Older adults Unit 3: Cognitive changes and pharmacology

what occurs to sensory memory

other than hearing and visual changes it remains stable along with implicit long term memory

what is procedural memory and what occurs to it with age

things like how to ger out of a chair or tie shoes which remains with age

what occurs with short term memory as we age

remains pretty stable but processing info may take longer and take more effort

what occurs to explicit memory with age

things like facts and words typically declines with age so it is common older adults can't find a word they're looking for or encode a new term into long term memory

how can older adults encode something int long term memory

they need more repetition

why does executive function get impacted wth age

due to changes in short term memory leading toa harder time with problem solving or planning an activity

what can changes in executive function impact

it can increase fall risk and self assessment regarding what they believe they are safely able to do

what is seen with attention with aging

there are declines in selective and divided attention with age

what should be done when educated an older adult

simplify language and cueing and avoid jumping from topic to topic but avoid too simple and a condescending tone

what is delirium

a state of disturbed consciousness with changes in perception impacting ill pts or post-op pts

how does delirium present

it comes on abruptly and often improves as the pts physical status improves

what may be seen in a state of delirium (4)

pts may be drowsy and sluggish (hypoactive) or restless and agitated (hyperactive)

changes in attention

fluctuating consciousness

incoherent/disorganized speech

easily distracted

what causes delirium

elevated cortisol from acute stress or illness leads to cognitive changes along with other factors

what are the risk factors for developing delirium (7)

vision impairment

hearing impairment

functional impairment

mild cognitive impairment (MCI)

dementia

comorbidities

psychoactive meds

anything that decreased mobility or sensory input

how can delirium be reduced

mobility and reducing sensory deprivation

how can sensory deprivation be reduced (3)

ensure pt is wearing glasses or has hearing aids in

orient the pt to location and familiar room objects

orient to healthcare team

what is seen with the onset of dementia

gradual onset progressing over months and years

what is the presentation of dementia

the pt has normal attention and consciousness but has problems with memory, executive planning, and speech

what are examples of dementia

Alzheimer's and vascular dementia

how is dementia diagnoses

through interviews with a doctor, neuro exam, medical screen, and neurocognitive test

what are potential medical reasons for cognitive changes in a dementia exam that should be ruled out (3)

depression

thyroid conditions

vitamin B12 deficiency

when is a dementia diagnosis made

when the symptoms are severe enough to impact function

what is mild cognitive impairment (MCI)

cognitive changes falling between normal aging and dementia

what is seen with MCI

the pt has more memory problems than other individuals their age but don't have personality changes related to the condition and can still carry out ADLs

how is MCI dianosed

based on subjective reports and obsrvations

what screening tests can be used to detect MCI (2)

MoCA

SLUMS

what diet is recommended to combat cognitive and memory changes

a Mediterranean diet

what exercise can help combat cognitive changes

aerobic and resistance training

what may be needed for transportation with MCI

an OT may need to complete a driving assessment for them

what is the first symptom of alzheimers

decline in memory and/or mood changes

what is the believed cause of Alzheimer's (4)

beta amyloid and tau protein activate inflammation in the brain causing the neurons to die

reduced synaptic density

inadequate ACH in brain

tissue atrophy

what is seen as symptoms progress with Alzheimer's (3)

the pt may struggle to communicate

disorientation/confusion

behavioral and functional changes in gait or swallowing

what are the risk factors for alzheimers

genetics

age

MCI

history of CV disease

history of head injuries or concussions

what is often seen in addition to vascular dementia

it often coexists with other types of dementia such as alzheimers disease or dementia with Lewy bodies

what is often seen in the history of a pt with vascular dementia (4)

history of smoking

diabetes

high cholesterol

HTN

what is the believed cause of vascular dementia

from ischemic brain damage from vascular strokes

what do the vascular dementia S/S depend on

the location of the brain impacted by the stroke

what are some S/S that are seen with vascular dementia (5)

slowed processing speed

impaired judgement

difficulty with executive planning

changes in gait and balance

memory impairment

what is seen with memory impairment in vascular dementia

it is less severe then pts with Alzheimer's

what is the treatment of vascular dementia

lifestyle changes and meds to control BP and prevent further ischemic brain damage

what is dementia with Lewy bodies

similar to alzheimers but the pts are more likely to have sleep disturbances, hallucinations, gait changes, imbalance, and parkinsonian movements

what may be seen with Lewy bodies dementia

they may not have significant memory impairment

what is the believed cause of dementia with Lewy Bodies

the buildup of Lewy bodies, which accumulate in the nuclei of neurons, in the cortex controlling motor function and memory

how is dementia with Lewy bodies differentiated from PD

in PD the onset is marked with motor impairment rather than cognitive changes

how is Dementia with Lewy bodies diagnosed (5)

progressive cognitive decline interfering with function

fluctuating cognitive alertness and attention

visual hallucinations

sleep disorders

cardinal features of parkinsonism

what is frontotemporal lobar dementia

progressive loss of neurons in the frontal or temporal lobes common in pts under 65

what is seen in frontotemporal dementia

they often has less difficulty with spatial orientation, memory, and disorientation but they struggle with problem solving and concentration

what are pts with frontotemporal lobe dementia prone to

risk taking activities

what are the early symptoms of frontotemporal lobe dementia (4)

disinhibition

apathy

lack of empathy

repetitive behaviors or changes in eating habits

what are the later symptoms seen with frontotemporal dementia (3)

