PTRS 853 - Dementia

Cognition

encompasses all forms of knowing and awareness, such as perceiving, conceiving, remembering, reasoning, judging, imagining, and problem solving

it is the process through which knowledge is acquired, retained, and used

Common Executive Function

reflects the ability to actively maintain task goals to direct lower-level processing

Shifting-Specific Executive Function

appears to reflect flexibility in transitioning to new task-set representations

Updating-Specific Executive Function

may be related to information gating and retrieval from long term memory

What types of memory tend to stay intact with dementia?

implicit memory & procedural memory

Delirium

- disturbance of consciousness

- change in cognition

- acute onset (hours to days)

- fluctuating symptoms

- evidence of medical etiology

What is a strong predictor of poor functional and cognitive status in the year following hospital admission

delirium

Mild Cognitive Impairment (MCI)

impairments in thinking and memory that do not interfere with everyday activities

- about 10-20% convert to dementia each year

- about 1/3 convert within 5 years

Symptoms of mild cognitive impairments

- forgetfulness

- missed appointments or events

- inability to maintain train of thought

- difficulty following conversations or plots

- difficulty making decisions, following directions, or completing tasks

- poor judgement

- difficulty navigating familiar places

Three main factors with dementia

1. significant decline in one or more cognitive areas

- learning and memory, executive function, language, complex attention, perceptial-motor, social cognition

2. interference with everyday function

3. not explained by delirium or other mental disorder

Stage 1 Cognitive Impairment

2-4 years

- repeats questions

- anhedonia

- word finding problems

- frequently loses items

- personality changes

Stage 2 Cognitive Impairment

2-10 years

- becomes lost easily

- confusion over recent events

- ADL impairments

- argumentative

- pacing

- anxiety / depression

- delusions

Stage 3 Cognitive Impairment

1-3 years

- unable to perform ADLs

- impaired speech / comprehension

- unable to recognize family / friends

- unable to recognize self

average survival time from cognitive impairment diagnosis

8 years

Cognitive symptoms of Dementia

o Disorientation

o Loss of logical reasoning

o Loss of insight

o Poor judgment

o Perceptual problems

o Inability to perform arithmetic

o Inability to learn

o Loss of attention

o Language impairment

o Apathy

o Withdrawal

Non-Cognitive Symptoms of Dementia

o Paranoia

o Delusions

o Sleep disturbance

o Hallucinations / Illusions

o Agitation / Aggression

o Wandering / Sundowning

o Anxiety

o Depression

o Hostility

o Fear

o Jealousy

o Insecurity

Revised guidelines for Alzheimers

- 3 stages: preclinical, MCI, and dementia

- recognize impairments in language and judgement

- better distinguish between other dementias

- identified potential use of biomarkers (MRI evidence of degeneration, amyloid levels, etc)

Vascular Dementia

- subcortical

- stroke related

- multi-infarct

- mixed

- # of small strokes

- will see changes that you associated with stroke

Lewy Body Dementia

deposits of alpha-synuclein protein

- often distinguished by visual hallucinations, movement and sleep disorders

- associated with Parkinson's disease

Frontotemporal Dementia

- varying pathological processes

- orbitofrontal

- anterior cingulate

- dosrsolateral prefrontal

- inappropriate emotional responses (crying or laughing uncontrollably)

- lack of safety awareness

Lund-Manchester Frontotemporal Dementia

Two or more of the following:

- loss of personal awareness

- strange eating habit

- preservation

- mood change

One or more of the following:

- executive dysfunction

- impaired speech

- intact visualspatial function

FTD work group criteria

cognitive deficits marked by:

-early, progressive personality or behavioral changes

-early, progressive expressive or semantic language changes

-impairment in social/occupational function

-gradual onset and continual decline

-not due to other medical/psych condition

-absence of delirium

Examples of other dementias

o CADASIL

o Corticobasal syndrome

o Pick's disease

o Progressive supranuclear palsy

o HIV-associated neurocognitive disorder

o Huntington's disease

o Prion diseases (Kuru, Creutzfeldt-Jakob)

o Normal Pressure hydrocephalus (reversible)

Assessing Behavior - What is the problem?

specifically identify action and context

- what was happening at the time of the problem?

- what happened before the problem?

- what happened after the problem?

- what were the consequences?

- was appropriate behavior ignored?

Assessing Behavior - Whose problem is it?

o Behaviors often occur at the same frequency throughout the day, but have greater impact at different times of day (or night)

o Adverse behavior is often reported at peak activity times

When do most problem behaviors get reported?

shift changes

Assessing Behavior - What caused the problem?

o Patient's wants, needs, or preferences

o Medication side effects

o Medical complications

- Communication, visual, or hearing loss

o Pain

- Infection (UTI, sinus, etc.)

- Dental disease

- Bowel dysfunction

o Environmental factors

Aerobic Exercise Prescription for CI's

Frequency = 3 days / week

Intensity = Light intensity progressing to moderate intensity based on performance (40-60% HRR or RPE 12-13/20

Time = Ideally 30-60 continuous or accumulated minutes; can start with bouts of < 10 minutes and progress at comfortable rate

Type = Prolonged, rhythmic activities involving large muscle groups

Resistance Exercise Prescription for CI's

Frequency = 2-3 days / week

Intensity = 40-50% of 1-RM progressing to 60- 70% of 1-RM

Time = 10-15 reps initially, progressing to ≥ 1 set of 8-12 reps

Type = Focus on body weight, bands, or machines; avoid free weights

Flexibility Exercise Prescription for CI's

Frequency = ≥ 2-3 days / week, ideally daily

Intensity = Full extension, flexion, rotation, or to the point of slight discomfort

Time = 2-4 reps held for 10-30 seconds

Type = Slow, static stretching of all major muscle groups

4 Principles for Developing Interventions

- relationship

- communication

- motor learning

- environment

Relationships with Patients with CI's

o Establish a personal connection

o Prioritize relationship over task

o Determine who or what is uniquely important

o Encourage reminiscence with "empathetic curiosity"

o Recognize and accept the offered "reality"

o Avoid triggers

o Be positive

Communication with Patients with CI's

o Use intentional verbal and non-verbal skills

o Use short simple phrases; yes/no options

o Avoid infantilizing (aka "elderspeak")

o Use confident friendly tone of voice

o Offer genuine smile and relaxed body language

o Provide consistent cue progression:

o Verbal prompt → model / gesture → physical prompt → physical guidance → physical assistance

o Recognize that behavior = communication

o Be flexible

Motor Learning with Patients with CI's

o Understand and exploit motor learning principles

o Prioritize procedural learning (i.e. "learn by doing")

o Set salient, functional goals

o Use repetitive, constant, blocked practice

o Emphasize specificity

o Create "errorless learning"; part-whole task practice

o Ensure sufficient level of intensity and challenge

Environment with patients with CI's

o Create a safe, comfortable space

o Ensure physical safety and emotional security

o Maximize consistency and familiarity

o Minimize distraction

o Use relevant music

o Provide environmental cues (e.g. signs/pictures for toilet, etc.)

o Maintain positive atmosphere