Cognition, dementia, end-of-life care, and death & dying

Question 1

What are Amyloid plaques and tau tangles more prevalent in?

Answer 1

Individuals with dementia

Question 2

What happens as we age to your brains?

Answer 2

Decreased gray and white matter structure & volume
Especially in frontal lobe
Decreased dopamine concentration, transported availability, and receptor density
Aging brain more susceptible to pathology
Synapses age

Question 3

What aspects of memory remain relatively stable with age?

Answer 3

Some aspects of memory (especially implicit memory), language, and social cognition remain relatively stable with age

Question 4

What types of cognitive processes show gradual and declines?

Answer 4

Processing speed, encoding of information into episodic memory, short-term memory, and executive function show gradual and linear declines with aging

Question 5

What are some typical normal cognitive aging features?

Answer 5

Need increased time for processing
Require more rehearsal to encode information into long-term memory
Have decreased ability to multi-task
Have difficulty with problem-solving

Question 6

True or false,Some older adults will exhibit no observable slowing of cognition, while others may display noticeable changes that are considered “within normal limits”

Answer 6

True

Question 7

What is delirium?

Answer 7

Abrupt change in mental status and behavior with impairment in cognitive processes and attention deficits2
Clinical syndrome characterized by disturbed consciousness, cognitive function impairment, and perception1

Question 8

What is link to delirium?

Answer 8

Linked to increased LOS, morbidity, mortality, discharge to SNF, re-admission1

Question 9

What group of people are at higher risk of delirium?

Answer 9

Hospitalized older adults are at increased risk, especially in ICU settings

Question 10

What is dementia?

Answer 10

A clinical syndrome of cognitive and functional decline
Usually chronic or progressive

Question 11

What are some common subtypes of dementia?

Answer 11

Alzheimer dementia (41%)
Vascular dementia (32%)
Dementia with Lewy bodies (8%)
Frontotemporal dementia (3%)

Question 12

How do you distinguish delirium from dementia?

Answer 12

Question 13

What is sundowning?

Answer 13

Syndrome characterized by restlessness, excitement, increased confusion, hallucinations, agitation
Can occur in patients with AD or other types of dementia
Seen in late afternoon or early evening

Question 14

What is mild cognitive impairment (MCI)?

Answer 14

Still able to carry out normal daily functions & do not experience personality changes
People with MCI have more memory problems than what is considered normal for others of the same age, but symptoms are not as severe as those with Alzheimer’s
A mild neuro-cognitive disorder
Prevalence in individuals 65+ is 15-20%

Question 15

What are some common signs of MCI?

Answer 15

Losing things
Forgetting appointments
Trouble with word-finding
Forgetting conversations
May be easily distracted
Difficulty managing finances or medications

Question 16

What is Alzheimer’s disease?

Answer 16

Alzheimer disease: brain disease characterized by amyloid plaques, neurofibrillary tangles, and neuronal loss;4 leading cause of dementia in late adult life2

Question 17

What is Alzheimer’s dementia?

Answer 17

Alzheimer dementia: a dementia syndrome that has gradual onset and slow progression, best explained as caused by Alzheimer disease 4

Question 18

What is vascular dementia?

Answer 18

Cognitive impairment with the essential feature of underlying cardiovascular disease, usually in a step-wide decline
Cerebrovascular disease, typically in the form of vascular strokes, results in ischemic brain damage and cognitive loss

Question 19

What are some characteristics of vascular dementia?

Answer 19

Question 20

What is dementia with Lewy bodies?

Answer 20

Progressive cognitive decline sufficient to interfere with daily function caused by build-up of Lewy bodies inside neurons
Accumulated bits of alpha-synuclein protein
Similar symptoms to AD, but more likely to have early symptoms of sleep disturbances, visual hallucinations, slowed gait speed with imbalances, and parkinsonian movement features (tremor, rigidity, bradykinesia)
Symptoms may occur without significant memory impairment

Question 21

What is frontotemporal dementia?

Answer 21

Group of dementias caused by progressive nerve cell loss in the frontal or temporal lobes, resulting in atrophy
Causes changes in behavior and personality, language disturbances, and alterations in muscle/motor function
Impairment of executive function and more difficulty with problem solving than patients with AD
Relatively preserved memory and spatial organization compared to those with AD
Cortical microvasculature changes and loss of synapses at the microscopic level
Insidious onset between age 45 – 70, with estimated duration 3 – 17 years

Question 22

What is geriatric failure to thrive?

Answer 22

A multi-factorial state of decline in vitality that may be caused by chronic concurrent disease and functional impairment
Not a normal consequence of aging, not synonymous with dementia, not a descriptor of later stages of a terminal illness

Question 23

What should a diagnoses of failure to thrive prompt?

