Cognitive Issues in Older Adults Pt 2 Flashcards
What should be included in your subjective exam in a geriatric pt with cognitive issues?
- PLOF
- Orientation/cognition
- Hx of falls
- Current physical activity
- Functional limitations
- Living environment
- Social interactions
- Community activities
- Behavior changes
- Goals from pt/caregiver
- Functional Comorbidity Index
list the 3 types of memory
- short-term → registration
- working → processing
- long-term → storage and retrieval
clinical context of memory
- recognize and understand pts cognitive level/stage of dementia
- present info at slower rate
- increase repetition of info
- recall greatly improved by compensating for age-related changes and making info personally relevant
QOL scales for mild dementia
Schedule for Evaluation of Individual QOL
QOL scales for mild-moderate dementia
- Cornell-Brown Scale for QOL in dementia
- Dementia QOL Instrument
- QOL Alzheimer’s Disease Scale
QOL scales for advanced dementia
- Dementia Care Mapping
- Qualidem and Discomfort Scale
are there caregiver burden scales available?
yes
16 scales specific to dementia, more than 35 available
what are the dimensions of caregiver burden in dementia?
- Direct impact of caregiver on caregiver’s lives → predicted by level of relationship satisfaction w/pt and pt’s functional independence
- also predicted by caregiver depression and age (younger age > guilt)
- Guilt → predicted by caregiver’s depression and age
- Frustration/embarrassment → predicted by pt’s behavioral problems and level of relationship satisfaction w/pt
- behavioral problems a strong predictor of nursing home placement
what is the Zarit Burden Interview?
a widely used measure of caregiver burden
covers impact of caregiving on caregivers in their health, relationships, and finances
List tools to screen for cognitive loss
- Blessed Orientation Memory Concentration Test
- Dementia Screening Indicator
- Functional Activities Questionnaire
- Geriatric Depression Scale (GDS)
- Global Deterioration Scale
- Mini-Cognitive Assessment Instrument (Mini-Cog)
- Mini Mental State Exam
- Montreal Cognitive Assessment (MoCA)
- Trial Making Test (parts A and B)
What are the 7 stages of Global Deterioration Scale
- No Impairment
- Very Mild Decline
- Mild Decline
- Moderate Decline
- Moderately Severe Decline
- Severe Decline
- Very Severe Decline
describe the Clinical Dementia Rating (CDR) Scale
0 → no cognitive impairment (NCI)
0.5 → very mild cognitive impairment (MCI)
1 → mild dementia
2 → moderate dementia
3 → severe dementia
what is the ACLS?
Allen Cognitive Level Screen
uses the task of sewing stiches to evaluate cognition using 3.0-5.8 scale
what should be included in physical performance testing of geriatric dementia pts?
- Activity tolerance
- Functional Mobility
- Balance/fall risk
things to remember when selecting the appropriate test in geriatric dementia pts
- use short instructions with no more than 3 steps
- tests of short duration best to avoid fatigue
- select tests based on goal
List several activity tolerance outcome measures
- 2-min walk test
- 6-min walk test
list several functional mobility tests
- repeated chair stand test
- 30-sec CRT
- 5x STS
- TUG
- TUG-Cog
- FIM
- DEMMI
- Short Physical Performance Battery
List Balance/Fall Risk outcome measures
- Berg Balance Scale
- Mini BESTest
- Figure-8 Walk Test (F8W)
- Groningen Meander Walking Test
- FICSIT-4
- Instrumented postural sway
- FEC-I
what is the Groningen Meander Walking Test?
measures dynamic walking ability by walking over meandering curved line with emphasis on walking speed and stepping accuracy while changing directions
what is the FICSIT-4?
test of static balance → parallel stance, semi-tandem, tandem, and one-legged stance tests
what is the relationship between cognitive function and gait?
- gait → automated rhythmic action
- higher brain centers involved for planning, execution, balance
- widespread network to control attention, executive function, visuospatial
- cerebellum, basal ganglia, motor cortex
- overlapping brain areas to control gait
list equipment that can be used to measure gait
- pressure sensitive walkways
- optical sensors
- accelerometer
- other → ink footprint, stop-watch
list several gait conditions
- single task
- usual pace
- slow pace
- fast pace
- dual task
- counting backwards
- letter fluency
- word fluency
T/F: exercise is beneficial for dementia pts
TRUE
exercise provides neuroprotective and neuroplastic effects on brain structures
list some exercise-induced physiologic mechanisms
- elevated troponin levels
- improved vascularization
- facilitation of synaptogensis
- mediation of inflammation
- reduced disordered protein deposition
how much exercise is suggested for older adults?
