Study Guide Q's: Cog Changes Flashcards
What are the 6 cog domains?
Complex Attention: sustained, divided, selective, processing, speed
Social Cognition: recognition of emotions, theory of mind, insight
Learning/Memory: free recall, cued recall, recognition memory, semantic and autobiographical memory, implicit learning
Language: object naming, word finding, fluency, grammar and syntax, receptive language
Perceptual Motor Function: visual perception, visuoconstructional reasoning, perceptual motor coordination
Executive Function: planning, decision making, working memory, responding to feedback inhibition, flexibility
Sensory memory subsets (3)
- Iconic (visual)
- Echoic (auditory)
- Haptic (touch)
Sensory memory definition
- Input from the 5 senses
- Can be ignored or perceived and transferred to short term memory in <1 sec
Sensory memory changes with age
Stable except for sensory impairment that may occur with age (eg. visual loss)
Sensory memory brain location
Initial input to the sensory areas of the brain then processed by the hippocampus
Short term working memory definition
how long does it take to process?
- Limited capacity
- Temporary recall
- Processed in 10-15 seconds long term storage or decay
Short term working memory changes with age
stable, but may require more effort to encode before decay
Short term working memory location
prefrontal cortex
Long term memory (implicit)
Subconscious influence of previously encountered information on subsequent performance, automatic, rote
long term implicit memory changes with age
stable
remains intact until late in a cognitive disease state
long term implicit memory location (4)
cerebellum
putamen
caudate nucleus
motor cortex
another term for implicit memory
procedural
Long term declarative memory (semantic) definition
structured facts, meanings, concepts, and knowledge
long term memory explicit (declarative) semantic age related changes
gradual and linear decline across lifespan, primarily associated with encoding and retrieval
explicit (declarative semantic) memory areas of the brain
prefrontal cortex
temporal cortex
explicit (declarative) episodic memory definition
autobiographical of events, contextual knowledge, and associated emotions
Age related changes to explicit (declaritive) episodic
Gradual and linear decline across the lifespan, primarily associated with the encoding and retrieval
long term memory explicit (declaritive) episodic definition
autobiographical of events, contextual knowledge, and associated emotions
explicit declaritive episodic long term memory areas of the brain
hippocampus connects various sensory areas of the brain to create an episode that is consolidated to one event
differences in delirum and dementia
- Differences in dementia and delirium
- Onset
- Duration
- Attention
- Consciousness
- Speech
- Cause
- Other features
- Generally: Delirium typically has a rapid onset (hours to days) and is a sign of an underlying condition (e.g. UTI, medication, anesthesia, infection, encephalopathy) in older adults. It is short duration and typically resolves once the underlying condition has been addressed. Dementia is more gradual in onset (weeks, months, years) and is not caused by a different condition.
types of delirium (3)
- Hyperactive
- Hypoactive
- Mixed
Delirium is associated with:
- Increased length of stay (LOS)
- Prolonged recovery times
- Institutionalized care
- Increased morbidity and mortality
Pathophysiology of delirium
- Brain structural changes
- Cortical atrophy
- White matter lesions
- Neurotransmitter disturbance in central cholinergic and adrenergic pathways
- Elevated inflammatory cytokines (IL-6, IL-8)
- Multifactorial in older adults
Prevention and management of delirium
- what percentage of cases are preventable?*
- what 3 classes of drugs are linked to delirium?*
- At least 30-40% of cases are preventable
- Determine cause and remediate ASAP
- Drugs linked to delirium
- Psychoactive agents
- Narcotics
- Anticholinergics
Delirium non pharm management (5)
- Cognitive orientation
- Early mobility
- Enabling adequate hearing and vision
- Promoting a normal sleep wake cycle
- Proper nutrition/hydration
Dementia definition
- Definition: a clinical syndrome of cognitive and functional decline, usually of a chronic or progressive nature
- Definition: a global impairment impacting intellectual functioning, memory, and at least one of the following:
- Abstract thinking
- Judgment and language
- Identification of people and objects
- Personality changes
- Ability to use object appropriately
- Cognitive deficits that cause significant impairment in occupational or social functioning that is a decline from previously higher-level functioning
- Diagnosed through a semi-structured interview, detailed medical and neurologic examination, neurocognitive testing
vascular dementia incidence and key features
- is onset abrupt or gradual?*
- is memory loss more or less severe than AD?*
Incidence: 20-30% cases
Key Features:
- Associated with cerebrovascular disease
- More often abrupt onset, but can be gradual with small vessel disease
- Memory loss is usually less severe than AD
- Mood changes and apathy are common
- Can occur in conjunction with AD (mixed dementia)
vascular dementia affected brain areas
- Medial temporal atrophy
- Cortical and subcortical regions
vascular dementia clinical symptoms (3)
- Impaired attention
- Difficulties with complex activities
- Disorganized thought
dementia with lewy body incidence
8% of dementia cases (frequently under-dx and mis-dx)
dementia with lewy bodies key features
what are the 3 types?
