dementia exam

why do slps work with patients with dementia?

because communication and cognition are core areas of slp practice

the slp’s role when working with patients with dementia

they support functional communication, teach cognitive-communication and compensatory strategies, provide caregiver education and training, dysphagia management, quality of life support, and help maintain independence for as long as possible

in normal aging, what is preserved?

language, sustained attention, simple tasks within divided attention, long-term memory, and procedural memory

in normal aging, what might decline?

selective attention, complex multitasking within divided attention, short-term memory, and episodic memory

there may be a mild word-finding difficulty present, a slower processing and reaction time, and difficulty in recalling details like when and where something happened

dementia

an umbrella term for multiple neurodegenerative diseases; memory loss plus deficits in at least one of the following areas: verbal expression or verbal and written receptive language skills, recognition and identification of objects, ability to execute motor activities (assuming normal motor skills, normal sensory function, and comprehension of the task), and abstract thinking, judgement, and execution of complex tasks

decline in cognitive domains that interferes with independence

*not a part of normal aging

domains affected in dementia

memory, language, executive function, visuospatial skills, and behavior

the difference between dementia and delirium

there is a gradual onset and progressive decline in dementia along with relative stability throughout the day

in delirium, it is a sudden onset and it fluctuates throughout the day

the etiology of dementia is a structural/degenerative brain change, and it is not reversible

the etiology of delirium is from an acute medical condition, and it is often reversible

the difference between dementia and mild cognitive impairment (mci)

dementia is a gradual onset and progressive, mci has a gradual, subtle changes, but in a lot of mci cases, it does not progress to anything worse (like dementia), although it is greater than normal aging

dementia is stable across the day and interferes with daily functioning and independence, mci does not significantly impact daily independence and mostly raises difficulty with stm, word finding, concentration, and difficulty with complex information

there is a chance that mci CAN develop to dementia

how many people have dementia worldwide?

approximately 55 million people

10 million new cases per year

6.7 million Americans over 65

RISK DOUBLES EVERY FIVE YEARS AFTER AGE 65

what is the most common dementia?

alzheimer’s disease (60-80%)

alzheimer’s disease

most common dementia, typical onset after age 65

genetic links: APP, PSEN1, PSEN2

risk factor: APOE-ε4

early and later signs of alzheimer's and relative strengths

early presentation: prominent episodic/STM loss, anomia, getting lost, and reduced new learning

later presentation: language impairments, behavioral changes, motor decline, and dysphagia

relative strengths: early autobiographical memory may be more accessible than new learning; procedural learning can be relatively available early

alzheimer’s disease neuropathology

beta‑amyloid plaques disrupt communication between neurons

tau tangles destroy neurons internally

disease progression:

hippocampus → temporal lobe → parietal → frontal

important for SLPs: temporal lobe damage affects language and semantic memory

symptoms of alzheimer’s disease with progression

early: memory loss, word-finding difficulty, spatial disorientation

later: language impairments, behavioral changes, motor decline, and dysphagia

vascular dementia

second most common dementia, caused by brain damage from reduced blood flow

types: large vessel infarcts, lacunar infarcts, small vessel disease

often occurs with alzheimer’s disease (mixed dementia)

risk factors include hypertension, diabetes, stroke, atrial fibrillation, and high cholesterol

how someone presents with vascular dementia will depend on the site of lesion

with those who have repeated strokes, they have a stepwise decline - symptoms worse after each vascular event

symptoms of vascular dementia with progression

early:

slowed processing

dysexecutive symptoms

attention problems

variable language profile

later:

motor slowing

gait disturbance

mood changes

relative strengths:

memory can be less disproportionately impaired than in ad, routines and external organization often help

*depends on severity and amount of stroke

lewy body dementia

5-10% of dementia cases, often begins between ages 50-70, more common in men

classic early features: visual hallucinations, fluctuating cognition, REM sleep disorder, mild parkinsonism

may go undiagnosed in a lot of individuals, some individuals may get a parkinson's diagnosis instead

lewy bodies = abnormal alpha-synuclein protein

affects multiple neurotransmitter systems including dopamine, acetycholine, and serotonin

symptoms of lewy body dementia with progression and relative strengths

early:

fluctuating attention/alertness

visuospatial problems

executive dysfunction

visual and auditory hallucinations (hallmark symptom)

mild parkinsonian movement

later:

severe motor impairment

autonomic dysfunction

relative strengths early:

memory may be less disproportionately impaired than in ad; performance may improve during optimal alert periods

frontotemporal dementia

behavioral variant FTD (bvFTD) and primary progressive aphasia (PPA)

typically have good memory

degeneration of frontal and temporal lobes.

common proteins:

•Tau

•TDP

memory may be relatively preserved early

behavior variant FTD (bvFTD)

changes in personality, behavior, and judgment

early signs: disinhibition, apathy, reduced empathy

language may be relatively preserved early

primary progressive aphasia (PPA) types and language variants

types:

nonfluent/agrammatic variant (nfvPPA)

semantic variant (svPPA)

logopenic variant (lvPPA)

language variant:

word-finding difficulty, comprehension problems, and speech motor planning errors

SLPs often identify language variants early

nonfluent/agrammatic variant PPA (nfvPPA)

effortful, halting speech

grammar errors

may look like aos

semantic variant PPA (svPPA)

loss of word meaning

fluent but empty speech

difficulty understanding words

logopenic variant PPA (lvPPA)

word-finding pauses (anomia)

difficulty repeating phrases

often associated with alzheimer’s

*slow decline in language abilities

diagnostic considerations

diagnosis includes:

patient history, brain imaging, neuropsychological testing, and biomarkers

key takeaways for dementia to remember going into treatment

what type of dementia does my client have?

what is the site of lesion?

what are my patient’s strengths?

what do we want to target in dementia treatment?

the preserved system and the function you want to restore

*think about the client’s strengths, level of dementia, and the early changes in that specific dementia

how to reduce the demands of the most impaired areas

start with the profile, not with a generic dementia plan

ppa is different from the other dementias because

it is language-led neurodegeneration

we should not default to memory-based dementia treatments just because PPA is categorized with the other dementias

its treatment looks more like progressive aphasia treatment than generic ad treatment

slp sophisticated treatment-selection framework for dementia

step 1: identify the dominant early problem

• episodic memory/new learning?

