Neurocognitive Disorders (really Dementia)

Question 1

Cognition

Answer 1

• the method that the central nervous system uses to process and utilize information
• outcome of an ongoing dynamic interaction between person, activity, and the environment
• ex: dressing = includes knowledge of the weather, schedule of activities for the day, awareness of which clothes coordinate with others, sequencing, and problem solving
• cognition is essential to the performance of everyday occupations

Question 2

Cognitive (neurocognitive) domains

Answer 2

• perceptual-motor function
• language
• learning and memory
• social cognition
• complex attention
• executive function

Question 3

Perceptual-motor function

Answer 3

• visual perception
• visuoconstructional reasoning
• perceptual-motor coordination

Question 4

Language

Answer 4

• object naming
• word finding
• fluency
• grammar and syntax
• receptive language

Question 5

Learning and memory

Answer 5

• free recall
• cued recall
• recognition memory
• semantic and autobiographical long-term memory
• implicit learning

Question 6

Social cognition

Answer 6

• recognition of emotions
• theory of mind insight

Question 7

Complex attention

Answer 7

• sustained attention = “I am going to do this right now”
• divided attention = getting dressed while being engaged in conversation
• selective attention
• processing speed

Question 8

Executive (functional) cognition

Answer 8

• planning
• decision-making
• working memory
• responding to feedback
• inhibition
• flexibility

Question 9

Mini-Mental State Examination (MMSE)

Answer 9

Slide 4

Question 10

Normal age-related cognitive decline

Answer 10

• it’s normal to have some decline as you age but once it starts to really interfere with the occupations, then that’s not normal
• subtle decline in cognitive abilities
• thinking is slower/names are harder
• decreased working memory = forgets part of something and remembers later
• reduced capacity to pay attention
• decreased attention/complex multi-tasking/organizing
• sensory changes: vision or hearing
• uses notes to remind themselves of something
• may forget where they put their keys but can retrace their steps to find them
• does not get lost in store/new place
• independent in all ADL/IADL
• does not progress to dementia

Question 11

Delirium

Answer 11

• NOT a long term, it’s short term
• typically caused by a disease, an illness, or an intoxication or being high in some sort of a drug
• can be reversible
• disorientation or psychosis
• usually occurs when a person is being treated or in need of treatment for a physical condition
• high fever
• UTI = an indicator of being delirious
• symptoms end when medical condition clears

Question 12

Diagnostic criteria of delirium

Answer 12

• a disturbance in attention with decreased ability to focus, sustain, or shift attention
• an additional change in cognition (such as memory loss, disorientation, or language disturbance) or the development of perceptual disturbance (hallucination, paranoid thoughts)
• changes in attention and cognition cannot be explained by a preexisting or developing NCD
• medical evidence that the disturbance is either caused by a medical condition or developed during intoxication or withdrawal from a substance

Question 13

Delirium diagram (slide 7)

Answer 13

• dehydration is huge with delirium
  Early intervention is key to prevention:
  At risk patients include those:
• who are over 65
• with existing cognitive decline
• who are actually ill
• with a fractured neck of femur
  Single question to identify delirium (SQID):
• Are they more confused then normal?
  Prevention and management:
• treat the cause of delirium
• avoid transfers
• reorientation to current place and time
• pain management
• adequate fluids
• use of eyeglasses and hearing aids, if applicable
• familiar objects and stimulating activities
• reduced noise and avoid sleep interruptions when possible
• address mobility
• engage with family and carers
  Screen for increased risk factors
• D = dehydration
• E = eyes and ears
• L = limited mobility
• l = infection
• R = reduced pain
• I = impaired cognition
• U = up at night
• M = medication
  Assessment and Review
• review level of confusion on admission
• daily observation for at risk patients
• use 4AT rapid assessment test for delink to diagnose delirium in more confused patients
• clinical assessments to identify source of delirium

Question 14

Subtypes of delirium

Answer 14

• if there is preexisting dementia, then changes may not be completely reversible (delirium can sort of kick-start the dementia and make it progress a little bit more
• hypoactive
• hyperactive
• once causative factor is cleared, it typically resides in 3-7 days

Question 15

Hypoactive delirium

Answer 15

• slowing or lack or movement, paucity of speech, and unresponsiveness
• premorbid dementia leads to the worse survival rate

Question 16

Hyperactive delirium

Answer 16

• more common, associated with medication side effects or substance withdrawals, restlessness, constant movement, agitation