- Complex visual hallucinations
- Parkinsonism
- Sleep disturbances
- Autonomic symptoms (e.g. hypotension)
- Fluctuating cognition
- Types:
- Parkinson’s Disease Dementia
- Dementia with Lewy Bodies
- Neuropsychiatric symptoms
dementia with lewy bodies affected brain areas
- Less severe medial temporal lobe atrophy than AD
- FDG-PET shows occipital hypoperfusion and hypometabolism
- Loss of dopaminergic neurons in the substantia nigra
- Limbic system
- Brainstem
- Neocortex
Frontotemporal dementia incidence
3-10% of dementia cases
frontotemporal dementia
- what age group is it more common in?*
- where do sig changes lie?*
- What are the three types?*
- More common in younger groups (50-60 years old)
- Memory often intact in early stages
- Significant changes in behavior and personality
- Disinhibition and impulsiveness are common
- Types:
- Pick’s Disease
- Progressive supranuclear palsy
- Corticobasal degeneration
frontotemporal dementia affected brain areas
- Frontal lobes
- Temporal lobes
- Specific areas of atrophy dependent on the type of variant
alzheimer’s disease incidence
50-60% of dementia cases
alzheimer’s key features
- Gradual loss of memory and function leading to total dependence on caregivers
- Eventual inability to recognize family/friends/self
- Diagnosis made through interview/hx, diagnostic testing
Alzheimer’s disease brain areas (4)
- Entorhinal area
- Hippocampus
- Amygdala
- Regions of the neocortex
What role does beta amyloid play in AD?
is it more prominent in the later stage or asymptomatic stage?
it appears to be the driving force behind it
during asymptomatic stages amyloid markers are the most prominent changes (later on structural changes are more prominent)
hypothesis that gene mutation causes amyloid beta to be cut into longer fragments that clump together and cause tau tangle formation
inflammation –> synapse dysfunction and cell death –> dementia
what are the brain biomarkers used to detect AD
- Medial temporal atrophy
- Temporoparietal hypometabolism
- Abnormal neuronal CSF markers
- Amyloid beta
- Tau
- P-tau
only one out of 3 needs to be present
APOE4 functions
it is a strong risk factor for developping AD and deals with lipid regulation as well as amyloid beta regulation. (vs. APOE2 ppl appear to have less risk and APOE3 have no increased risk)
Found on chromosome 19.
- Synthesized in the liver
- Maintains cholesterol homeostasis
- Transports lipids
- Synthesized in the brain
- Regulates mitochondrial function
- Regulates neuroinflammation
- Regulates neuronal signaling
- Regulates glucose metabolism
- Regulates brain lipid transport
- Regulates level of amyloid beta
APOE4 relationship to amyloid beta
- APOE appears to play a role in regulating levels of amyloid beta in the brain (low APOE might cause amyloid beta accumulation in APOE4 carriers)
- APOE4 carriers have greater amyloid beta deposits than non carriers
compare and contrast the meds used to treat dementia
- Emerging and not yet effective medications
- Disease modifying
- Aim to slow or prevent the onset of disease
- Controversial, minimal efficacy shown
- Current drugs
- Neurotransmitter based
- Acetylcholine is dramatically reduced from neuron degeneration
- Loss of 60-90% of ACh activity 🡪 memory impairment
- Serotonin
- Somatostatin
- Norepinephrine
- Acetylcholine is dramatically reduced from neuron degeneration
- Treat symptoms
- Block acetylcholinesterase
- Target the NMDA pathway
- Attempt to delay progression
- Neurotransmitter based
Concerns for dementia meds
specifically what is common with cholingeric meds? And then memantine?
