Module 2: Lesson 4: Cognition and Productive Aging Flashcards
The following cognitive interventions below have what type of evidence support:
- Multifaceted transition care intervention
Moderate evidence
The following cognitive intervention has what type of evidence support?
- Home based OT services targeting IADL
Strong evidence
The following cognitive intervention has what type of evidence support?
- Chronic disease self-management programs based on the Stanford Model of Chronic Disease Self Management
Moderate evidence
True or false: There is weak evidence to support the OT cognitive interventions targeting community dwelling older adults IADL performance?
False - strong evidence
What outcomes were noted with an OT facilitated 10 wk functional task exercise group (IADLs w/ focus on cognitive components)?
Pts demonstrated significant improvement with:
- General cognitive functions
- Memory
- EF
- Functional status
- Everyday problem solving
What are the most critical cognitive issues to be addressed in acute care?
- Consciousness
- Attention
- Working memory
- Safety judgement
What capacities are easily observed in acute care settings?
- Memory
- Attention deficits
- Overt problem solving
What term describes this LOC?
- Awake and participates in therapy with no efforts to increase arousal
Alert
What term describes this LOC?
- Drowsy, requires loud verbal stimulation to arouse, responds slowly
- May need to be sitting to maintain arousal, but will be able to participate minimally (follow occasional 1 step directions)
Lethargic
What term describes this LOC?
- Requires constant tactile or motor stimulation to obtain and maintain arousal
- May need to be sitting to maintain arousal
- When awake, the pt is confused and not able to productively participate in therapy
Obtunded
What term describes this LOC?
- Minimally arousable only with noxious stimuli such as sternal rub, calling the pt loudly, pinching arm or leg, deep nail bed pressure, shaking shoulders or bed
- Will not actively participate in therapy and has minimal awareness of self
Stupor
What term describes this LOC?
- Not arousable with any type of stimulus, including noxious
- The pt may exhibit physiological reflexive responses that are abnormal or normal
Coma
What is the primary skill required for memory and judgement?
Attention
In acute care, what four separate steps of memory are important to focus on?
- Encoding
- Consolidation
- Storage
- Retrieval
Name some common ICU medications that can impact cognition
Sedatives/hypnotics
- Lorazepam (Ativan)
- Midazolam (Versed)
- Dexmedetomidine HCL (Precedex)
- Propofol tirated (Diprivan)
What term is described below:
- Acute cognitive changes
- Fluctuating arousal
- Altered motor activity (hypo or hyper)
- Sleep disruption
Delirium
Describe delirium
- Acute cognitive changes
- Fluctuating arousal
- Altered motor activity (hypo or hyper)
- Sleep disruption
What is the incidence of delirium in the ICU
16-89%
What is ICU delirium linked to?
- Increased LOS
- Increased mortality
- Increased long term functional issues
- Increased cognitive deficits
- Increased time on mechanical ventilation
- Increased self extubation
What are some risk factors for delirium?
- Pre existing dementia
- History of hypertension
- History of alcoholism
- High severity of illness on admission
What are assessments used with cognition, disorders of consciousness and delirium in the ICU?
- Glasgow coma scale
- JFK Coman Recovery scale
- Richmond Agitation Sedation Scale (RASS)
- Confusion Assessment Method for the ICU
- Intensive Care Delirium Screening checklist
What are some issues that OT addresses with delirium?
