Dementia Lecture Flashcards
1
Q
what is dementia?
A
a group of disorders characterized by development of multiple cog deficits
physiological effects of a medical condition
cog impairment that interferes with ability to fxn at work or at usually activities
2
Q
t/f: dementia cannot be explained by delirium or a major psychiatric disorder
A
true
3
Q
dementia involves impairment in 1 or more of what cognitive domains?
A
complex attention
executive fxn
learning and memory
language
perceptual
motor
social
4
Q
describe the onset of dementia?
A
chronic onset, usually gradual
5
Q
if there was a sudden onset of dementia sx, what is more likely the reason?
A
something like a stroke
6
Q
what are the common characteristics of disease progression in dementia?
A
memory and language probs
IADL difficulties
visuospatial probs
disorientation to place and time
delusions, depression
short-tempered, hostile
lose control of bodily fxns
7
Q
what conditions may mimic dementia?
A
delirium
depression
med side effects
infections (UTI, pneumonia)
thyroid conditions
vitamin deficiencies
excessive alcohol use
age-related cog decline
mild cog impairment
delirium
depression
8
Q
what is involved in cognition?
A
complex attention
learning and memory
executive fxn
language
perceptual-motor
social cognition
9
Q
what brain structural changes are involved in normal cognitive aging?
A
atrophy
loss of neurons
protein-forming plaques
tangles created by dead cells
10
Q
what behavioral changes involved in normal cognitive aging?
A
slowing of cog processing
decline in word-finding
memory loss
making occasional error managing finances/household bills
word finding errors
misplacing things from time to time
may see personality changes as memory loss progresses
11
Q
what are the key differences bw normal changes and sx of cognitive impairment? (KNOW THIS)
A
in normal changes, the pt is able to fxn independently, recall episodes of forgetfulness, doesn’t get lost in familiar places, occasionally has work finding difficulty, but not trouble holding convo, and has intact judgement/decision-making
in cog impairment, they have difficulty with simple tasks, unable to recall episodes of forgetfulness, get lost in familiar places, frequently forget words, repeat stories and phrases, and have trouble with decision making
12
Q
in pre-clinical AD, do pts have brain changes that indicate AD?
A
they may
13
Q
what are examples of AD brain changes?
A
abnormally high levels of beta-amyloid and tau and decreased glucose metabolism on PET scans
changes in tau protein in CSF
14
Q
in pre-clinical AD, even though brain changes may be present, why can the individual fxn normally?
A
bc the brain compensates
15
Q
what is mild cognitive impairment (MCI)?
A
a new memory complaint with objective findings of impairment in episodic memory, normal cog fxns, no substantial life interferences, but may have biomarkers for AD
16
Q
ppl with MCI have an increased risk of developing what?
A
AD dementia
17
Q
do all ppl with MCI develop AD?
A
nope
18
Q
those with what type of MCI are more likely to develop dementia due to AD?
A
amnestic (memory) type
19
Q
what are the s/s of MCI?
A
missing appointments
asking the same question repeatedly
forgetting names, places, and common items
difficulty following instructions
changes in mood
confusion regarding dates and time
apathy
20
Q
what are the three Ds?
A
dementia
delirium
depression
21
Q
what is the difference bw AD and dementia?
A
AD is a specific brain disease that accounts for a large % of dementia
dementia is a general term for sx like decline in memory, reasoning, or other thinking skills
22
Q
what are the greatest risk factors for AD?
A
age
genetics
fam hx
23
Q
what age group has the highest % of ppl with AD?
A
those over 85 yo
24
Q
what gene is a possible risk factor for AD?
