Week 3 guided notes- dementia and delirium

What is the definition of delirium? 

acute clinical syndrome characterized by sudden confusion as noted by altered attention consciousness, behavior and cognition.  

What is the timeframe for delirium?

comes on quickly for hours or days, but is temporary

When does delirium tend to present?

long hospital stays, ICU

What are common symptoms of delirium? 

new or worsened: Distractibility, Disorientation, Sudden change in physical ability, Unable to speak clearly, follow directions, saying strange things, Sudden mood swings, Hallucinations/delusions , Increased lethargy/drowsiness, Disrupted sleep-wake cycle/restlessness 

What are the three clinical profiles of delirium?

hyperactive, hypoactive, or mixed

Risk factors for the development of DELIRIUM?

age >65, male, hospitalization, prior episode, multiple comorbidities, sensory impairment, pre-existing cognitive impairment

common causes of delirium

• D: dehydration, deficiencies, discomfort, drugs, detox 

• E: electrolyte abnormalities, elimination abnormalities 

• L: lack of sleep, long hospital stay, lungs, liver disease 

• I: infection 

• R: restraints, restricted movement, renal failure 

• I: inactivity, injury, intoxication 

• U: unfamiliar environment 

• M: medication, metabolic abnormalities, metastasis 

ways to prevent delirium

• Mental stimulation 

• Physical activity 

• Proper nutrition 

• Proper hydration 

• Sensory stimulation (hearing aides, glasses) 

• Sleep hygiene 

treatment for delirium

• Early recognition 

• Speak calmly in short clear sentences 

• Provide reassurance 

• Improve environmental cues and familiarity 

• Promote sleep, hydration, physical activity, nutrition 

Define dementia

Is a general term for decline in cognitive functioning that is severe enough to interfere with a person’s relationships and ability to carry out daily activities 

To be considered dementia, one must have substantial decline in ___ area of cognition or impaired ability in ___ areas

1, 2

What are the possible areas in which dementia can affect?

• Learning and memory 

• Language 

• Executive functioning 

• Attention 

• Perception and motor 

• Social cognition 

Risk factors for developing dementia

• Women 

• Older 

• Racial ethnic minorities 

• Family history or genetics 

• Cardiovascular risk factors 

• Depression/social isolation 

• Sensory loss 

What are 2 protective factors that are associated with decreased risk of developing dementia? 

More education, more cognitive reserve, Married/partnered people due to increased social interaction 

True or false: all forms of dementia are progressive

false

What condition can cause dementia temporarily until treatment is provided?

normal pressure hydrocephalus: when CSF volume gets under control, symptoms will cease

Typical clinical signs/sx of normal pressure hydrocephalus

dementia, gait dysfunction, urinary incontinence

What are characteristic findings noted in imaging or brain specimens in frontotemporal disorders/dementia? 

Prominent degeneration of frontal and temporal lobes 

3 main subtypes of frontotemporal dementia

behavioral, primary progressive aphasia, movement dysfunction

behavioral variant FTD

changes in personality, behavior and judgement

primary progressive aphasia

changes in language skills

movement dysfunction FTD

may or may not have sx of behavioral or PPA, ALS with FTD, corticobasal degeneration, progressive supranuclear palsy

typical age of onset for frontotemporal disorders?

45-64

Progression of lewy body dementia

rapid progression with life expectancy of 5-8 years

 What are characteristic findings noted in histopathology of brain specimens in LBD? 

• Lewy bodies accumulate within brainstem and cortex, made up of alpha synuclein and ubiquitin proteins 

• Acetylcholine deficiency in temporal and parietal cortexà visual hallucinations 

What are the typical clinical signs / symptoms (including the cognitive domains affected)?

psychiatric sx: visual hallucinations, depression. cognitive sx: impairments in attention, executive function, visuospatial, memory. motor sx: parkinsonism. REM sleep disorder

What is the “12 Month Rule” for distinguishing LBP from Parkinson’s disease with dementia? 

If cognitive impairment is noted within 12 months of motor sx, it is LBD. If just motor sx, more likely Parkinsons 

How is lewy body dementia treated?

cholinesterase inhibitors to keep ACh in system, antipsychotics for hallucinations, carbidopa/levodopa for motor sx, melatonin for sleep, SSRI for depression

What is vascular dementia?

