picture naming

2. Relatively preserved comprehension of single words & intact object knowledge

3. Lack of motor speech impairments

4. Spared syntactic processing

What is the disease progression of logopenic PPA?

• Atrophy begins to extend anteriorly into anterior temporal lobes, eventually

What is nonfluent PPA?

• impaired grammatical processing &/or apraxia of speech d/t frontoinsular atrophy, greater in the language dominant hemisphere

What are the core clinical features of nonfluent PPA?

• At least 1 of the following:

• Agrammatism (difficulty using correct grammar & syntax)

  • instead of saying "The cat is sitting on the mat," someone with agrammatism might say, "Cat...sit...mat". 

• Apraxia of speech (difficulty planning and coordinating the movements needed for speech

What are the supporting features of nonfluent PPA?

• At least 2 of the following:

  • Syntax comprehension deficit, particularly for complex syntax

  • Relatively preserved comprehension of single words

  • Relatively preserved object knowledge

What is the disease progression of nonfluent PPA?

• May develop generalized movement disorder, including dysphagia

• Increasingly unintelligible & agrammatic

• Mutism