Question 17

Incidence and prevalence of delirium

Answer 17

• high rate of delirium in medical and surgical settings
• 20% of all hospital inpatients acquire delirium
• 25% at 50 years of age
• 35% at 85 years of age
• 1-2% at older than 65 years of age in the community

*the older you get, the more likely you’ll get it

Question 18

Medical treatments of delirium

Answer 18

• treat the underlying in medical condition
• clear the infection, simplify polypharmacy (takes lots of medications at once)
• antipsychotic medication to help with agitation, aggression, paranoia, and hallucinations (Haldol)
• this medication has a risk of increased cerebrovascular adverse events, death, and this risk elevated for months after use (have to be careful because they do lead to a risk of a stroke)

Question 19

Occupational performance deficits of delirium

Answer 19

• impairments due to cognitive, motor, and sleep deficits
• impairment in orientation, attention, memory, and visuospatial abilities
• motor agitation or retardation limits their physical abilities
• can cause an increase in length of hospital stay and high rates of nursing home placement

Question 20

Neurocognitive disorders (NCD)

Answer 20

• mild
• major
• based on the level of function

Question 21

Mild NCD

Answer 21

• can set lots of timers, reminders, have people check on you and can still live on your own
• mildest decline in cognitive function performance
• requires compensatory strategies and accomodations to maintain independence
• may or may not progress to major NCD
• not due to delirium
• not due to other mental disorders

Question 22

Major NCD

Answer 22

• dementia
• a significant decline in cognitive performance
• interferes with independence in everyday activities
• supervision, more assistance
• affects motor issues
• not due to delirium
• not due to other mental disorders

Question 23

Dementia

Answer 23

• an umbrella term used to describe a collection of brain diseases and their symptoms, which include: memory loss, impaired judgment, personality changes, and an inability to perform daily activities
• Alzheimer’s Disease
• Vascular Dementia
• Frontotemporal Dementia
• Lewy Body Dementia
• Other Dementias

Question 24

Alzheimer’s Disease (dementia diagram on slide 12)

Answer 24

• prevalence = 60-70% of dementia cases
• characterized by = amyloid plaques and beta tangles
• symptoms include = impairments in memory, language, and visuospatial skills

Question 25

Vascular dementia (dementia diagram on slide 12)

Answer 25

• prevalence = 10-20% of dementia cases
• characterized by = disease or injury to the blood vessels leading to the brain
• symptoms include = impaired motor skills and judgment

Question 26

Frontotemporal dementia (dementia diagram on slide 12)

Answer 26

• prevalence = 10% of dementia cases
• characterized by = deterioration of frontal and temporal lobes of the brain
• symptoms include = personality changes and issues with language

Question 27

Lewy Body dementia (dementia diagram on slide 12)

Answer 27

• prevalence = 5% of dementia cases
• characterized by = Lewy body protein deposits on nerve cells
• symptoms include = hallucinations, disordered sleep, impaired thinking and motor skills

Question 28

Other dementias (dementia diagram on slide 12)

Answer 28

• prevalence = 5% of dementia cases
• dementias related to = Parkinson’s Disease, Huntington’s Disease, HIV, Crutzfeldt-Jakob Disease, and Korsakoff syndrome

Question 29

Risk factors for dementia

Answer 29

• age (biggest factor)
• family history
• Black or Hispanic ethnicity
• poor heart health
• TBI
  Modifiable risk factors:
• physically inactivity (the more you move, the more you decrease the risk for dementia)
• unbalanced diet
• tobacco and harmful ETOH use (ETOH = chemical compound in alcohol)
• DM
• HTN
• social isolation
• low education attainment (grade level because not much cognitive stimulation)
• cognitive inactivity
• midlife depression

Question 30

Alzheimer’s Disease (AD)

Answer 30

• the clinical diagnosis is one of the exclusion = MRI, cerebrospinal fluid analysis, and PET
• these advanced tests through only yield 60-90%
• actual definitive diagnosis is after death with brain autopsy

Question 31

Incidence and prevalence of Alzheimer’s disease

Answer 31

• 6th leading cause of death in the U.S.
• 6.9 million Americans age 65 and older have Alzheimer’s
• 1 in 9 Americans age 65 and older have Alzheimer’s
• nearly 2/3 of Americans with Alzheimer’s are women
• Black Americans are 2x as likely to have Alzheimer’s or other dementias as White people
• Latinos are 1.5x as likely to have Alzheimer’s or other dementias as White people
• by 2060, the number of people age 65 and older with Alzheimer’s dementia is projected to read 13.8 million