Infarcts or ischemic damage affecting areas of brain related to congition 

• Large infarct = cortical > subcortical damage 

• Small vessel disease = subcortical damage 

Progression of vascular dementia

• Commonly have step-wise progression of dementia over time due to recurrent cardiovascular events that occur over time 

• i.e sudden change in cognition following a CVA or MI, then stable, then has another CVA leading to greater loss of function 

What are the typical clinical signs / symptoms (including the cognitive domains affected) of vascular dementia? 

Largely dependent on area of brain affected 

Impaired executive function is common 

Behavior changes: depression and apathy 

Gait changes, balance impairment, falls 

What treatment is provided for vascular dementia?

treat underlying risk factors

What is the most common form of dementia?

alzheimers

True or false: alzheimers progresses quickly

false: slow progression with life expectancy over 5-15 years

What are characteristic findings noted in imaging or brain specimens? 

Neurofibrillary tangles due to build up of tau protein 

Accumulation of beta-amyloid plaques around neurons 

Inflammation 

Loss of cholinergic neurons in memory pathways 

Where does the pathophysiology of alzheimers occur?

entorhinal cortex and hippocampus

risk factors for alzheimers

hx of head trauma, women>men, older age

What are the typical clinical signs / symptoms (including the cognitive domains affected) of Alzheimers? 

• Memory loss and impaired ability to learn 

• Apraxia 

• Executive dysfunction: poor problem solving, visuospatial impairment 

• Language impairments: initial word-finding difficulties to profound loss of verbal fluency 

• Behavioral and personality changes 

• Wandering 

• Sundowning 

• Depression/agitation 

• changes in gait  

True or false: Patients can only have a single type of dementia affecting them.  

false

Treatment for Alzheimers

cholinesterase inhibitors to slow progression, NMDA receptor antagonists

 

What are common reasons that a person with dementia will require referral to PT? 

 

Pain, Orthopedic injury, Deconditioning, Balance issues/falls 

How can you screen for dementia as a PT?

• Subjective interview 

• BIMs cut off 13/15 

• MiniCOG cut off <3/5 

• Sematic verbal fluency cut off <17 words (animals) 

Mini Mental State Exam (MMSE): cut off value for dementia and cons

• <24/30 

• Not free to use 

• More prone to ceiling effects 

• Cannot detect MILD cognitive impairment 

Montreal Cognitive Assessment (MoCA): cut off value and cons

• <26/30 

• Cons 

• Not free 

• Requires certification 

St. Louis University Mental Status Exam (SLUMS): cut off scores and cons

• Depends on level of education 

• Score remains unchanged but interpretation of score changes 

• Not heavily researched as MoCA or MMSE 

What are the 2 most common “staging” tools used for dementia

Global deterioration scale, functional assessment staging tool 

Stages of dementia

1-7

 Stage 1

 No functional or cognitive impairment 

Stage 2

early functional changes (subjective complaints of word-finding difficulties or forgetting location of objects), forgetting names of more distant people. Does not interfere with overall function

Stage 3

mild functional loss, job performance declines, some difficulty traveling to new locations, declining executive function (decreased organizational capacity), word and name finding difficulties evident to others, losing items of value, difficulty learning new info, concentration or attention deficits begin. Being in this stage does NOT mean they will progress to dementia

Stage 4

moderate functional loss, decreased ability to perform complex tasks (planning dinner, managing finances), decreased knowledge of current events, deficit in memory of own personal history, concentration deficits, more difficulty traveling, can still live independently. Still intact orientation to time and space and recognition of familiar people or places

Stage 5

moderate-severe functional losses, significant difficulty recalling major aspects (address, phone number, grandchildren, college), disorientation to time and place, require assistance to choose appropriate clothes, assistance with adequate food choices, difficulty managing medications, unable to live alone safely. Still intact orientation to own name, spouse or children, significant historical facts about themselves, still able to complete eating or toileting, but may need reminders

Stage 6

severely impaired functional abilities, largely unaware of all recent events, speech may no longer make sense, sundowning, personality and emotional changes, can usually remember own name

What are the subcategories of stage 6?