• attention fluctuation/visuospatial breakdown?

• executive dysfunction/initiation?

• language system breakdown?

step 2: identify what is still relatively intact neurologically/cognitively

step 3: decide what function you want to restore: communication, navigation, participation, safety, mealtime success, identity, or role performance

step 4: match the treatment to what we know both in terms of what the client wants and what their strengths could be

treatment approaches to ad

spaced retrieval (strongest clinical fit in ad), effortless learning, reminiscence, memory prostheses, goal-oriented cognitive rehabilitation

reminiscence therapy

often used in ad

definition: semi-cued discussion of past experiences

rationale: ltm often preserved in ad

goals: orientation, communication, social engagement

materials: photos; music, objects, videos

clinical consideration: most recommendations are to focus on positive memories

it is NOT quizzing people, having a few people on the same level/with the same dementia is great with this activity

effortless learning

definition: minimize errors during learning; tasks set within patient ability level

thinking about neuroplasticity, practicing correcting errors, prevents learning incorrect responses

best for early and mid-level ad

spaced retrieval

practice recall over increasing time intervals

targets functional info (names, safety)

uses repetition and success

often combined

successful for ad because procedural memory is intact

ex: read a concept, remember it, close the book, give it a few minutes (add distracters), then try again

montessori approach

break tasks into small steps (bottom up approach)

provide cues and feedback

promote independence and engagement

effective across stages of dementia

help them improve their mood, increase social skills, and develop a routine

they feel like productive citizens of society by doing things like sweeping, folding laundry, etc.

basic memory aids

external aids: memory books, calendars, and smartphones

support orientation and communication

must be accessible and used consistently

often requires caregiver cueing

dr. koz isn't a huge fan of these, you really need someone around to support clients with understanding what they mean (example: a calendar)

environmental modifications (indirect)

goals: improve safety, orientation, and function

examples: labels, calendars, clocks, and lighting

reduce confusion and agitation

often more effective than direct therapy alone

remove firearms, poisonuous substances, car keys, maybe mirrors

appropriate communication strategies and styles towards those with alzheimer’s

slow rate of speech, allow a longer processing time

facial expression and verbal tone carry a lot of meaning

simplify sentences, maybe add pictures

avoid sarcasm, but not joking around overall

lewy body dementia and approaching treatment

think about visuospatial weakness, fluctuation with attention and alertness, and executive functioning deficits; always remember hallucinations and fatigue

treatment implications

• schedule therapy during best alert periods

• reduce visual clutter and cognitive load

• use short, concrete, highly functional tasks

• lean heavily on environment, caregiver cueing, and safety planning

• use repeated practice cautiously and individually, rather than assuming consistent procedural learning

vascular dementia and approaching treatment

might present different depending on severity of language impairment and site of lesion

executive dysfunction, slowed processing speed, attention problems, variable language impairment

clinical fit:

• structured routines and visible sequencing supports

• task breakdown and initiation cues

• external organization systems

• goal-oriented cognitive rehabilitation focused on specific everyday tasks

• partner coaching to simplify, pace, and cue rather than just repeat

ftld/bvftd characteristics and treatment

behaviors can make group therapy challenging, reduced insight/judgment, personality and behavior changes, poor initiation and self-monitoring, and impaired social cognitiion and conversation pragmatics

focus on caregiver training and notice which behaviors are the most aggatating

treatment implications include partner and caregiver training (often central), simplify the communicative environment, use concrete routines and behavior supports, build functional communication supports around real-life contexts, be realistic: direct impairment-based SLP evidence in bvFTD is still limited

what to consider to fit a certain type of treatment with your client

treatment is not one-size-fits-all, what is common distress and limitations with the individual, site and lesion and the stage of their disease process, something that works in january may not work later in december with progression of the disease

other treatment options for dementia

environmental supports: labels, calendars, simplified layouts, reduced clutter, reduced noise, visual cueing

communication-partner training: slower rate, shorter utterances, more wait time, less sarcasm, better cueing, one speaker at a time

memory/organization supports: books, wallets, schedules, phones, visible routines, checklists

goal-oriented rehabilitation: especially helpful when tied to a specific real-life activity that matters to the person

what are we actually restoring with dementia treatment?

we can not change the brain and reverse the underlying neurodegenerative disease process, but we can keep individuals independent for as long as possible, keep their environment safe, help them have a sense of purpose and joy, find an identify that they are comfortable, family counseling, and improve overall quality of life - a few priorities that are restorative in ways

a few examples of things we can restore include the ability to find the bathroom, call for help, participate in family stories, complete a familiar routine with support, and the experience of dignity, purpose, identity, and social connnection

*this is why dementia treatment requires sophisticated clinical reasoning