Cognitive and Psychological Issues Flashcards
What is executive function?
Higher order cognitive skills
- sequencing
- self awareness
- planning
- organizing
- evaluating
Cognitive flexibility
- knowing how to adapt to situations
Decision making
- financial (are you getting a good deal, forward planning)
Ability to regulate emotion
Feedback utilization
Self perception
Standardized test for cognitive issues
MMSE
- Not sensitive to address the suitable changes associated with aging
- EF more of a predictor of function
3 approaches to assess executive function
Neuropsychological approach: relationship between impaired brain areas and behavior
- MRI’s other “hard” diagnostic tools
Cognitive approach: focus on specific cognitive process that make up EF
- Don’t usually have a baseline, so how do we know?
Functional approach
- Kettle Test
- Multiple Errand Test
What is metacognition?
Knowing what you know and what you don’t know
Self awareness of your intellect
What is the MMSE?
The MMSE consists of 11 simple questions or tasks grouped into 7 cognitive domains:
1) Orientation to time
2) Orientation to place
3) Registration of three words
4) Attention and calculation
5) Recall of three words
6) Language
7) Visual construction
Levels of impairment have been classified as:
None: score = 24-30
Mild: score = 18-24
Severe: score = 0-17
Common executive function assessments
Trail Making Test
Verbal Fluency Test
VFT Animals Category
Clock Draw Test
Digits Forward and Backward subtest (Digits Span Test)
Stroop Test
Wisconsin Card Soring Test
Behavioral Assessment Of the Dysexecutive Syndrome
Kettle Test
Multiple Errand Test
Executive Function Test
3 approaches to EF intervention
- Cognitive
- Exercise
- Social Engagement
Cognitive intervention for EF
Think, “If you don’t use it, you loose it”
Several studies looked at video games that required (Tetris, Rise of Nations, Cooking task)
- Problem solving
- Memory
- Sequencing
- Shifting attention
They all saw an increase in cognitive skills (per standardized testing) in as little as 4-6 weeks
However, the link to actual FUNCTION is very weak AND how long does the effect last is uncertain
These studies were virtual (video game), but it is likely the same could be accomplished through real life tasks (occupations)
Exercise interventions for EF
Connection between physical ability and cognitions
Multiple studies have shown that with increase physical activity and exercise, cognition improves
Most effective time line is 31-45 min sessions 3-5 times per week
Correlation between walking speed decline and cognitive decline
Social engagement interventions for EF
Idea that elderly clients who are socially engaged maintain or improve cognitive function
Problem based learning
Fits well with OT interventions because it is more function based
- Plan a fundraiser
- Bible study
- Volunteer at school
- Pickle ball
Functional, occupation-based tasks provide the vehicle for improving cognition
Why do we see a decline in cognitive ability with aging?
Multiple reasons
- changes in technology
- culture
- removed from experience
Benign cognitive decline: typical and mild
- ARCD: Age Related Cognitive Decline
Malignant Cognitive decline: atypical, disease or disorder driven
Types of dementia
Alzheimer’s
Vascular
Lewy body
Frontotemporal
Huntington’s
Mixed
Medication induced
CVA, TBI
Characteristics of alzheimer’s
Slow progression
No disturbance of consciousness
No other disorders or medication that may cause the symptoms
Symptoms don’t go away
Hallucinations in late stages
Must have impairment in at least 2 of the following areas:
- memory
- language (aphasia)
- praxis (apraxia)
- recognition (agnosia)
- executive function (impaired judgement)
Signs of alzheimer’s
Memory loss
Challenges in planning/problem solving
Difficulty completing familiar tasks
Confusion with time or place
Trouble understanding visual images and spatial relationships
New problems with words in speaking/writing
Changes in mood/personality
Decreased/poor judgement
Withdrawal from work/social activities
Misplacing things
Early stage Alzheimer’s
Symptoms are mild and characterized by general forgetfulness
Role of OT:
- structure
- cuing
Symptoms include:
- forgetting recent material
- trouble organizing/planning
- forgetting where valuable have been placed
- trouble managing money
- forgetting recent evens
- trouble with challenging tasks
- wandering and becoming lost in familiar places
Middle stage Alzheimer’s
Symptoms are more disabling and additional care may be needed
Symptoms include:
- delusions, compulsions, or repetitive behavior
- agitation, restlessness, and anxiety
- needs assistance with getting dressed
- bowel and bladder function issues
- trouble learning new things
- problems with reading and writing
- loses track of time or surroundings
- sleep disturbances
Late stage alzheimer’s
Symptoms are significant and apparent
Symptoms include:
- significant personality and behavior changes
- loss of ability to hold a conversation
- difficulty moving, eating, and swallowing
- loss of bladder and bowel
- lack of awareness of recent activities or surroundings
- highly susceptible to infections like pneumonia
Stage 1 Alzheimer’s
Normal behavior with no impairment
No noticeable symptoms or problems
Stage 2 Alzheimer’s
Very mild decline or changes
Minor memory problems may appear, like forgetfulness, which may also be due to normal aging
Stage 3 Alzheimer’s
Mild decline
Mild cognitive and physical impairments may become noticeable, like cognitive problems, decreased attention, and memory
Stage 4 Alzheimer’s
Moderate decline
May experience impairment in the ability to perform daily tasks
Stage 5 Alzheimer’s
Moderately severe decline
Symptoms may become moderate to severe, the pt may require help and support from caregivers in daily activities
Stage 6 Alzheimer’s
Severe decline
May need continuous supervision with basic tasks, like wearing clothes or eating
Stage 7 Alzheimer’s
Very severe decline
May lose ability to communicate and may need constant assistance
OT role with moderate stage Alzheimer’s
Motor
Safety
OT role with severe stage Alzheimer’s
Swallowing
Incontinence
Wheelchair
Simple tasks
OT role with end stage Alzheimer’s
Pressure ulcers
Aspiration
Palliative care
Lewy body dementia
Often confused with Alzheimer’s
Caused by a build up of lewy body proteins in the brain which can be definitively diagnosed
Memory vs attention and visual perceptions
Much wider swings of “bad days”
- Episodes of extreme confusion
- Zoning out
Early stage lewy body
Delusions
Restlessness
REM sleep disorder
Movement difficulties
Urinary issues
Middle stage lewy body
Motor impairment
Speech difficulty
Decreased attention
Paranoia
Significant confusion
Late stage lewy body
Extreme muscle rigidity and speech difficulty
Sensitivity to touch
Susceptibility to infection
Vascular dementia
Caused by:
- untreated HBP
- diabetes
- high cholesterol
- heart disease
Symptoms:
- confusion and agitation
- unsteady gait
- memory problems
- urinary issues
- night wandering
- decline in ability to organize thoughts/actions
- difficulty planning
- poor attention
Can be reversed if caught early enough. If damage is caused by infarction, it’s nonreversible, but future incidents can be controlled.