total exercise volume appears to moderate atrophy in medial temporal lobe
exercise volume that is neuroprotective is similar to recommended volume for older adults (150 min/week, 5 days/week of moderate intensity aerobic acitvity)
other than aerobic interventions list other physical interventions that can be used in dementia pts
- Tai Chi reduced gait variability during dual task in both healthy subject and those with PD
- RAS at 110% reduced gait variability in pts with PD
- Rhythmic auditory cueing at comfortable speed tempo produced
list aerobic exercise options
- walking and jogging may be option
- dancing
- aquatics
- group exercise classes
- bicycle: stationary or outdoors
- tennis, golf or other sports
- outdoor activities
impact of strength training on cognition
moderate and high-intensity resistance exercise may improve several cognitive domains (STM, LTM, attention span)
but may require longer duration to achieve these changes
recommended dosage for strength training
- moderate-high intensity resistance strengthening 2 days/week for major muscle groups, 48-72 hr recovery between sessions
- 60-80% of 1RM for healthy individuals
- 40-50% of 1RM for deconditioned or frail individuals
- 8-12 reps for 2-3 sets
- 2-3 min rest period between sets
T/F: only some aspects of balance control deteriorate with cognitive impairments
FALSE
all aspects worsen with increased severity of cognitive impairment
list the 6 domains of balance
- biomechanical constraints
- stability limits/verticality
- anticipatory postural adjustments
- postural responses
- sensory orientation
- stability in gait
describe some considerations for developing a balance training program
- Consider single, dual, and multi-task exercises
- training specificity applies to improving postural control
- Basic level → sit on ball w/large BOS
- Moderate level → add juggling balloon with reduced BOS
- Advanced level → add uneven surface under feet, counting backwards, buttoning shirt, EC
impact of cognitive training on dual task load
- 6 week cognitive training program (2 sessions/week, 90 min each) → had less reduced gait speed during dual task after cognitive training which persisted up until 3 months follow-up
- reduced CoV of both stride time and stride length after intervention
- 10 week computer-based 60-min cog training, 3 days/week resulted in improved TUG
comparison of VR to traditional cognitive training
VR physical and cognitive training showed greater improvements in gait and cognition compared to traditional physical and cognitive training
physical activity considerations
- physical activity appears to elicit compensatory brain mechanisms that improve cog function
- hippocampal atrophy linked to risk of progression from MCI to AD
- 1 year of moderate aerobic activity was shown to improve memory and hippocampal volume in healthy older adults
- combining exercise modalities more effective in enhancing cognitive health
- individuals with cog impairments may require higher doses of physical activity to affect positive cog function
what is the Otago Exercise Program?
- series of 17 strength and balance exercises
- PTs assess, coach, and progress over course of 6-12 months
- first 12 weeks → PT management phase
- 9 weeks and beyond → self-management phase w/monthly phone calls
- has not been researched using participants w/cog impairment
HEP considerations for geriatric pts
- customized and specific to address level of cog impairment
- may involve caregiver training to implement program
- clear and simple language
- big print and pictures
- communicate instructions w/demos
- have pt (and caregiver) demo all exercises
- limit number of prescribed exercises
Pharmacologic interventions
- Acetylcholinesterase inhibitor (donepezil)
- NMDA receptor antagonist (memantine)
- Vitamin D
Acetylcholinesterase inhibitor (donepezil) impact on gait
- 4 month Phase II clinical trail → mild AD group increased speed. CoV stride time decreased but not sig
- 6 month CRT w/MCI older adults → sig reduction in dual-task cost during gait; improved gait speed but not sig
NMDA receptor antagonist impact on gait
- sig decrease in CoV stride time compared to acetylcholinesterase inhibitor
Acetylcholinesterase inhibitor vs memantine impact on gait
- both improved stride time parameters in ST condition, only AChEIs improved DT condition
- inconclusive effects of meds on stride time variability
Vitamin D impact on balance and gait in cognitively impaired older adults
- low serum Vitamin D associated with high stride time variability
- lower Vitamin D concentrations predict executive dysfunction
- balance and muscle strength are improved w/daily Vitamin D supplementation doses of 800-1000 IU
- Vitamin D supplementation can improve gait and balance function in older adults, especially those w/severe deficits
List some community resources available for older adults with cognitive impairments
- Dementia Alliance of NC
- Project CARE (caregiver alternatives to running on empty)
- Alzheimer’s Support Group at Sharon Towers
- MemoryCare
- Carolina Geriatric Education Center (CGEC)
describe effective communication with individuals who have dementia
- establish eye contact to ensure attention
- use short, simple, concrete communication
- avoid the use of pronouns (too ambiguous)
- one topic at a time and repeat/rephrase as necessary
- use multisensory input: auditory, visual, tactile
- use close-ended questions
- use external orientation/memory aids (calendar, signs, etc)
- share successful communication techniques with caregivers
- reduce background noise
- do not stand w/glare behind you
- always face pt (avoid standing behind or to side)
- if possible, remove mask before speaking
- ask questions, to confirm pt has understood
- avoid interrupting
- do not take negative comments perosnally
- be patient
tips to working with individuals who have dementia
- utilize validation method → uses empathy and listening to acknowledge a person’s thoughts/reality
- focus on abilities
- gear interventions and trx toward what the person can do
- use routines and familiar environments and people to reduce negative behaviors
when can exacerbations of negative behaviors (like agitation, combativeness, increased confusion) occur?
- new/unfamiliar:
- environment
- caregiver
- routine
- open environment that requires increased cognitive processing
quality documentation should explain what?
- why pt required increased time for recovery
- impact of comorbidities/meds on progression in PT
- explanation of benefits of PT services in spite of cog impairments
