PT for Dementia Part 1-5 Flashcards
dementia definition:
Dementia is an umbrella term for a group of cognitive disorders typically characterized by memory impairment, as well as marked difficulty in the domains of language, motor activity, object recognition, and disturbance of executive function – the ability to plan, organize, and abstract.”
Signs and symptoms of dementia
-memory loss that disrupts daily life
-challenges in planning or solving problems
-diff 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
-changs in mood and personality
Behavioral and psych symptoms of dementia
- Aggression
- Agitation
- Apathy
- Depression
- Dis-inhibition
- Mood lability - mood swings
- Repetitive questioning
- Sleep disturbances
- Socially inappropriate behaviors * Wandering
CIND- cognitively impaired, no dementia
has minimal impact on day to day functioning and does not meet criteria for dementia
not progressive
MCI- mild-cognitive impairment
A clinical subsyndrome of CIND.
Anmestic or non-amnestic
4 types:
1-amnestic MCI- single domain
2-amnestic - multiple domains
3- non-amnestic MCI- single domain
4-non-amnestic-multiple domains
DIAGNOSIS:
-memory complaints
-normal general cognition
-normal ADLs
-abnormal memory for age
-not dementia
Is dementia related to delirium?
no, not related
Alzheimer disease–> Alzheimer dementia
a brain disease characterized by plaques, tangles, neuronal loss–> gradual onset and slow progression and is best explained as caused by Alzheimer’s disease
What percentage of ppl with MCI develop dementia each year?
10-12%
2 main subcortical dementias discussed in class:
dementia with lewy bodies
huntington’s disease
Dementia with lewy bodies definition:
lewy body proteins are present in the brain stem, depleting dop, causing parkinsonian symptoms
-lewy body proteins can also be found in brain
-hard to differentiate between PD, LBD, and AD
HD def
Hereditary disorder that causes degeneration in the brain resulting in
a movement disorder and cognitive decline
behavioral changes too
5 types of cortical dementias discussed in class:
-AD- 60-80% - neurofibrillary tangles and beta amyloid plaques
-vascular dementia - 2nd most common ; caused by stroke or partially blocked blood flow; mini-strokes
-frontotemporal dementia - degen of nerve cells in the frontal or temporal lobes of the brain- NEARY CRITERIA TO DX; ppl with ALS typically develop this type of dementia in later stages
pugilistic dementia - due to multiple concussions; CTE
Wernicke-Korsakoff syndrome-ETOH abuse –> shrinkage of brain and cognitive symptoms
Early onset AD:
before age 65, many in 40s and 50s
AD characteristics:
80% with AD are 75 or older
more common in AA (2X)compared to older white americans; hispanics about 1.5 times as likely as older whites
-more common in women
-time from onset to death typically 7-11 years
-death often secondary to dehydration or infection
-may have more implicit memory than originally thought
-40-60% of AD pts with late-onset –> psychotic symptoms such as hallucinations, delusions, dramatic verbal/emotional or physical outbursts
Pathology of AD:
-affects the temporal and parietal lobes early on –> most of the cortex in most severe stages
-BETA-AMYLOID PLAQUES:
-proteins stick together and block synapse signaling
-proteins come together in clumps to form plaques that attach to the neuron
-microglia react to the plaque and an inflammatory response results
-NEUROFIBRILLARY TANGLES:
-show up inside neuron
-tau proteins are chemically changed at microtubules; normally they provide structural support for the microtubules
-disruption of “rail” system
CTE characteristics:
chronic traumatic encephalopathy
** CANNOT BE DIAGNOSED IN LIVING PEOPLE
-triggered by repetitive head trauma
-length of exposure to head impacts
-tau protein clusters around blood vessels in the brain
Diagnosis of DEMENTIA
initially you notice deficits in higher cortical function –> most noticeable
-safety and early behavior modification
-visuospatial tasks
personality changes: egocentricity, impulsivity, irritability
Age associated memory impairment
Age-associated memory impairment = benign
senescent forgetfulness = decline in short-term memory which doesn’t progress to other mental or intellectual impairments
STRESS AND COGNITION
DECREASED
* Tolerance to ambiguity
* Concentration
* Initiative
INCREASED
* Preoccupation
* Errors in judgment
* Anger
* Crying
* Depression
Genetic testing for Alzheimer’s Dementia
Apolipoprotein E gene (APOE) on
chromosome 19 removes beta amyloid
* APOE 4 allele is less effective at removing
beta amyloid, thus INC risk
* APOE 2 allele – is protective, thus DEC risk
- Risk for AD by 85 years of age:
- No APOE 4 allele, 9-20%
- If one APOE 4 allele, 25-60%
- If 2 APOE 4 allele, 50-90%
Chromosome 21 has a beta-amyloid precursor protein, thus producing amyloid–> worse prognosis
What lab tests are used to diagnose dementia/rule out other conditions?