- Potential AE
- Cholinergic medications: GI issues (NVD) most common
- Memantine: dizziness -> falls
- Communication of behavioral issues to healthcare providers
- Timing of PT
- Provide structure to reduce behavioral issues
- Reduce behavioral issues related to sundowning
- Utilize time of day when the patient is most alert
general treatment approach for AD meds
what is used in mild vs. moderate vs severe stage?
Mild: cholinesterase inhibitor
Moderate stage: cholinesterase inhibitor + memantine
address behavioral and psychological symptoms
Severe stage: consider if meds will provide a benefit
possible utlilzation of a drug free trial
may continue memantine or cholinesterase inhibitor approved for late stage disease
QOL scales
mild dementia
mild to moderate dementia
advanced
-
Mild dementia
- Schedule for Evaluation of Individual Quality of Life
-
Mild to moderate dementia
- Cornell-Brown Scale for QOL in Dementia
- Dementia Quality of Life Instrument
- Quality of Life Alzheimer’s Disease Scale
-
Advanced
- Dementia Care Mapping
- Qualidem and Discomfort Scale
domains of caregiver burden in dementia
- Domains
-
Direct impact of caregiving on caregivers’ lives
- Predicted by level of relationship satisfaction with patient and patient’s functional independence
- Predicted by caregiver depression and age
-
Guilt
- Predicted by caregiver depression and age (younger age 🡪 increased guilt)
-
Frustration and embarrassment
- Predicted by patient’s behavioral problems and level of relationship satisfaction with the patient
- Behavioral problems are a strong predictor of nursing home placement
- Predicted by patient’s behavioral problems and level of relationship satisfaction with the patient
-
Direct impact of caregiving on caregivers’ lives
Zarit Burden Interview
- Widely used measure of caregiver burden
- 22 items assessing burdens associated with patient behavioral and functional impairments
- Covers impact of caregiving on caregivers in their health, relationships, and finances
- Utilized as a single measure of caregiver burden but may be able to address various dimensions
- Interventions to address caregiver burden should be tailored to the subtype of burden
list cog screening tools (13)
- blessed orientation memory concentration test (short blessed test)
- dementia screening indicator
- functional activities questionnaire
- geriatric depression scale
- global deterioration scale
- mini cog asssesment instrument
- mini mental state exam
- clinical dementia rating scale
- functional assessement staging
- montreal cognitive assessment
- trail making test A&B
- Allen Cognitive Level Screen
- Allen Cognitive Levels
dementia screening indicator
simple, can be used in primary care settings
functional activities questionnaire
bill paying, tracking current events, and transportation questions hve the greatest diagnostic utility
geriatric depression scale
- (self-report yes/no questionnaire to identify depression, long form has 30 questions, short form has 15 questions)
global deterioration scale
(7 stages to characterize where the individual is in the dementia disease process, done through observation)
mini cog
3 step assessment of 3 word registration, clock drawing, and 3 word recall)
mini mental state
(11 question measure that tests five areas of cognitive function: orientation, registration, attention and calculation, recall, and language)
clinical dementia rating scale
functional assessement staging scale
montreal cognitive assessment
(30 question test; evaluates orientation, short term memory, executive function/visuospatial ability, language abilities, animal naming, abstraction, attention, and clock drawing)
trail making test Parts A & B
(used to assess executive function, visual search, scanning, speed of processing, and mental flexibility)
allen cognitive level screen
(uses the task of sewing stitches to evaluate cognition using a 3-5.8 scale; establishes the best ability to function)
allen cognitive levels
- (0-6 scale, information processing model; measures global cognitive processing abilities through observation of activity performance, novel and familiar)
evidence for physical activity
Summary: aerobic exercise can help decrease negative effects of dementia and a multimodal approach is better. Less inflammation, tangles, protein deposits, better hippocampal function
- Exercise provides neuroprotective and neuroplastic effects on brain structures
- Exercise mediated physiologic mechanisms
- Elevated troponin
- Improved vascularization
- Facilitation of synaptogenesis
- Mediation of inflammation
- Reduced disordered protein deposition
- Dementia is linked to cardiovascular risk factors
- HTN associated with white matter disease and atrophy (hippocampal neurofibrillary tangles)
- HTN is a precursor to cognitive impairment