Parkinson’s disease dementia
Quick/dramatic progression
Symptoms come and go
Hallucinations usually caused by meds for Parkinson’s
Festinating/ shuffling gate
Symptoms
- memory loss
- anxiety/depression
- hallucinations
- slow blinking
- drooling
- difficulty swallowing
- temors
- loss of FM
- problems with balance
Frontotemporal dementia
Basically they become jerks
Symptoms:
- disinhibition
- poor insight/judgement
- loss of social graces
- perseverative behaviors
- apathy
Characteristics of depression very important, may have to write out
Onset: weeks to months
Mood: low/apathetic
Course: chronic; responds to treatment
Self-awareness: likely to be concerned about memory impairment
ADLs: may neglect basic self-care
IADLs: may be intact or impaired
Characteristics of delirium very important, may have to write out
Onset: hours to days
Mood: fluctuates
Course: acute; responds to treatment
Self-awareness: may be aware of changes in cognition; fluctuates
ADLs: may be intact or impaired
IADLs: may be intact or impaired
Characteristics of dementia very important, may have to write out
Onset: months to years
Mood: fluctuates
Course: chronic, with deterioration over time
Self-awareness: likely to hide or be unaware of cognitive deficits
ADLs: may be intact early, impaired as disease progresses
IADLs: may be intact early, impaired before ADL as disease progresses
Apathy syndrome
Disengaging from enjoyable activities
Relying on others for daily tasks
No positive or negative emotions
Other symptoms of dementia
Apathy syndrome
Agitation: restless, disruptive, violent
Wandering: aimless motor activity
Psychotic symptoms: hallucinations/delusions
Assessments for dementia
SLUMS
CAM-ICU
- Great for ICU
- Acute onset delirium
Short Blessed Test
Kettle Test
MiniMental
Cognitive Assessment of Minnesota (CAM)
Lowenstein Occupational Therapy Cognitive
Assessment (LOTCA)
ADL Situation Test
Direct Assessment of Functional Abilities (DAFA)
Kitchen Task Assessment
Performance Assessment of Self Care Skills (PASS)
Executive Function Performance Test (EFPT)
Large Allen Cognitive Level Screen (LACLS)
Routine Task Inventory-Expanded (RTI-E)
Tips to assist with cognitive decline
Maximize their retained abilities
Short clear cues to keep clients engaged
Modify the environment or task
Training to family and caregivers
- Focus on one task at a time
- Cognitive methods
- Lists, mnemonics, cues, alarms, notes and notebooks
- For new learning: brain games, new task (dancing, game) - Rehearsal
- Be patient, don’t challenge. “You know this”
- Exercise and activity
- Especially familiar tasks - Diet
- Fuel in the tank
- Heart = brain
5 activities for seniors with dementia
- creative: painting, making music, crafting
- fulfilling: folding laundry, puzzles
- technology-based: Google Earth, virtual museums
- reminiscent: looking at photo albums, listening to old music
- sensory: smelling familiar scents, touching distinctive textures
Trail Making Test
Involves visual scanning and working memory. The TMT has two parts; the TMT-A (rote memory) and TMT-B (executive functioning)
If the person cannot complete the test in 5 minutes, the test is discontinued. An average score for TMT-A is 29 seconds and a deficient score is greater than 78 seconds. For TMT-B, an average score is 75 seconds and a deficient score is greater than 273 seconds.
Difference between sign and symptom
Symptom: what the patient reports (subjective)
Sign: can be objectively measured; hard neurological signs
Diseases dx through signs and symptoms
RA
CRPS
SPD
ADHD
Hallucination vs Delusion
Hallucinations involve hearing, seeing, smelling, or feeling things that are not really there.
Delusions are false beliefs that the person thinks are real.
Things that look like dementia but can be reversible
Age related memory impairment
Delirium (not permanent)
- Medication related
Brain tumor
Blood clot
HIV
Depression
(D)rugs
(E)motions
(M)etabolic disturbances
(E)ye and ear impairments
(N)urtitional disorders, normal pressure, hydrocephalus
(T)umors, toxicity, trauma to head (subdural hematoma)
(I)nfection (UTI)
(A)lcohol
How to assess dementia
No single process
Detailed history
- Including medications, recent changes etc.
Physical and neurological exam
Neuroimaging
Standardized assessments
- Based on primary symptoms
Neuropsychological testing