complete blood cell count
blood chemistries
liver function
syphilis
TSH
vitamin B12
** look for drug interactions, nutritional deficiencies, infections, poisoning
What conditions do you need to rule out when performing brain imaging for Alzheimer’s Disease?
brain tumor
vascular causes
What is delirium?
*PART OF DIFFERENTIAL DIAGNOSIS FOR DEMENTIA
A condition of severe confusion and rapid changes in brain function, not a disease but a cluster of symptoms that result from a disease or other clinical process
Often the result of treatable and therefore transient physical or mental illness
RAPID ONSET
-cognitive fluctuations over hours or days
-impaired consciousness and attention
-altered sleep cycles
Normal Pressure Hydrocephalus (NPH) symptom triad:
*PART OF DIFFERENTIAL DIAGNOSIS FOR DEMENTIA
diff walking
decline in thinking
loss of bladder control
CAUSE: excess CSF accumulates in the brain’s ventricles–> may need shunt
What three depression rating scales were discussed in class?
Geriatric Depression Scale
Cornell Scale for Depression in Dementia
Hamilton Rating Scale for Depression
Max score and score ranges on MOCA:
visuospatial/executive
naming
memory
attention
language
abstraction
delayed recall
orientation
MAX SCORE: 30
26-30: normal range
27.4: average
22.1: MCI
6.2: AD
MMSE categories and score:
less specific than MOCA
registration
attention and calculation
recall
language
TOTAL: 30
20-24: mild dementia
13-19: moderate dementia
<13: severe dementia
What is a test for working memory:
digit span backward
STROOP test:
The Stroop test can be used to measure a person’s selective attention capacity and skills, processing speed, and alongside other tests to evaluate overall executive processing abilities.
What are the two primary medication types that are used for individuals with Alzheimer’s Disease?
AChE blocker –> AChE normally eats up acetylcholine, which is bad for individuals with AD, these drugs prevent that from happening so that Ach can continue to help neurons communicate
drugs that block glutamate
-glutamate in too much quantity can affect learning and memory poorly and neural tissue can be affected with too much–> drugs that block glutamate can help avoid killing the cell with overstimulation
What are the 7 categories of the Global Deterioration Scale:
1-no cognitive decline
2-very mild cognitive decline (age-associated memory impairment)
3-mild cognitive decline (mild cognitive impairment)
4-moderate cognitive decline (mild dementia)
5-moderately severe cognitive decline (moderate dementia)
6-severe cognitive decline (moderately severe dementia)
7-very severe cognitive decline (severe dementia)
THE GEMS MODEL -What are the different colors?
blue sapphire - true blue, no dementia
diamond - clear, sharp, rigid, doesn’t like change, stubborn, create the right setting and care
emerald- green–> go but not always sure where, words aren’t always clear, there are more flaws, struggling occasionally, may get lost with directions
amber - caution; caught in moment of time, no safety awareness, lacks patience, impulsive, behavior very different than past, invade spaces, take things, low or high sensory needs
ruby- STOP light, lost fine motor in eyes, fingers, mouth, feet, have strength but loss of skill, visual interpretation impaired, still have rhythm and music, hands are more gross movement than fine, can’t settle down and get started with a task
pearl- turns down reflexes, shuts down skills, with the right care you can still see the beauty of the gem, give them the right setting and the right care
Physical activity recommendations for patients with dementia
leisure-time physical activity at midlife at least twice per week –> associated with reduced risk of dementia
PA may alter: Tau accumulation, synapse number, and function, restore neurogenesis, increase neurotrophin levels, positively alter inflammation and immunity, affect circadian rhythms, improve cognition
Executive function tests:
trail-making test (set shifting)
verbal digits backward test (working memory)
Stroop colour-word test (response inhibition)
what is declining cognition associated with?