- Sleep disturbances
- Immobility
- Cognitive deficits
- Visual deficits
- Lack of natural light exposure during the day
What cognitive scale is described below:
- 15 pt rapid assessment of consciousness and brain injury assessing eye opening and verbal and motor ability
Glasgow Coma Scale
Describe the scores of the GCS
- > or equal to 13 mild brain injury
- 9 to 12 moderate injury
- < or equal to 8 severe injury
What cognitive assessment is described below:
- Used w/ DOC
- Assists in differential diagnosis
- Quantifies emergence from a minimally conscious state
- Provides prognostic assessment and treatment planning
- Assesses the following functions: Auditory, visual, motor, oromotor, communication and arousal
The JFK Recovery Scale - Revised (CRS-R)
Describe the scores of the JFK Coma Recovery Scale - Revised
Scores range from 0 (deep coma_ to 23 (able to follow commands and use objects purposefully)
Describe the cognitive assessment listed below:
- 10 level scale (Scores range from +4 combative to 0 alert and calm to -5 unarousable)
The Richmond Agitation-Sedation Scale (RASS)
Describe the scoring/interventions of the RASS scores
-3 and -2: Appropriate for PROM and sitting EOB
`-1, 0, +1: As tolerated, progress toward ambulation and ADL
What cognitive assessment is described below:
Four feature assessment:
- AMS
- Inattention
- Altered consciousness (RASS score other than 0)
- Disorganized thinking
the Confusion Assessment Method for the ICU (CAM-ICU)
Describe the results of the Confusion Assessment Method for the ICE (CAM-ICU)
Positive for the presence of delirium if both features 1 and 2 are present, with at least one of features 3 or 4
What cognitive assessment is described below:
8 item check list assessing:
- LOC
- Inattention
- Disorientation
- Hallucinations or delusions
- Psychomotor agitation or retardation
- Inappropriate speech or mood
- Sleep wake cycel disturbances
- Symptom fluccuation
The Intensive Care Delirium Screening Checklist
Describe the scoring of the Intensive Care Delirium Screening Checklist
A score of > or equal to 4 within an 8 to 24 hour period is positive for delirium
Name some evidence based interventions that target prevention of delirium
- Establishing a daily schedule that promotes participation in daily activities
- Early mobilization
- Emotional regulation techniques
- Scheduled rest
- Establishing premorbid sleep wake cycles
- Frequent reorientation
- Assessing for pain and agitation during sessions when communicating findings to the team
- Coordinating with team for treatment while sedation is lifted
What term is described below:
Conditions involving progressive damage to the function, structure, or both of neurons from the central and or peripheral nervous system.
Can be chronic, progressive, generally incurable, sometimes fatal, variable types and severity
Neurodegenerative disease (NDD)
Name some assessments that are appropriate for use with adults in NDD population.
- Arnadottir OT- ADL Neurobehavioral Evaluation (A-One)
- EFPT
- KELS
- Multiple Errands Test (MET)
- Occupational Self Assessment (OSA)
- Performance Assessment of Self Care Skills
What percent of the population of MS patients have cognitive dysfunction?
50%
What are some common cognitive issues with MS patients?
- Memory
- Attention
- Concentration
- EF
What should interventions focus on for MS patients (in regards to cognition)?
Process skills targeting cognition and emotion regulation
What are some therapeutic intervention/precautions for patients with MS in relation to cognition?
Therapeutic interventions:
- Assess safety judgement for home
- Memory strategies (i.e. writing down questions)
- Best if the patient is permitted to work through steps of the task on their own vs being told how to do a task
- Assess medication management issues
- Reduce environmental distractions
Precautions:
- May be impulsive/have poor self monitoring
- Fall risk
True or false: There is moderate evidence of high quality support, that demonstrated immediate and or short term improvements in regards to computerized cognitive training targeting specific skills of MS patients.
True
Describe memory training with MS patients
- Moderate evidence of medium quality
- Modify activities and contexts to bolster adaptation or compensation
Describe cognitive treatment of parkinsons patients.
- Employ cognitive behavioral interventions addressing overarching capacities.
- Focus is on participant wellness and personal control, improved QOL via lifestyle modifciation
Describe interventions used for cognition with parkinsons patients
- Education
- Goal setting
- Performance skill training
- Practice
- Feedback related to incorporating habits into daily life
Describe the support for parkinsons disease cognitive interventions.
- Moderate evidence to support tx effectiveness
- Noted effectiveness of dosage
- 6 to 8 week interventions
- Greater then or equal to 20 sessions
Describe clinical interventions for ALS in regards to cognition.