Question 32

10 warning signs of Alzheimer’s Disease

Answer 32

• memory loss that disrupts daily life
• challenges in planning or solving problems
• difficulty completing familiar tasks
• confusion with time or place
• trouble understanding visual images and spatial relationships
• new problems with words in speaking or writing
• misplacing things and losing the ability to retrace steps
• decreased or poor judgment
• withdrawal from work or social activities
• changed in mood and personality

Question 33

Stages of memory loss

Answer 33

• age related memory impairment
• mild cognitive impairment
• dementia

Question 34

Mild cognitive impairment: beyond normal aging

Answer 34

*can progress to dementia and it usually does
- recent memory is poor and the cues don’t always help
- can progress to dementia, usually AD type
- may initially live independently but with signs of problems/depression
- ex = function changers interfere with complex tasks
- retain less information and very forgetful
- may forget paragraph, just read, or can’t follow topic
- family will notice problems, but the patient does not
- routine tasks ADL/IADL/work/social skills become harder
- safety becomes a concern = cooking/driving/power tools
- change in mood

Question 35

5 stages of Alzheimer’s

Answer 35

• some say 3, some say 7, but we will focus on the 5 stages one
• pre-dementia = memory and mood (can live in that stage for years)
• mild = language and praxis
• moderate = sensory changes/need more care/poor new learning/BPSDs
• severe = profound cognitive loss/incontinence/verbal loss
• terminal = end stage complete dependence/moaning/weight loss/bedridden/sleeping
• life span generally 5-8 years post diagnosis once to mild stage but can be pre-dementia for many years (meaning once you get to the mild stage, you generally have 5-8 years till death

Question 36

Pre-dementia stage (AD)

Answer 36

• memory loss is the first visible sign
• changes in mood (irritability, depression, anxiety
• changes in personality

Question 37

Early stage - mild (AD)

Answer 37

• a person may function independently
• may still drive, work, and be part of social activities
• despite this, the person may feel as if they were having memory relapses such as forgetting familiar words or the location of everyday objects
• symptoms may not be widely apparent at this stage but family and close friends may take notice and a doctor would be able to identify symptoms using certain diagnostic tools

Common difficulties include:
- coming up with the right word or name
- remembering names when introduced to new people
- having difficulty performing tasks in social or work settings
- forgetting material that was just read
- losing or misplacing a valuable object
- experiencing increased trouble with planning or organizing

• during the early stage, it is possible for people with dementia to live well by taking control of their health and wellness and focusing their energy on aspects of their life that are most meaningful to them
• in addition, this is the ideal time to put legal, financial, and end-of-life plans in place because the person with dementia will be able to participate in decision-making

Question 38

Middle stage - moderate (AD)

Answer 38

• typically the longest stage and can last for many years
• as the disease progresses, the person with AD will require a greater level of care
• the dementia symptoms are more pronounced, the person may confuse words, get frustrated or angry, and act in unexpected ways, such as refusing to bathe
• damage to nerve cells in the brain can also make it difficult for the person to express thoughts and perform routine tasks without assistance

Symptoms vary from person to person:
- being forgetful of events or personal history
- feeling moody or withdrawn, especially in socially or mentally challenging situations
- being unable to recall information about themselves like their address or telephone number, and the high school or college they attended
- experiencing confusion about where they are or what day it is
- requiring helping choosing proper clothing for the season or the occasion
- having trouble controlling their bladder and bowels
- experiencing changes in sleep patterns, such as sleeping during the day and becoming restless at night
- showing an increased tendency to wander and become lost
- demonstrating personality and behavioral changes, including suspiciousness and delusions or compulsive, repetitive behavior like hand-wringing or tissue shredding

• in the middle stage, the person living with Alzheimer’s can still participate in daily activities with assistance
• it’s important to find out what the person can still do or find ways to simplify tasks
• as the need for more intensive care increases, caregivers may want to consider respite care or an adult day center so that they can have a temporary break from caregiving while the person living with Alzheimer’s continues to receive care in a safe environment
• when talking with them, you can engage in conversation with them, but something doesn’t seem right, they used simpler words in their conversation, not engaging in big, complex conversation with you

Question 39

Late stage - severe (AD)

Answer 39

• stops walking
• as it progresses cognitively, it also progresses physically
• dementia symptoms are severe
• individuals lose the ability to respond to their environment, to carry ona conversation and eventually to control movement
• they may still say words or phrases, but communicating pain becomes difficult
• as memory and cognitive skills continue to worsen, significant personality changes may take place and individuals need extensive care