increased number of falls
falls occur in approx 30% of clients with AD –> lack of perception of where their bodies are in space and their inability to move adequately around objects
-executive function plays an important role in balance control–> increasing cognitive impairment leads to decrease in balance
balance gains after intervention may not be help after one month when the intervention is stopped
motor learning and dual task training
Dual task cost definition:
represented in a decrement of motor and cognitive performances during dual tasks
Dual-task costs express performance changes as a percentage of each individual’s single-task performance. Positive values represent performance decrements under dual-task conditions, and negative values represent performance improvements.
What type of feedback is recommended early in the progression of dementia?
external feedback
explicit memory strategies
Dual tasking is recommended in what stage of dementia severity?
early stage
Things to reduce in the middle stage of dementia severity
- Reduce some cognitive challenges
- Reduce some explicit memory strategies
- Reduce some verbal instructions
- Reduce verbal external feedback
*Reduce dual tasking
With regular exercise and home based caregiver support, there can be a delay in ____
institutionalization
High intensity functional ex. program among older ppl with dementia (AD vs non-AD) living in nursing homes:
Supervised, group-based and individualized high-intensity exercise program is applicable in this population if we identify and alleviate limitations such as fear, pain, fatigue, etc.
Recommendations for treatment of late stage dementia:
Physical Activity
* Exercise
* Mobility
* Fall Prevention
* Implicit Memory Use
* Demo instructions
* Manual Guidance
* Increase/Decrease arousal
** meet them at their reality at that time
A high-intensity functional exercise program for patients living in residential care facilities may:
inhibit AD progression and delay shrinkage of parts of the brain dedicated to memory
RCT on regular exercise 1 hour 2x/week and how long were the gains maintained after study completion?
12 months after
Although participants had no explicit memory of the program in a Balance Study for people with AD, they had greater than or equal to 2 outcome measure improvements, such as:
BBS, gait speed, TUG
Person with late-stage dementia and hip fracture Body Weight Support Treadmill Training long term results:
6 month follow up with scores similar to those at discharge
What is required to maintain participation in those with neurodegenerative disease (ex: physical therapy treatment)
social support for activity and exercise
neurodegenerative disease: the above PLUS structure and facilitation and eventually assistance
GAIT SPEED ICC AND MDC
ICC: 0.973 (excellent reliability)
MDC:9.44 cm/s
6MWT ICC AND MDC:
ICC: 0.973 (excellent reliability)
MDC: 33.5 m (110 feet)
BBS MDC:
6.6 points
max total of 56 points
What happens to cognitive evaluation over time?
Eventually, continuing to evaluate cognition may not yield additional information and caregivers must adapt
What is an example of a pain assessment for individuals with dementia?
pain assessment in impaired cognition (PAIC 15)
What is one strategy that can help to improve movement and function in those with dementia?
identify stress triggers and remove them from the environment if possibel- example: background noise
Cognitive stimulation program in individuals with AD
- Enhances neuroplasticity
- Reduces cognitive loss
- Helps patients to stretch functional independence through better cognitive
performance - Combine with behavioral management techniques can improve physical health
and depression in individuals with AD
—> behavioral management such as:
-redirection: distraction or suggestion of alternative activities, reassuring tone, warm approach, smile, comfort
-validation: assist the person to feel acknowledged and understood, accept the reality of the person, use conversation to redirect
Strategies from a study about an individualized exercise program for individuals with dementia:
STRENGTH BASED:
-keeping it short and simple
-external memory aids: visual aids, calendars
-learning by modeling
-allowing pts to choose the activity
-using familiar activities or hobbies in exercise