A
APOE-e4 gene
25
t/f: the APOE-e4 gene increases the risk of developing AD, but doesn't guarantee it
true
26
t/f: individuals with the e-4 form gene are more likely to have beta-amyloid accumulation and AD at a younger age
true
27
what did a conflicting study find about the APOE-e4 gene?
if they had more yrs of early life education, mentally challenging work in midlife, participated in leisure activity, and/or strong social networks late in life, there was a decreased risk of developing AD
28
what is the link bw fam hx and developing AD?
if you have a first-deg relative with AD, you are at a higher risk
29
what are modifiable risk factors that may contribute to dementia?
physical activity
smoking
education
staying socially and mentally active
BP
diet
30
the Lancet Commission suggests that up to 40% of dementia cases may be due to what?
modifiable risk factors
31
t/f: reducing risk factors for dementia is synonymous to preventing cog decline and dementia
false
32
t/f: increased CV disease 2/2 HTN, smoking, and DM are associated with higher risk of developing AD
true
33
t/f: age when risk factors develop has no effect on dementia risk
false
34
late life obesity and HTN after what age is associated with decreased risk of dementia?
80 yo
35
t/f: physical activity may be protective of the heart and brain
true
36
emerging evidence suggests what about a heart healthy diet?
that it may be associated with a decreased risk of dementia
37
what are the two big pathologies behind AD that eventually lead to cell death?
protein fragment beta amyloid plaques outside neurons
protein tau tangles inside neurons
38
t/f: sx of AD dementia worsen over time
true
39
is the rate of disease progression in AD the same for everyone?
no, it varies
40
on avg, how long does a person with AD live after dx?
4-8 yrs and up to 20 yrs (often longer now)
41
can changes in the brain begin b4 any signs of the disease in AD?
yes, this is the pre-clinical stage
42
what things are occuring during the pre-clinical stage of AD?
degenerative changes in the endorhinal cortex
progress into hippocampus
ventricles enlarge
43
in the early mild stage of AD, does a person fxn independently?
probably, they will drive, work, and be part of social activities
44
in the early mild stage of AD, do pts experience memory lapses?
yes
45
what are the changes we may see in early mild AD?
they may forget words or location of everyday objects, have lapses in judgement, or subtle personality changes
46
what is typically the longest disease stage of AD?
moderate middle stage AD
47
in the moderate/middle stage of AD, damage occurs in what areas of the brain?
areas of the brain that control language, reasoning, sensory processing, and conscious thought
48
t/f: memory loss and confusion worsens in the moderate middle stage of AD
true
49
t/f: greater care is required as AD progresses
true
50
what are the sx of the moderate middle AD stage?
shortened attention span
confusing words
probs recognizing fam/friends
unable to learn new things
getting frustrated or angry
restlessness
perseveration
difficulty expressing thoughts and performing routine tasks
hallucinations, paranoia
51
what sx may be noticeable to other in the moderate middle stage of AD?
forgetfulness of events/personal hx
feeling moody/withdrawn
unable to recall their address, phone #, of schools attended
confusion about where they are or what day it is
need help choosing proper clothes
B/B issues
changes in sleep
increased wandering/becoming lost
personality/behavior changes
52
what are the brain changes involved in severe late stage AD?
plaques and tangles spread throughout the brain
brain tissue shrinks significantly
53
what are the sx of severe late stage AD?
complete dependence for daily care
inability to communicate/speak
loss of awareness
loss of ability to recognize fam
changes in physical abilities
complete B/B incontinence
infections (esp pneumonia)
54
in what stage of AD do pt lose the ability to respond to their environment?
in late stage AD
55
what is a common cause of death in late stage AD?
aspiration pneumonia
56
t/f: care decision in late stage dementia can be some the hardest that families have to face
true
57
what is delirium?
acute onset of a disturbance in attention and awareness that is generally a direct physiological consequence of another condition (UTI, meds, etc)
58
what is the difference in onset of AD vs delirium?
AD dementia is a gradual onset, while delirium is an acute/subacute onset
59
t/f: with delirium, there is a short duration of time sx are detected to intervention and recovery
true
60
do sx with delirium fluctuate throughout the day?
yes
61
do sx with dementia fluctuate throughout the day?
no
62
what is a major cause of delirium?
meds (failure to take them, interactions, slow absorption, anesthesia)
63
other than meds, what are some causes of delirium?
underlying medical probs
environmental factors
64
what underlying medical probs can cause delirium?