At this stage, individuals may:
- require around-the-stock assistance with daily personal care
- loss awareness of recent experiences as well as of their surroundings
- experience changes in physical abilities, including walking, sitting, and eventually swallowing
- having difficulty communicating
- become vulnerable to infections, especially pneumonia

• the person living with AD may not be able to initiate engagement as much during the last stage, but they can still benefit interaction in ways that are appropriate like listening to relaxing music or receiving reassurance through gentle touch

Question 40

End stage - terminal (AD)

Answer 40

• bedridden
• unable to talk (groan or moan)
• lost all ability to communicate
• completely depending on others for care
• weight loss, seizures, skin infections, difficulty swallowing, groaning, moaning, increased sleep
• incontinent of all bowel and bladder
• during this stage, caregivers may want to use support services, such as hospice care, which focus on providing comfort and dignity at the end of life
• hospice can be of great benefit to people in the final stages of Alzheimer’s;s and other dementias and their families
• once they stop eating is when the end of life is kind of there

Question 41

Dementia with Lewy Bodies

Answer 41

• Lewy bodies = collections of proteins that deposit into the brain (identified as a foreign thing), like plaques in the brain
• onset age 50+
• early changes in attention and executive function
• visual hallucinations (complex and vivid) = very real to the patients (very vivid for a second and then their brain rebounds and they’re fine until more and more of the Lewy bodies are packed in there and then the brain cannot rebound anymore
• sleep disturbances
• fluctuating cognition
• spontaneous Parkinsonian traits
• falls and syncope
• unexplained loss of consciousness
• autonomic dysfunction
• delusions
• poorer quality of life than AD
• Lewy body plaques affects the dopamine because the plaque enters where the dopamine needs to be transporting back and forth

Question 42

Vascular dementia (mini strokes - TIAs)

Answer 42

• cognitive impairment is abrupt onset
• typically associated with stroke or evidence of infarctions
• slowing down of mental processing
• impaired judgment, personality changes, aphasia, visuospatial disturbances
• all these strokes keep happening in the brain and build upon each other and that leads down the road of needing more assistance

*long term poor blood flow to the brain (typically because of a series of strokes)

Question 43

Parkinson’s Disease Dementia

Answer 43

• occurs in a person with PD
• rest tremors, hypokinesia, masked facial expression, soft voice, tiny handwriting, soft voice, tiny handwriting, cogwheel rigidity of the limbs, gait problems
• lack of dopamine being able to get into their system

Question 44

Frontotemporal dementia

Answer 44

• can still move but is still affected
• this type of dementia declines so much faster
• second most common in clients younger than 65
• shorter survival rate and faster decline than AD
• lose interest in socialization, self-care, and personal responsibilities
• display socially inappropriate behaviors
• insight is usually impaired
• dramatic alterations in self-identity
• changes in political, social or religious values
• semantic dementia - progressive loss of knowledge about words and objects, lose the ability to talk
• loss of empathy and sympathy
• compulsive cleaning or euphoria
• can be sexually inappropriate and racially inappropriate because there is nothing in the brain that gives them the inhibition to say that it is not appropriate

Question 45

Sundowning

Answer 45

• when the sun goes down, your internal clock in your body starts telling you that you’re tired = however AD doesn’t understand that, so it makes the person agitated, confused, and tired
• a theory connects the symptoms of sundowning to a disturbance in the body’s “internal clock”
• the brain damaged caused by AD sets off permanent confusion between when “I’m tired and need to sleep” and “when I’m rested and ready for activity”

Question 46

Sundowner’s syndrome symptoms

Answer 46

• the person is hard to redirect
• agitation, aggression
• anxiety
• confusion, disorientation
• visual and auditory hallucinations
• apathy, anger
• delusions
• insomnia
• pacing, wandering, restlessness
• suspiciousness
• crying
• respective behaviors
• doesn’t happen to every patient with dementia
• to prevent people from feeling agitated or distressed is to keep them busy during the day, to not let them nap so much during the say so that they are not tired

Question 47

Treatments for AD and Dementia

Answer 47

• a big crux of occupational implication with AD is when do they stop driving?
• medications = no cure or prevention but may help symptoms (slows the progress down)
• ensure safety = manage agitation/wandering/pain
• psychosocial environment = encourage occupational engagement such as exercise/music/activities/spirituality/family
• caregiving training and support = “the long goodbye” support groups
• recommendations from Alzheimer’s Association = helpful for normal aging and mild to moderate stages of Alheimer’s:
  S = sleep 7-8 hours
  H = handle stress
  I = interaction/socialize
  E = exercise
  L = learn new things/hobby/music
  D = diet for brain health

