Cognitive Impairment

Learning Objectives

  • Recognize the features of dementia and delirium.

  • Identify screening tools for older people with dementia and delirium.

  • Describe multidisciplinary management of dementia.

  • Discuss the role of physiotherapists in supporting cognitive impairment.

  • Identify strategies to optimize physiotherapy interventions in those with cognitive impairment.

Pre-Lecture Knowledge Check

What is Cognition?

  • Cognition includes reasoning, judgment, awareness, and perception.

Conditions Causing Cognitive Impairment

  • Conditions that may have cognitive impairment as a comorbidity:

    • Stroke

    • Cerebral Palsy

    • Post-Traumatic Stress Disorder

    • Schizophrenia

Dementia Overview

Definition

  • Dementia is characterized by progressive deterioration of intellect, behavior, and personality due to diffuse disease affecting the brain's cerebral hemispheres, especially the cortex and hippocampus.

  • It is not a part of normal aging and involves:

    • Loss of memory

    • Changes in emotional reactions, social skills, and intellect

Features of Dementia

  • Affects various cognitive domains including:

    • Complex attention

    • Executive function

    • Learning and memory

    • Language

    • Perceptual-motor skills

    • Social cognition

Prevalence of Dementia

  • Worldwide: 55 million currently; projected to reach 139 million by 2050.

  • Australia: Approximately 487,500 living with dementia in 2022; expected to rise to 1.1 million by 2058.

Types of Dementia

  1. Alzheimer's Disease (60-80%)

  2. Vascular Dementia (~20%)

  3. Fronto-temporal Dementia (5-10%)

  4. Dementia with Lewy Bodies (5%)

  5. Other Types: Normal pressure hydrocephalus, multi-infarct dementia, etc.

Stages of Dementia

Early Stage

  • Forgetfulness (e.g., forgetting to turn off gas/water).

  • Losing track of time and becoming lost in familiar places.

Mid-Stage

  • Increased forgetfulness, becoming lost at home, and difficulty with communication.

  • Requires assistance with personal care.

End-Stage

  • Unaware of time and place, unable to recognize family, and increased need for self-care assistance.

  • Behavioral changes such as aggression and wandering occur.

Delirium

  • Commonly encountered in patients with dementia.

  • Subtypess include:

    • Hyperactive: Agitated, alert, restless (20% of cases).

    • Hypoactive: Drowsy, inattentive (30% of cases, higher mortality).

    • Mixed: Around 50% of cases.

Cognitive Screening Tools

  • **For Delirium: **

    • Confusion Assessment Method (CAM)

    • 4AT Test

  • For Dementia:

    • Mini-Mental State Examination (MMSE)

    • Abbreviated Mental Test Score (AMTS)

    • Clock Drawing Test* (more effective than MMSE when standardized)

    • Alzheimer's Disease Assessment Scale - Cognitive subscale (ADAS-Cog)

    • Mini-Cog and Rowland Universal Dementia Assessment Scale (RUDAS)

Gait and Cognition

Importance of Gait Assessment

  • Gait analysis is critical in dementia risk assessment:

    • Changes in pace, rhythm, variable gait speed are linked to cognitive decline.

    • Significant associations with increased dementia risk when gait slows by over 0.05 m/s.

Components of Gait Assessment

  • Include factors such as gait initiation, posture, arm swing, and turning.

  • Measure velocity, cadence, step length variability, and the impact of dual-tasking (e.g., talking while walking).

Gait and cognition are important indicators for developing early interventions in dementia and predicting risks associated with falls.