UTI and bladder infections
penumonia
dehydration
metabolic disorders
constipation
urinary retention
65
what environmental factors can cause delirium?
sensory overload/sensory deprivation
hearing impairment
lack of environmental stimulation
change in environment (hospitalization)
66
delirium is marked by what characteristics?
confusion and disorientation
fluctuating levels of consciousness
jerking motions
disruption of sleep-wake cycles
hallucinations
delusions
anxiety
memory impairment
altered speech
67
what behavioral probs may be involved in delirium?
aggression and wandering
68
t/f: delirium may cause changes in BP and pulse
true
69
is delirium usually worse in the morning or at night?
at night
70
does delirium usually involve structural brain damage?
nope
71
what are the core sx of delirium?
inattention, distractibility
drowsiness
befuddlement
72
what are common associated sx of delirium?
cog impairment
hallucinations
mood lability
73
what is depression?
disturbance in mood, associated with low vital sense and low self-esteem
74
t/f: depression may coexist with dementia and exacerbate dementia if already present
true
75
what are the core sx of depression?
sadness
anhedonia (lack of pleasure)
crying
76
what are common associated sx of depression?
fatigue
insomnia
anorexia
guilt
self-blame
hopelessness
helplessness
77
why is depression often confused with dementia in the elderly?
bc clinical depression includes cog probs like difficulty concentrating, memory complaints, slowed thinking, indecisiveness, perceived lack of competence and control
78
30-40% of older adults with major depression have what?
MCI in executive fxn
79
t/f: most cases of depression don't progress to dementia
true
80
t/f: the elderly are less vulnerable to depression than the rest of the adult population
false, they are just as vulnerable as the rest of the adult population
81
t/f: guilt, self-derogation, and suicidal impulses are less common in elderly with depression
true
82
what sx of depression are more common in the elderly?
apathy, low motivation, low energy, sleep disturbances, and loss of appetite
83
t/f: somatic sx of depression may be part of a co-existing physical illness
true
84
are symptoms of depression usually worse in the am or pm
am
85
what are the 5 Ms to focus on in geriatrics PT? (KNOW THIS)
Mind
Mobility
Meds
Multicomplexity
what Matters most
86
what Matters most in geriatrics PT?
each individual's own meaningful health outcomes, goals, and care preferences
87
what are the items in the Six Item Screener (SIS) screening tool?
asking the pt to ID the day, month, and yr
asking the pt to repeat 3 items then again a few minutes later
88
what are the possible cut off score for the SIS that signifies more cog impairment?
less than 3/4 (2-3 errors)
89
what are the items in the mini-cog screening tool?
ask the pt to repeat 3 words
ask pt to draw a clock and fill in a time
ask the pt to repeat the 3 words again
90
what score on the Mini-cog indicates (+) for dementia and which indicates the need for further testing?
0-2
91
what score on the Mini-cog indicates (-) for dementia?
3-5
92
what is the SLUMS exam tool?
an exam tool used to differentiate normal cog status form MCI and dementia
93
t/f: scoring in the SLUMS exam tool accounts for pt's levels of education
true
94
what are common challenges in dementia care?
impaired capacity for memory/learning
communication
behaviors that interfere with tx sessions and goals
effective involvement of fam members/caregivers
95
what is the role of PT in dementia care?
maximize fxnal ability for all levels
change or simplify the environment
assist caregivers with providing meaningful, safe activity
96
t/f: we should completely change someone's environment in dementia care
false, don't completely change their home unless they are willing and necessary
97
what are the recommendations for effective therapy?
find remaining strengths/spared abilities
make intervention tasks fxnal
use procedural/implicit memory
say less, gesture more
simplify tasks
establish structure and routine
reduce unnecessary background noise
don't expect improvement in cog fxn
98
should we use more words or more gestures in dementia care?
more gestures, be a model!