deterioration in behavior and personality

language disturbances

alterations in muscle function

what is the MiniCog

a three step test of word recall and clock drawing with a score less than 4 indicating a need for further testing for dementia

what is the Mini Mental Status Exam (MMSE)

a test assessing 6 areas of cognition with 11 questions with a cut off score of 27/30

what is the Montreal Cognitive Assessment (MoCA)

a test for MCI including assessment of visual spatial ability, naming, memory, attention, language, etc with a score

what is the St Louis University Mental Status (SLUMS)

a test for early dementia with 27-30 being normal, 21-26 indicating mild cognitive disorder, and 0-20 indicating dementia

if the pt has less than HS education tha scale drops to 25-30 is normal, 20-24 is mild cognitive impairment, and 1-19 is dementia

what is the Global deteriotation scale (GDS)

a tool used to stage dementia

what is GDS stage 1 (2)

normal individual with no functional deficits related to cognition

MMSE score 29-30

what is GDS stage 2 (2)

a pt with MCI and subjective report of memory loss

MMSE score 28-29

what is GDS stage 3 (2)

mild dementia with the pt only struggling with function of complex tasks

MMSE 24-28

what is GDS stage 4 (2)

the pt is still classified for mild dementia but instrumental ADLs are now impacted

MMSE score 19-20

what is GDS stage 5 (2)

moderate dementia with ADLs impacted but the pt can assist with them

MMSE 15

what is GDS stage 6 (3)

moderate severe dementia with ADLs more severely impacted and the pt having limited ability to assist with them

they may struggle with incontinence

MMSE 1-9

what is GDS stage 7

severe dementia with the pt dependent with ADLs with limited to no interaction

when are meds used for Alzheimers and Lewy body dementia

in the early stages but they don't reverse or stop the progression

what meds are often seen with AD and LBD (2)

Cholinesterase inhibitors

Memantine

what meds are seen with vascular dementia

meds to manage blood pressure and cholesterol

how is a pt with dementia treated

rather than orienting them we are accepting the reality they experience as it is important to not tell them they are incorrect

how should a pt with AD be approached

approach them in front of their visual field as their visual field often narrows

why should yes no questions be asked with caution to a pt with AD

the pt may be embarrassed or frustrated that they don't understand so they may say yes or no without understanding the question

what should be maintained with cognitive deficits

routines as novel tasks may be challenging

how can Tai Chi be helpful for cognitive deficits

it challenged memory and cognition with physical benefits

how can mobility be assessed with cognitive deficits

TUG or 6 min walk

how should pain be assessed with dementia

the pt may not be able to identify pain so their agitation and changes n body or fascial language should be assessed

what in the PAINAD

a tool to assess pain for pts with AD

why do older adults take the most beds

because 80% of adults over 65 have at least one chronic condition

what is polypharmacy

taking more than 4 meds at once which is seen in 26% of older adults

what are the risks of polypharmacy

increases the risk of adverse drug events, drug interactions, and nonadherence

what is a medication cascade

where a SE from one med is being treated with another med

what is pharmacokinetics

how the drug moves through the body included absorption, distribution, metabolism, and excretion

how does drug absorption change with age

there is altered gastric acid production and changes in motility and blood flow

what changes are seen in drug distribution with aging

decreases in body water and lean mass and increases in body fat which can increase or decrease response to drugs depending on properties

how does drug metabolism changewith age

liver function may decline with age slowing drug clearance

how is drug excretion affected with age

renal function decreased with age resulting in slower elimination and increased risk of toxicity from the drug

what increased the risk of adverse drug reactions in older adults (5)

presence of multiple comorbidities

multiple health issues leading to polypharmacy

limited drug testing and regulations

medication nonadherence

inappropriate meds due to risk profile

how does the presence of multiple comorbidities increase the risk for adverse drug reactions

it can impair function of organs like the liver and the kidneys making it more difficult to process and eliminate meds

why are drug testing and regulations limited for older adults

most clinical trials exclude pts with multiple comorbidities or those with complex medication regimens

why is medication nonaderence common in older adults

physical and cognitive limitations can contribute as well as cost of side effects

what are sedative hypnotics used for

sleep

what can sedative hypnotics lead to in older adults (4)

hangover effect due to metabolism changes which increase fall risk

sleepwalking, sleep eating, sleep driving

episodes of amnesia

dependence on meds

what can be done to combat the adverse effects of sedative hypnotics

sleep hygiene strategies and advocating for meds with shorter half life

what are the adverse effects of antianxiety meds (3)

sedative effects that increase fall risk

dependence

rebound anxiety with abrupt discontinuation

what are the adverse effects seen with antidepressants and antipsychotics (2)

increased fall risk

tardive dyskinesia

what SE are seen with PD meds (6)

dyskinesias

hallucinations

behavior changes

end of dose akinesia

diminishing response

on/off periods

what should be avoided when taking levodopa

high protein meals as it can interfere with absorption

what are the adverse effects seen with pain meds especially opioids (5)

overdose

dependence

OH

constipation

increased fall risk

what are the adverse effects seen with antihypertensive meds (2)

hypotension

increased fall risk

what adverse effects are associated with diuretics (4)

dehydration

electrolyte imbalance

lightheadedness

cardiac arrhythmias

what are the adverse effects of Digitalis

high risk of toxicity presenting as bradycardia or other arrhythmias

when is a doctor notified with a pt on Digitalis

if their HR drops below 60 bpm

what are the adverse effects seen with nitroglycerin

OH contributing to fall risk

what are the adverse effects seen with statins

myopathy and muscle cramps