Answer 23

End-of-life questions/options

Question 24

What is geriatric failure to thrive associated with?

Answer 24

increased healthcare costs, as well as increased morbidity and mortality

Question 25

What are some of the manifestations of geriatric failure to thrive?

Answer 25

Manifestations include weight loss, decreased appetite, poor nutrition, inactivity
Frequently accompanied by dehydration, depression, impaired immune function, low cholesterol levels

Question 26

What is a good death?

Answer 26

The idea: a dying person is free from discomfort, in the presence of loved ones, and in the environment of their choice1

Question 27

What is palliative care?

Answer 27

An approach that improves the quality of life of patients & their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering

Question 28

Can patients remain in palliative care while seeking curative or supportive managers?

Answer 28

Yes

Question 29

What does palliative care also include?

Answer 29

patients with life-threatening illness who are not imminently dying, but in physical decline who need holistic, multi-disciplinary support services

Question 30

What is hospice care?

Answer 30

Covered by Medicare hospice benefit, but can also be covered by Medicaid, other insurance, or private pay
Must meet certain criteria
Physician determined prognosis of <6 months, from hospice physician and patient’s PCP
Acknowledgement that they no longer seek curative measures
Patient’s can revoke if they wish to seek curative measures
PT is covered by Medicare Hospice Benefit

Question 31

What are some live discharge reasons for hospice stay?

Answer 31

Patient revoked hospice
Patient transferred to different provider
Patient no longer terminally ill per MD
Patient moved out of service area

Question 32

What is the PT’s role in palliative and hospice care

Answer 32

Pain management
Rehabilitation in reverse: Optimize patient’s remaining function with safe and energy-efficient mobility, through education of patient and family/caregivers
Enhance quality of life for remaining time

Question 33

What is an advanced directive?

Answer 33

Documented desires of medical management
Legal document

Question 34

What is advanced care planning?

Answer 34

Identifies the patient’s requests for healthcare decisions in the event of serious illness
Can be very specific

Question 35

What is the durable power of attorney for healthcare decisions?

Answer 35

Appointment of a trusted person 18+ years old to make decisions on the patient’s behalf when they are no longer able to do so themselves
Can be granted for decisions related to financial matters, mental healthcare, or general healthcare
Notarization may be required in some states
If not “durable,” the document can be seen as void if the grantor becomes incompetent

Question 36

What is a living will?

Answer 36

Advanced directive
Competent adult identifies their requests for healthcare decisions in the event of serious illness
Can be very specific
Must be accompanied by durable POA to be respected by physicia

Question 37

What are POLST/MOLST: Physician/Medical Orders for Sustaining Life Treatment

Answer 37

Typically completed when a person is terminally ill or facing the possibility of imminent death
Enables a person to explicitly identify the extent & nature of life-sustaining interventions, which range from comfort care only to hospitalization and full resuscitation
Can be very specific
Ex: No compressions, OK to intubate

Question 38

What does a do not resuscitate stands for?

Answer 38

Clearly specifies the patient’s refusal for cardiac resuscitation DNR

Question 39

What are some of the multisystem physiological signs of approaching death

Answer 39

Confusion, delirium, disorientation, increased time spent sleeping, anxiety, restlessness, hallucinations (visual & verbal)
Weakness, loss of function, fatigue
Drop in BP, HR variability, breathing variability
Cold, clammy skin; distal extremities may be bluish, edema
Loss of interest in food/fluids, GI disturbance, incontinence, decreased urine output as death nears

Question 40

What are the 5 stages of dying?

Answer 40

Denial: common defense mechanism; rejection
Anger: expressed as patients concede the reality of a terminal illness; may project as blaming others
Bargaining: patient seeking control over their illness
Depression: sadness; fatigue
Acceptance: recognizing the reality of the diagnosis while no longer struggling against it

Question 41

Personal cultural issues with acceptance of death?

Answer 41

You must be sensitive and aware of cultural norms and desires of the patient/client
Patients or family members may want traditional healers present
Some cultures do not wish for the patient to be aware of the prognosis
This can present challenges of ethical conflicts between a well-intentioned healthcare provider who is worried about the patient’s autonomy and a relative’s right to care for a loved one in a cultural or traditionally appropriate manner
Culture, religion, and spirituality tend to have increased influences on end-of-life care, including physical therapy
It is essential that healthcare providers meet the spiritual needs of patients and family members receiving hospice care, even if their spiritual or religious beliefs/traditions differ from one’s own

Question 42

What is physician assisted death?

Answer 42

Allows mentally competent patients with a terminally-ill condition to request and receive a prescription medication to hasten their imminent and inevitable death
Also called “death with dignity” laws
Allowed in some states
Controversial and ethically-complex issue
Not legal in Louisiana