99
should we expect our therapy interventions to improve cog fxning in dementia?
no
100
what should we do in therapy for early dementia?
promote brain health
maximize mobility, endurance, and fxnal strength
fall prevention (remove hazards)
reinforce current events, choice
procedural learning (errorless learning and spaced retrieval)
monitor for neglect
101
what is the emphasis in therapy in moderate dementia?
errorless learning, spaced retrieval
102
what should we do in therapy for moderate dementia?
errorless learning, spaced retrieval
use lighting, environment, and cuing to orient
fall prevention
maximize mobility
caregiver training
address problem behaviors
103
what should we do in therapy for severe dementia?
positioning for skin integ and contracture prevention
cognitive stimulation
pain management
hospice referral/advanced directives
caregiver training and support
104
what are some strategies to address anger and aggression in dementia?
RULE OUT PAIN
think about what happened right b4 that could have triggered the behavior
be pos and reassuring, speak in a soft tone
limit distractions
try a relaxing activity
shift focus to another activity
take a break
ensure safety
105
what items are included in the pain assessment in advanced dementia scale (PAINAD)?
breathing and independence of vocalization
neg vocalization
facial expression
body language
consoleability
106
what are some strategies to address anxiety and agitation in dementia?
check for pain
listen to frustration and provide reassurance
involve the person in activities
modify the environment
find outlets for energy
107
what are some strategies to address forgetfulness and confusion in dementia?
STAY CALM
respond with a brief explanation
show photos and other reminders
offer corrections as suggestions (avoid responses that sound like scolding)
try not to take it personally
108
t/f: in dementia care, we should suggest, not correct
true
109
what are strategies to address repetitive actions in dementia?
look for a reason
focus on the emotion
turn the action/behavior into an activity
stay calm, be patient
use memory aids
110
what are some strategies to address new suspicions in dementia?
don't take offense
don't argue or try to convince
offer a simple answer
switch the focus to another activity
duplicate lost items
111
when a pt with dementia thinks it is a certain time or year, should we correct them?
no
112
what are some strategies to address wandering and getting lost in dementia?
encourage activity
inform others
make the home safe
113
do we currently use re-orientation approaches in our interventions for dementia?
no, it creates undue stress!!!
114
what are the 2 general approaches to interventions in dementia care?
re-direction and validation
115
what is re-direction in dementia care?
distracting or suggesting alternative activities while avoiding "no" or "can't" to decrease stress
redirecting focus to something they want to do
116
what is validation in dementia care?
accepting the values, beliefs, and reality of the person with dementia
assisting the person to feel that the problem and responses to the problem are acknowledged and understood
117
what are some common criticisms of re-direction and validation in dementia care?
some say that it is "lying" to the pt and there are ethical concerns
118
has the Alzheimer's association determined that re-direction and validation are ethical concerns?
no, they have determined that these strategies don't pose ethical concerns
119
what are verbal strategies for dementia care?
Introduce yourself
Use a calm, reassuring manner
Use simple terms (KISS)
Speak slowly
Assist in finding words
Make statements: avoid asking questions when possible
Use one step commands
Individualize the convo
Rephrase questions
Focus on immediate rather than short term memory (ie do you have pain now)
Re-direct with verbal cues
Narrow choices
120
what things should we avoid with our verbal strategies in dementia care?
rushing
infantilizing
trying to reason or use logic
arguing
using negative words
saying "do you remember"
121
what are some non-verbal communication strategies we can use in dementia care?
make eye contact (don't stare(
observe and listen
use facial expressions-smile!
use appropriate touch
use gestures
respond to the pt's body language
122
in pts with dementia, do we have to rely more on their words or their body language?
their body language
123
what are some external memory aids we can implement in dementia care?
calendars
signs and labels
lists
notebooks
memory wallets
memory books
124
what are the characteristics of an ideal external memory aid?
accessible
bright
legible
explicit
done
125
what is procedural learning?
