Geriatric Rehab Care and Dementia

Question 1

prevalence of dementia

Answer 1

Current prevalence rates of dementia
– 6-8% if older than 65
– 30% if older than 80

Question 2

dementia

Answer 2

an acquired syndrome consisting of a decline in memory and other cognitive functions

aphasia, apraxia, agnosia, or impaired executive functioning

deficits cause significant impairment in social or occupational functioning.

Question 3

Aphasia

Answer 3

Characterized initially by a fluent aphasia
– Able to initiate and maintain a conversation
– Impaired comprehension
– Intact grammar and syntax however the speech is vague with paraphasias, circumlocutions, tangential and often using nonspecific phrases (“the thing”)

• Later language can be severely impaired with mutism, echolalia.

Question 4

apraxia

Answer 4

Inability to carry out motor activities despite intact motor function

Contributes to loss of ADLs

*keep environments as clutter free as possible
keep routine as consistent as possible
keep room the same

Question 5

agnosia

Answer 5

The inability to recognize or identify objects despite intact sensory function
Typically occurs later in the course of illness
Can be visual or tactile

• HOH
• simplify environment
• pics better than words

Question 6

Impaired Executive Function

Answer 6

Difficulty with planning, initiating, sequencing, monitoring or stopping complex behaviors.

– Occurs early to midcourse
– Contributes to loss of instrumental activities of ADLs such as shopping, meal preparation, driving and managing finances.

Question 7

Dementia Subtypes

Answer 7

Early onset: before the age of 60
– Less than 5% of all cases of AD
– Strong genetic link
– Tends to progress more rapidly

Late onset: after age 60
– Represents the majority of cases

Question 8

Features Associated with Dementia

Answer 8

Agitation 
Aggression 
Sleep disturbances
Apathy (can be misdiagnosed as depression)
Depression or anxiety 
Personality changes
Behavioral disinhibition
Impaired insight
Hallucinations (visual more common than auditory)
Delusions (often paranoid or persecutory

Question 9

Medical Assessment of Dementia

Answer 9

History 
Physical and Neurological Exam 
Cognitive Screening Test 
Rule out Reversible Causes 
Neuroimaging 
Consider the Etiology 
Treatment or Referral

Question 10

Assessment for Reversible Dementia

Answer 10

Labwork
(electrolytes, CBC, liver enzymes, TSH, B12, syphllis)

Neuroimaging
(CT or MRI if vascular dementia suspected)

Question 11

Alzheimer’s DiseaseDementia Syndrome

Answer 11

Insidious onset and gradual progression.
Presentation usually related to primary deficits in recent memory.
Incidence age-related: 8% per year by 85.
1/2-2/3 of the time, the cause of dementia is AD.
Ultimate diagnosis based on pathology of plaques and tangles

Question 12

Course of AD

Answer 12

Insidious onset and progressive course with typical loss of 3 points on MMSE each year and death occurring 8-12 years after diagnosis.

Question 13

Course of AD: Mild

Answer 13

MMSE 20-24
Usually the first 2-3 years after diagnosis
Primarily memory and visual-spatial deficits
Mild difficulty with executive functioning

*look at compensations

Question 14

Course of AD: Moderate

Answer 14

MMSE 11-20
3-6 years following diagnosis
Aphasia and apraxia become more pronounced
Loss of IADLS and increased assistance with ADLs
Beginning to exhibit some neuropsych symptoms particularly paranoia

*more help with organizing shopping list
laundry tasks

Question 15

Course of AD: Severe

Answer 15

Usually 6-10 years following diagnosis
Severe language disturbances: mutism, echolalia, repetitive vocalizations
Pronounced neuropsych manifestations including agitation, aggression
Very late in the course can see muscle rigidity, gait disturbances, incontinence, dysphagia

*more housebound less ability to interact with environment and ADLs

Question 16

Vascular DementiaDementia Syndromes

Answer 16

Second most common form of dementia after AD
One or more strokes, two or more cognitive functions affected.
Abrupt onset and stepwise course– different from AD
Aka “Binswanger’s Disease,” “lacunar state,” or “multi-infarct dementia.”

Should be reserved for patients with clear evidence of stroke on imaging or physical examination.
– 10-40% of all dementia cases
– 10-15% of AD cases are “mixed”

Question 17

treatment for Vascular DementiaDementia Syndromes

Answer 17

– Treatment focused on risk factors
smoking 
atrial fibrillation 
diabetes 
hypertension

Question 18

Dementia with Lewy BodiesDementia Syndromes

Answer 18

Lewy Body= Abnormal protein
High Incidence: 7-26%
Memory Impairment may come AFTER
Visual Hallucinations, delirium, parkinsonism
Sensitive to neuroleptics 
Decline faster than in AD?