- Assess frontal lobe characteristics such as EF and initiation
- Develop strategies to compensation for decreased EF (i.e. using calendars)
- Behavioral management strategies education for family
- Medication management strategies
What term is described below:
An alternation in cognitive skills and functioning.
Generally a symptom, not a diagnosis
Altered mental status
What are the main causes of altered mental status?
- Progressive degrees of major NCD
- Delirium
- Metabolic encephalopathy
- Depression
The following symptoms describe what condition?
- Fluctuations in occupational performance skills as a result of decreased cognitive functioning
- Altered alertness and LOC
- Sleep disturbances
- Confusion
- Disorientation
- Attentional and memory deficits
- Agitation (aggressive or non aggressive)
- Irritability
Altered mental status
Name some assessments used for altered mental status.
- MMSE
- St Louis University Mental Status Exam
- MOCA
- Confusion Assessment Method
What are some ways to help staff work with patients with altered mental status?
- Provide normalcy to patient routines by: Increasing orientation, clocks and calendars, performing daily routines at normal times, sleeping at night and a few naps during the day
- Diminish sensory overload
What condition is described below:
Chemical, electrolyte, water or vitamin abnormalities resulting in diffuse brain dysfunciton
Metabolic encephalopathy
What are some systemic causes of metabolic encephalopathy?
- Anoxic or ischemic encephalopathy
- Sepsis
- Electrolyte imbalance
- Medication effects
- Hypercapnic, hepatic or uremic encephalopathy
What could a low lab value for thyroxine indicate?
- Slowness to respond
- Fatigue
- Depression
- Apathy
- Potential psychosis and major NCD
- Confusion
What low lab value is described below:
- Slowness to respond
- Fatigue
- Depression
- Apathy
- Potential psychosis and major NCD
- Confusion
Low thyroxine
What symptoms occur with low thyroid-stimulating hormone?
- Symptoms similar to hypothyroidism, but also may include:
- Anxiety
- Agitation
- Sleeplessness
- Irritability
- Lability
- Psychosis, mania and paranoia
What low lab values are described below:
- Symptoms similar to hypothyroidism, but also may include:
- Anxiety
- Agitation
- Sleeplessness
- Irritability
- Lability
- Psychosis, mania and paranoia
Low thyroid stimulating hormone
What symptoms are found with hypercalemia?
Irritability
What symptoms are found with CO2 (hypercapnia)?
- Confusion/disorientation
- Lethargy
- Panic Calcium hypocalemia
- Drowsiness
- Lethargy
- Confusion
- Anxiety
- Mimics depression, dementia or psychosis
What poor lab values are associated with the symptoms below:
- Confusion/disorientation
- Lethargy
- Panic Calcium hypocalemia
- Drowsiness
- Lethargy
- Confusion
- Anxiety
- Mimics depression, dementia or psychosis
Hypercapnia
What are some symptoms of hypoxia?
- Confusion
- Lethargy
What are some symptoms of high blood urea nitrogen and creatinine levels?
Confusion
What are some symptoms sees with hyponatremia and hypernatremia (sodium)?
Hyponatremia
- Agitation
- Irritability
- Restlessness
- Confusion
- Delirium
Hypernatremia
- Lethargy
- Obtundation/coma
What type of natremia has issues with the following:
Lethargy
Obtundation/coma
Hypernatremia
What are some symptoms of hypokalemia (potassium)?
Confusion
Fatigue
What are some symptoms with hypo or hyperglycemia?
- Confusion
- Impaired memory
- Lethargy
- Irritability
- Nervousness
- Inappropriate behavior
What are some symptoms associated with low hematocrit or hemoglobin?
- decreased attention
- irritability
- depression
- fatigue
What are some symptoms with metabolic alkalosis (increased pH, CO2, and bicarbonate)?
Lethargy and stupor
What are symptoms associated with respiratory acidosis
Drowsiness or if severe progression to stupor and coma
What are some symptoms associated with vitamin B12 deficiency?