- Physical activity appears to elicit compensatory brain mechanisms that improve cognitive function
- Hippocampal atrophy is linked with progression from MCI to AD, and 1 year of moderate aerobic activity was shown to improve memory and hippocampal volume in healthy older adults
- Combining exercise modalities (aerobic, strength, and balance) is more effective for enhancing cognitive health
- Individuals with cognitive impairments may require higher doses of physical activity to affect positive cognitive function
evidence for aerobic activity
- Preferentially benefits executive function
- 6 months of aerobic and strength exercises -> significant cognitive and functional improvements with medium to large effect size
- Helps manage T2DM and hypercholesteremia
- Strong association between: metabolic syndrome, elevated inflammatory markers (IL, CRP), and cognitive decline
- Exercising adults have lower levels of inflammatory markers
- Elevated plasma insulin linked with increase in amyloid beta and inflammatory agents
-
Exercise might be particularly important for APOE4 carriers
- Improvement in hippocampal function
- Volume
- Total exercise volume appears to moderate atrophy in medial temporal lobe (key area for memory and executive function)
- Exercise volume that is neuroprotective is similar to recommended volume for older adults
-
150 min/week, 5 days per week of moderate intensity aerobic activity or 60 min/week of vigorous activity
- Added benefits with 300 min/week
- Duration and variety are important factors
evidence for physical interventions
- tai chi*
- RAS*
- Tai chi
- Reduced gait variability (healthy and PD)
- Rhythmic auditory stimulation
- Deleterious effects in an AD group
- Increased gait speed
- No gait variability
evidence for strength training
-
Moderate and high intensity resistance improves cognitive domains (short term memory, long term memory, attention span)
- May require longer duration to bring about cognitive changes
- Resistance exercise contributes to functional plasticity in brain regions associated with executive function
evidence for balance training
- All aspects of balance control deteriorate with increased severity of cognitive impairment (executive function plays a role in balance control)
- 6 domains of balance
- Biomechanical constraints
- Stability limits/verticality
- Anticipatory postural adjustments
- Postural responses
- Sensory orientation
- Stability in gait
evidence for cog training
- 6 week cognitive training program (2x per week for 90 min) targeting attention, working memory, planning, verbal fluency, learning, and memory 🡪 reduced CoV of stride time and stride length and less reduction of gait speed during dual task
- 10 week computer based cognitive training program, 3 days/week resulted in improved TUG
- Virtual reality physical and cognitive training showed greater improvements in gait and cognition compared to traditional physical and cognitive training
program design for aerobic exercise
- Walking and jogging
- Dancing
- Aquatics (swimming or water aerobics)
- Group exercise classes
- Bicycle (stationary or outdoor)
- Tennis, golf, or other sports
- Outdoor activities (gardening, yard work)
program design for physical interventions
- Tai chi
- Rhythmic auditory stimulation
program design for strength training
- Recommended dosage
- Moderate to high intensity resistance strengthening 2 days/week for major muscle groups, 48-72 hour recovery between sessions
- 60-80% of 1RM for healthy individuals
- 40-50% of 1RM for deconditioned or frail individuals
- 8-12 reps for 2-3 sets
- 2-3 minute rest period between sets
- Adding balance, agility, coordination, and flexibility exercises will enhance neuromuscular fitness
balance training program design
- 3 days/week for 3 months
- Should involve standing, challenging balance exercises
- Consider single, dual, and multi task exercises
- Utilize training specificity
- Regaining postural stability after perturbations
- Quickly avoiding obstacles
- Dual task (walking and talking)
otago exercise program
- Series of 17 strength and balance exercises
- PTs assess, coach, and progress patients over the course of 6-12 months
- First 8 weeks: PT management phase
- 9 weeks and beyond: self-management phase with monthly phone calls
- Has not been researched using participants with cognitive impairment
home exercise program program design
- Customized and specific to address level of cognitive impairment
- May involve caregiver training to implement the program
- Clear and simple language
- Big print and pictures
- Communicate instructions with demonstration
- Have the patient (and caregiver) demonstrate all exercises
- Limit the number of prescribed exercises
Compare pharmacological interventions that can improve cognition and physical function