• 6a = improperly puts on clothing 

• 6b= unable to bathe without help 

• 6c= difficulty with toileting 

• 6d= urinary incontinence 

• 6E = fecal incontinence 

Stage 7

total dependence

What are the subcategories of stage 7?

• 7a = speech limited to few intelligible words over day 

• 7b = speech limited to single word used over the day 

• 7c = ambnulatory ability lost 

• 7d = can’t sit up without assistance 

• 7e = loss of smile ability 

• 7f = loss of ability to hold head up  

At which stage do “objective” findings start to be noted? 

Stage 3 

At which stage can a person no longer live alone safely? 

Stage 5 

What is the theory of retrogenesis? 

First in, last out. Loss of cognitive abilities in in the opposite order in which they are gained in childhood.

True or false: patients need to demonstrate everything in each stage to be considered that stage?

false

Skills appropriate to teach in stage 3

teach compensation (note taking, list making, phone reminders, med planners), focus balance through functional tasks and exercise, progressive resistive exercise, family/caregiver training and education for carryover may be needed. Evidence based interventions include dual task training and music based intervention 

Skills appropriate to teach in stage 4

teach compensation, strength training, progressive resistive exercise, balance, gait. May need to simplify verbal cues and add visual cues. Family/caregiver training required. Teach assistive device use now. Evidence based interventions include music based, Montessori, maybe dual task

Skills appropriate to teach in stage 5

continue strength, gait balance, and functional mobility, must use short/clear instructions. Incorporate external and visual cues, consistent use of AD, give choices rather than open ended, AVOID dual task. Evidence based interventions include music based, Montessori, errorless learning

Skills appropriate to teach in stage 6

emphasis on caregiver training for assisting mobility and performance of HEP. Maintain mobility levels with help, may need lift equipment or wheelchair. Same interventions as stage 5 

Skills appropriate to teach in stage 7

tertiary prevention of significant complications. Positioning recommendations to support dysphagia/aspiration concerns, train ROM and stretching for contracture risk, train use of positioning for pressure sores, maintain hygiene

When is music based interventions appropriate?

all stages

What is montessori based programming?

Structured stimulating activities that are appropriate to the person’s cognitive abilities. Fosters social interaction, participation, and engagement to maintain function and QOL 

Categories of montessori activities

• 1. sensory 

• 2. squeezing 

• 3. Seriation (arranging) 

• 4. scooping 

• 5. pouring 

• 6. Fine motor 

• 7. matching 

• 8. Care of environment (watering plants) 

• 9. Care of person (ADL skills, folding clothes, setting the table 

What stages is montessori based activities appropriate?

stages 3-6

What is Errorless Learning? 

Techniques completed together. Develop prompt question for target behavior and then tell them/show them the correct answer. Immediately correct an incorrect answer with the correct one and have them repeat it. Do not provide negative feedback to incorrect response 

How many repetitions may be needed for “learning” to occur? 

>1500 

What is paratonia? 

Involuntary resistance to passive movements or involuntary assistance to passive movements 

 

What are the 2 types of paratonia that may be seen in people with cognitive impairment? 

 

Oppositional paratonia and facilitatory paratonia 

 

How can paratonia affect PT examination / interventions? 

 

Difficult to assess ROM and strength, may result in them “fighting” against you as you assist with mobility, can impact dressing, bathing, feeding 

 

What are potential causes / influences affecting sundowning behavior? 

 

Not fully understood but likely altered circadian rhythm due to changes in acetylcholine and melatonin, unmet physiologic needs, underlying medical disorders, environmental factors such as inadequate exposure to sunlight, excessive stimulation or social isolation, changes in habits or routine, or medications. 

What are potential treatment / management strategies to decrease sundowning behavior? 

Keep predictable routine, encourage physical activity during day, limit napping, reduce background noise or stimulating TV, play familiar gentle music in evening, familiar items such as photographs, low dose melatonin, encourage use of glasses or hearing aides 

True or False: It is appropriate to use elderspeak when communicating with older adults or persons with cognitive impairment.  

false