Confusion
What are some symptoms associated with zinc deficiency?
Cognitive dysfunction
Name some lab values that could have impact on cognition
- Sodium
- Potassium
- Blood sugar
- Hemoglobin (low)
- Vitamin B deficiency
- Zinc deficiency
- Respiratory acidosis
- Metabolic alkalosis
- Low thyroxine
- Low thyroid stimulating hormone
- Hypercalcemia
- Hypercapnia
- Hypoxia
What psychiatric illnesses can affect cognitive functioning and behavior?
Bipolar disorder
Schizophrenia
Describe treatment with bipolar disorder and cognition.
- General stimulation programs: Broad combination of different cognitive processes
- Process specific training
- Functional adaptation programs
Describe rehabilitation treatment for cognition and schizophrenia
- Computer based & paper and pencil (targeted social abilities and work outcomes)
- Cognitive remediation
True or false: There was a marked improvement noted in improvement favoring vocational vs computer based programs in treatment with schizophrenic patients.
False
21 Strategies for addressing older adults WM deficits
- Intensify Attention
- Discuss speed of info processing declines
- Slow therapists rate of speech to allow time for processing, encoding, storage and retrieval
- Older adults do best when tasks are self paced vs timed
- Encourage older adults to think aloud when practicing a new skill
- Recognize that repetition alone is a weak way of learning, it is far more effective to rehearse w/ elaboration.
- Attention may be thought of as a state of activity that is triggered by various kinds of emotional arousal.
- Organize and simplify the teaching environment
- Minimize # of sources of information
- Provide clearer instructions for organizing a complex task into basic components.
- New info or skills are best retained when they build on previous ways of doing things.
- Encourage older adults to use organizational strategies that allow them to avoid drawing on limited memory resources.
- Encourage to make what they need to remember more interesting, more meaningful, more emotionally significant and more connected to already learned information.
- Make sure that the older adult understands the information they need to remember.
- Encourage older adults to avoid multitasking as much as possible.
- Encourage older adults to practice listening to new information that needs to be remembered.
- Memory works best when a person is relaxed and can think clearly.
- Reassure that memory lapses and slowing of responses are a normal part of the aging people and not necessarily mental deterioration.
- Reassure learning capacity does not necessarily diminish with age it just takes more dedication, practice, attention, rehearsal and review of info.
- Reassure that it is not that they have forgotten it is likely that the information was never recognized as important enough to be stored in the first place.
Levys 9 considerations/approaches for addressing older adults LTM deficits.
- Reassure clients that age related declines in memory function do not necessarily have a large impact on functioning in daily life.
- OTs need to be cognizant of the fact that age related declines are a powerful concern for older adults.
- Reassure older adult clients that semantic knowledge accumulated over a lifetime does not deteriorate with age.
- Recalling newly learned information may be enhanced by organizing information more efficiently in relation to other well learned, easily retrieved information.
- Writing things down is one of the simplest ways to remember episodic information.
- Memory pathways weaken when not used over time.
- Memory lapses may result in a temporary inability to recall something, but the memories are not lost.
- Difficulty in recalling specific information reflects a decline in the ability to retrieve information instantaneously.
- Once information is in LTM, it generally stays there
Ture or false:
Among those with multimorbidity, there is moderate to strong evidence to support cognitive interventions targeting IADL performance.
True
What is the primary skill required for memory and judgement?
Attention
The following medications can impact what?
- Ativan
- Versed
- Precedex
- Diprivan (propofol)
Cognition
The following are risk factors for what?
- Pre existing dementia
- h/o hypertension
- h/o alcoholism
- high severity of illness on admission
Delirium
What treatment shows moderate evidence for MS patients?
Computerized cognitive training targeting specific skills
What should OTs focus on with MS patients?
- Interventions should focus on process skills targeting cognition and emotional regulation
What should OTs focus on with ALS patients?
- Develop strategies to compensate for decreased executive function skills
- Behavioral management
- Medication management strategies