*need right meds to decrease symptoms

Question 19

Dementia SyndromesLewy Body vs Parkinson’s

Answer 19

In DLB, Lewy Bodies are cortical
In (idiopathic) Parkinson’s Disease, Lewy
Bodies in substantia nigra
In PD, motor symptoms precede dementia
for years.
In LBD the motor symptoms more closely linked to the memory problems

Question 20

Pick’s Disease

Answer 20

Pick’s Disease is type of frontotemporal dementia.
– Personality changes, disinhibition, executive dysfunction
– Memory impairment
– FT atrophy on brain imaging. Assymetric?

Presenile” in onset: 50-60
More progressive and rapidly deteriorating than AD
Final diagnosis also autopsy-based

Question 21

Behavioral Treatment

Answer 21

Should actually be tried first, before medications.

– Generally consist of reassurance, distraction, redirection, structure
– Don’t argue: it makes things worse
– Provide for safe place where dysfunctional behavior can occur without causing harm

• reassure pt. that everything is ok
• distract/re-direct pt.
• structure-keep tx moving along, no down time, can see when they are done/have had enough!

Refer to Adult Day Care 
Respite/Adult Family Homes 
Caregiver Support Groups 
Psycho-education 
Depression in caregiver 
SNF’s before crisis

Question 22

TreatmentPharmacologic

Answer 22

Behavioral problems can warrant most attention secondary to...
– Agitation 
– Depression 
– Delusions 
– Aggression
 Improvements are modest

Antidepressants (Trazodone)
Neuroleptics (psychosis, agitation)
Anticonvulsants(Carbamazepine, Divalproex for disinhibition such as yelling in the absence of psychosis or depression)
Psychostimulants
Cognitive Enhancers (Aricept, Exelon, Reminyl)
Benzodiazepines

Question 23

BADLS

Answer 23

Bathing
Dressing 
Grooming 
Toileting 
Continence 
Transferring

*pts usually unaware of deficits. less zippers, buttons, etc. look @ standard of care that is acceptable. simplify clothing/footwear
grab bar/shower seats etc.

Question 24

IADLs

Answer 24

Telephone 
Travel 
Shopping 
Meals
Housework 
Medicine 
Money

Question 25

Screening Assessments

Answer 25

Mini-Mental State Exam (MMSE)
Clock Drawing Test (CDT) 
Mini-Cog 
Time and Change 
7-Minute Screen
Others

Question 26

MMSE

Answer 26

Orientation (10 points)
Registration (3 points)
Attention and Calculation (5 points)
Recall (3 points)
Language (8 points)
Visuospatial (1 point)
Total=30, if less than 25, consider dementia.

Question 27

MMSE Pros & Cons

Answer 27

Pros
– Widely used and therefore can track cognition over time and between clinicians
– 5-10 minutes.
Cons
– False positives: those with little education.
– False negatives: those with high premorbid intellectual functioning.
– Psychologically stressful–makes people angry & defensive!

Question 28

Clock Drawing Test (CDT)

Answer 28

Draw a large circle on the (blank) page.”
“Put numbers on the circle.”
“Place hands to show 10 past 11.”
– Tests planning, visuospatial abilities, but not memory
– Less stressful, less culture-bound

Question 29

Mini Cog

Answer 29

Clock-Drawing + three-item memory test
– More sensitive than CDT
– Same advantages as CDT
– Not as commonly used as MMSE, but FAST
– Involves visuospatial, executive and planning, and memory functions
• “Positive”= 2 word recall and/or abnormal clock

Question 30

Time & Change Test

Answer 30

Telling Time Task:
Pt. asked to tell the time when presented with a clock face set at 11:10. Two tries allowed within 60 seconds.

Making Change Task:
Present Pt. with 3 quarters, 7 dimes, 7 nickels, and ask them to give one dollar’s worth of change. Two tries within 120 seconds.

Question 31

OT Assessment

Answer 31

ADL, motor, sensory, cognitive and environmental
Determine AE or DME needs considering the learning abilities of the pt.
Nonaillada article (OT Practice Dec. 15, 2008):

Short Orientation Memory Concentration (SOMC)
Physical Self-Maintenance Scale (scores 6 areas of ADLs and has an 8 item IADL scale)
Geriatric Depression Scale

Question 32

OT Intervention

Answer 32

Memory clinic
Reminisance therapy
Snoezelen (multi sensory stimulation)
Environmental strategies
Caregiver teaching
Animal assisted treatment
Music therapy *help with automatic speech 
Creative art therapy
Movement therapy
Cognitive stimulation
Distraction and diversion