Question 48

Complex attention

Answer 48

• includes sustain attention, divided attention, selective attention, and processing speed
• OTPF classifies attention as a bodily function, superficially a mental function, and includes a person’s ability to sustain, shift, and divide attention as well as their concentration or distractibility

Question 49

Occupational implications in complex attention

Answer 49

Mild NCD:
- longer to perform tasks
- begin to make mistakes
- difficult to do 2 things at once
- thinking becoming difficult with stimuli
- neglects minor grooming details (ex: brushing the back of the hair instead of the front or only brushing the front teeth because that’s all they see)
Major NCD:
- information must be kept simple
- may not see task through to completion
- cannot do 2 things at once
- cannot think with stimuli
- neglects grooming
- end stage = attention is only seconds or responds to only pain, hunger, or fear

Question 50

Executive function

Answer 50

• planning, making decisions, retrieving memories, maintaining task goals, responding to feedback/error correction, overriding habits/inhibition, and mental flexibility
• OTPF identifies executive functions as a component of higher-level cognitive function, which includes judgment, concept formation, meta cognition, praxis, cognitive flexibility, and insight

Question 51

Occupational implications of executive functioning

Answer 51

Mild NCD:
- increased effort to perform multi-step tasks
- difficulty returning to task when interrupted
- decline in IADLS
Major NCD:
- abandon complex tasks
- focus on only one task at a time
- does not complete whole BADL task
- may use tools unsafely
- lack of problem-solving and judgment
- needs step by step cuing to complete meaningful tasks

Question 52

Memory

Answer 52

• includes short-term memory, long-term memory (semantic autobiographical), and working memory

Question 53

Occupational implications of memory

Answer 53

Mild NCD:
- impairments with short-term memory
- may have trouble learning new tasks
- forgets tasks
- loses thread of conversation
- misplaces things
- deficits in episodic memory or semantic memory and general knowledge
Major NCD:
- repeating self in conversation
- failure to remember plans for the day
- poor orientation to time and date
- get lost in familiar environments
- cannot follow cues after a few seconds
- may think they are back in an earlier stage of life
- not bothered by memory loss
- may begin to not recognize their own face or family and friends
- inability to cope in new or unexpected situations

Question 54

Language

Answer 54

• involved expressive language (naming, word-finding, fluency, grammar, and syntax) and receptive language
• voice and speech functions consist of fluency and rhythm but also rely on mental functions and though, including control and content of thought, awareness of reality vs delusions, and logical and coherent thought

Question 55

Occupational implications of language

Answer 55

Mild NCD:
- word finding difficulty
- forget names
- less complex sentences structure
- decreased word retrieval
- decreased ability to make a list
Major NCD:
- decline in receptive and expressive language
- language is either concerns of the movement or reminiscing
- decreased verbal responses
- decrease in number of words produced

Question 56

Perceptual-motor skills

Answer 56

• involves motor reflexes, involuntary movement reactions, control of voluntary movement, and gait patterns
• a mental function that one uses to discern sensations
• these may be auditory, tactile, visual, olfactory, gustatory, vestibular, and propioceptive

Question 57

Occupational implications of perceptual-motor skills

Answer 57

Mild NCD:
- difficulty with topographical orientation
- more effort with visual spatial tasks
- hearing loss
Major NCD:
- difficulty using tools and operating MV
- sundowning
- visual inattention
- slower gait
- trouble swallowing
- decreased depth perception
- motor skills decline, weakness, apraxia, immobility

Question 58

Social cognition

Answer 58

• involves the ability to recognize and identify the emotions of others and consider another person’s mental state (thoughts, desires, or intentions) or experience
• OTPF incorporates social cognition as a specific mental function of thought and emotion
• this includes the content of thoughts and its coherence, an awareness of reality, the regulation and range of emotions and their appropriateness, and a person’s liability of emotions
• social interaction skills, a performance skill, include an ability to regulate speech production as when speaking in a quiet voice or when speaking at an intelligible pace
• individuals must have the ability to appropriately interact and express themselves but also to interpret cues when communicating with others

*doesn’t have awareness of somebody else which is why they are unable to care for a pet or a minor

Question 59

Occupational implications of social cognition

Answer 59

Mild NCD:
- personality changes
- more rigid
- more irritable
- less spontaneous
- suspicious
- depression/anxiety
- decreased ability to read non-verbal cues
- disregard needs of others
Major NCD:
- insensitive to acceptable social standards
- poor decisions
- inappropriate topic of conversations
- unable to care for a pet or minor
- assist with community participation
- eventually very limited social interaction