learning by doing a performed skill
automatic learning without realizing it
126
what is another name for procedural learning?
implicit learning
127
what is a key characteristic of procedural learning?
high repetitions, low task variability
128
does learning in procedural learning require conscious awareness of rules of performance?
nope
129
t/f: we want to "over learn" in procedural learning
true
130
why do we want to "over learn" in procedural learning?
so that the skill just happens without having to think about it or recall the rules and steps
131
procedural learning works best with what activities and skills in dementia care?
familiar and meaningful skills
132
t/f: procedural learning of familiar, meaningful skills leads to more efficient interaction with the environment and positive behavioral and fxnal change
true
133
what is errorless learning based on?
the implicit learning principles of high reps, low task variability
134
what is errorless learning?
practicing conditions to prevent or minimize errors in performance
135
what are some strategies to promote errorless learning?
feed-fwd instruction
modeling
physical assistance
modifying the task to ensure error-free performance
spaced retrieval
136
what is feed-fwd instruction?
when the PT provides verbal and/or manual cues prior to the pt performing the task or each step in a sequential task
137
in errorless learning, initially, should the task be difficult?
no
138
how can we manipulate the difficulty of a task in errorless learning?
by modifying variables such as speed or distance
139
in errorless learning, once the pt is performing the task without errors, what should we do?
increase the challenge of the task
140
what is spaced retrieval?
a memory technique that uses active recall attempts over progressively longer time periods
141
what is the goal of spaced retrieval?
to remember info for relevant time periods
142
what is the method for spaced retrieval?
unconscious/effortless acquisition (repetition), correct answer always given, spaced recall
143
what is the procedure of spaced retrieval?
Therapist asks a prompt question
If target answer not provided in short time (5 sec), tell the pt the answer
Ask the client to repeat the answer
Ask the prompt question again
If target answer is correct, ask again, and gradually increase the time interval bw recall
If target answer is incorrect, therapist verbalizes the correct answer
Pt immediately repeat the answer
Time interval of last successful recall is repeated
144
successful rehab is based on what pt/PT premise?
the premise that the pt and professional have similar goals and the pt will cooperate and adhere to the rehab plan
145
what is the optimal strategy for successful rehab?
shared decision-making with the pt and PT that integrates the pt's view of rehab into the POC
146
when the optimal rehab strategy of shared decision making fails, what strategies may be considered?
persuasion
incentives and inducements
threats and coercion
override pt's autonomy
147
t/f: we should override a pts autonomy when they aren't cooperating
false
148
a pt's ability and freedom to make a valid choice with dementia may be diminished by what factors?
stage of cognitive decline
competence, capacity
pain
frailty
149
t/f: when a pt understand the benefits, risks, and goals of tx, they are more inclined to participate than refuse
true
150
t/f: persuasion is based on the ethical ideal of shared decision making and pt-centered care
true
151
does persuasion treat the pt as a competent adult capable of making a decision based on outcomes of the plan?
yes
152
does persuasion respect the pt's autonomy?
yes
153
t/f: persuasion may be seen as a form of paternalism
true
154
what are inducements?
use of incentives or rewards to encourage a pt to participate
155
what is the only way that inducements are ethical?
if the reward does not leave the pt worse off, is easy to avoid, doesn't involve deception, concealment, or misrepresentation
156
does inducement diminish the capacity to make an autonomous decision?
yes
157
t/f: for inducements to be ethical, the person must be able to review the inducement objectively and determine whether it's consistent with their own values
true
158
t/f: interpersonal leverage is a form of manipulation
true
159
is persuasion and inducements or interpersonal leverage more ethically problematic?
interpersonal leverage
160
t/f: interpersonal leverage plays on pt guilt
true
161
what can rise to a violation of trust relationship bw pt and therapist?
interpersonal leverage
162
are threats ethically acceptable?
yes
163
what are threats?
a form of coercion that leaves a person worse off if they don't comply
164
how is a threat different from an inducement?
in inducement, the reward is given in return for a favor and doesn't leave the pt worse off if they continue to refuse
threats propose to take away a privilege if the pt refuses and leaves the pt worse off if they refuse
165
if a threat is true, it may be an example of what?
an unwelcome predicton rather than a coercive threat
166
if a threat is not true is a ____ _____
coercive threat
167
if the therapist knows the statement in a threat is not true and fails to correct the false belief, what is this?
deception
168
t/f: deception may be benign if it promotes a beneficial outcome
true
169
what is the downside of deception?
it diminishes the pt's ability to weigh info and make informed decisions and actively engage in collaborating in the rehab plan
170
what is a benign example of deception?
telling a pt who is unwilling to bring their knee post TKA to sit on the edge of the bed with the knee unsupported
171
what is a troubling example of deception?
telling a pt that PT won't hurt when in reality tx will cause considerable pain
172
t/f: deception overrides a pt's capacity to make a voluntary, informed choice
true
173
t/f: deception diminished the trust relationship bw the pt and PT
true
174
t/f: compulsion overrides a pt's expressed wishes and forces a competent pt to comply and participate in an activity
true
175
what is an example of compulsion?
pulling a pt out of bed after a pt refuses
176
t/f: compulsion can rise to be a criminal charge?
true
177
what are the ethically acceptable strategies for successful rehab?
persuasion and inducements
178
what strategies for rehab are ethically problematic?
threats and coercion
179
what rehab strategy is generally unethical and may be illegal?
compulsion
180
what walk tests can be used for AD?
TUG, 6MWT, gait speed, bwd walk test
181
what has the best impact on whether the tests of walking are effective on individuals with dementia?
communication style
182
what communication strategies should be used for walking tests in dementia?
personal connection
low-stress environment
friendly expressions, eye contact
one step commands
state meaningful goals
183
what cuing can improve a pts with dementia's completion of a walk test?
verbal instruction with concurrent visual cues or gesture
modeling/demo
tactile guidance
physical assistance if necessary
184
those with higher cognitive impairments in AD showed ____ performance on the TUG and gait speed, ____ distance on the 6MWT
slower, shorter
185
are the TUG, 6MWT, and gait speed reliable outcomes in the dementia populations?
yes
186
what are some strategies to accommodate cognitive deficits in dementia with walk tests?
quiet environment
progressive cuing
type of cue
187
were any norms determined for dementia with the bwd walk test?
no
188
t/f: the bwd walk test is generally safe, reliable, and valid for evaluating balance and gait performance of individuals with dementia
true
189
the bwd walk test distinguished what individuals with dementia?
those who walk with and w/o an AD
190
t/f: the bwd walk test was able to discriminate fall status or ID individuals with dementia who had a fall in the past yr
false
191
were dementia pts with higher levels of physical cues or verbal cues only slower on the bed walk test
those with higher levels of physical cues
192
what are the 6 physical performance tests that are reliable to dementia?
6MWT
figure 8 walk test
TUG
FICSIT-4
30 sec chair rise
Jamar dynamometer grip strength
193
t/f: our tx regime should stimulate cognitive fxn with dementia
true
194
what are some non-pharmacological intervention options for dementia?
reminiscence therapy
music therapy
aromatherapy
massage
195
what is reminiscence therapy?
use of memory aids, pics, objects, vids to trigger memories
196
t/f: reminiscence therapy is shown to improve communication, self-identity, and self-worth, and decrease depression in dementia
true
197
music therapy has been shown to enhance what?
communication, increase cog fxn (speech and attention)
198
t/f: massage has been shown to reduce agitation
true
199
what are informal ways to assess caregiver stress?
Ask if more help is needed at home
Good communication with social work/case manager if concerns about burnout
Know area resources
200
what are formal ways to assess caregiver stress?
Caregiver burden inventory
Modified caregiver strain index
Caregiver self-assessment questionnaire
201
what are some options for caregiver relief?
respite care
day programs
in home help
PACE programs
Medicare Waiver program
