Week 8- Progressive Cognitive Disorders Flashcards
PART 1: INTRODUCTION
PART 1: INTRODUCTION
What happens to cognition as we age?
Normal age-related changes vary from person to person in degree and severity.
Disturbances in ability to _______, ______, and ____________ certain experiences happen as we age.
-register, retain, and recall
With Cognition as We Age We See:
- Slowed rate of learning ____ material.
- Slowed ______ learning capabilities.
- Slowed motor performance on tasks that require _______.
- new material
- motor learning
- speed
10 Early Warning Signs of Abnormal Cognitive Decline:
- Impaired ________/__________ memory, repeats self frequently.
- Difficulty doing __________ but difficult tasks (managing medications, money, driving).
- ______-finding difficulty, mis-naming, comprehension difficulties.
- Disorientation to _____ and _______ (Getting lost while driving, Missing several appointments).
- Worsening __________.
- Impaired ________-______ or reasoning.
- Misplacing things- finding them in “odd” places.
- __________ changes.
- ______ or _________ changes.
- Loss of ________ (withdrawal from normally salient activities of interest).
- immediate/short-term
- familiar
- word-finding
- time and place
- judgement
- problem-solving
- personality
- mood or behavior
- initiation
What are some other issues (besides dementia or neurological condition) that could lead to the 10 signs of abnormal cognitive deficit?
- Medication side effect
- Hearing loss, visual loss
- Depression, anxiety
- Acute illness
- Etc…
What is dementia?
Describes a group of symptoms that involve a decline in memory, reasoning, and other cognitive skills, despite full alertness.
Dementia typically involves _______ and ____________, plus an addition of 1 or more of what 4 things?
-memory and orientation
- impaired abstract thinking
- impaired judgement and problem solving
- impaired language
- personality changes
What are some potential causes of dementia?
- CVA
- NPH
- toxin exposure
- infection
- TBI
- neurodegeneration
- idiopathic
With dementia, do we see a chemical change or structural change in the brain?
both chemical and structural
\_\_\_\_\_\_\_\_\_\_ = More acute and abrupt changes. (fluctuation of dementia) \_\_\_\_\_\_\_\_\_\_ = Long standing changes (largely irreversible)
- Chemical
- Structural
PART 2: ALZHEIMER’S DISEASE
PART 2: ALZHEIMER’S DISEASE
Alzheimer’s Disease:
- Most common ___________ disease.
- _____ cases in the US.
- Accounts for ___-___% of all dementia cases.
- Prevalence increases by ___% every 5 years >/=85 years.
- Can onset at any age, but most likely after age ___.
- neurodegenerative
- 5.5 million
- 60-80%
- 20%
- 65
What is the cause of Alzheimer’ Disease?
Ultimately unknown, genetics and environmental factors may play a role.
What is the “Amyloid Cascade Hypothesis”?
The amyloid cascade hypothesis postulates that the neurodegeneration in AD caused by abnormal accumulation of amyloid beta (Aβ) plaques in various areas of the brain.
Describe the Amyloid Cascade Hypothesis.
Abnormal buildup of amyloid beta and tau plaques throughout the brain leads to toxicity → inflammation, oxidative stress, impaired homeostasis → neuronal death and dysfunction → AD
- Alzheimer’s = ______ immediate recall
- Age-Related Memory Loss = ___________ immediate recall
- absent
- impaired
- Alzheimer’s = ________ retrains short-term memory
- Age-Related Memory Loss = often shows _________ of short-term memory
- rarely
- retention
- Alzheimer’s = gradual ______ in response to memory aids
- Age-Related Memory Loss = responds ______ to memory aids
- decline
- well
- Alzheimer’s = progression to __________ in ADLs and functional mobility
- Age-Related Memory Loss = retains some degree of ________ in ADLs and functional mobility
- dependence
- independence
Alzheimer’s Disease General Characteristics:
- Initially ______, _________ onset with subtle loss of interest or withdrawal from enjoyable activities as well as early memory loss.
- As disease progresses, dysfunction includes ___________ deficits such as word-finding (anomia), apraxia, and/or visuospatial disorders.
- Moderate to advanced stages may see _________ changes such as wandering, paranoid, agitation, aggression, sexual disinhibition, or failure to recognize family/friends.
- slow, insidious
- perceptual
- behavioral
With Alzheimer’s Disease, ________ dysfunction is usually seen in absence of many other neurological functions (motor, sensory functions and procedural memory usually spared).
cognitive
What are the 3 stages of Alzheimer’s Disease?
- Mild
- Moderate
- Severe
Which stage is the longest and is where we will see a patient develop symptoms, loss of functional independence, and behavioral problems?
Moderate
AD Mild Stage (Memory and Thinking):
- ↓ _____-_____ memory
- slowed processing
- ↓ attention
- awareness of deficits initially __________
AD Mild Stage (Language):
- _____-finding difficulties
- cognitive fatigue leads to _______ compromise
AD Mild Stage (Mood):
- frustration, irritability, agitation
- apathy, ___________
- _________
- short-term
- maintained
- word-finding
- language
- depression
- anxiety
AD Mild Stage (Function):
-breakdown of _______ and _____ function
AD Mild Stage (Behavior)
- frequently losing items
- constant _________
AD Mild Stage (Safety Concerns):
- ______________
- exploitation
- IADL and ADL
- repetition
- driving
AD Mild Stage:
- How long does it usually last?
- In the mild stages of AD, are patients still aware of their deficits and losses as they are occurring?
- They often try to ______ their deficits in the earlier stages because of denial or trying to hide it from family.
- How are the mild stages noticed usually?
- 2-4 years
- Yes
- mask
- family member speaking up
AD Moderate Stage (Memory and Thinking):
- Continued ↓ ____-_____ memory, beginning to see ↓ ____-_____ memory.
- Inability to recognize _______, _______, and ____________.
- Inability to understand _____.
- ↓ Insight
- ↑ Self-absorption and withdrawal
AD Moderate Stage (Language):
- ↓ Verbal and written __________.
- ↓ Verbal _________.
- Frequent __________ of words.
AD Moderate Stage (Mood):
- ↓ Stress tolerance.
- Very flat affect, blunted emotions.
- “____________”
- short-term, long-term
- family, friends, and familiar tasks
- time
- comprehension
- expression
- repetition
-“Sundowning”
AD Moderate Stage (Function):
- ADL ___________.
- Functional decline when tasks involve _________.
- Altered __________ perception.
- Impairment with starting an activity.
- Often shows resistance to mobility attempts.
- _____________
AD Moderate Stage (Behavior):
- Withdrawal from ___________.
- Fear of ____________.
- Refuses care and services.
- Increased confusion, agitation, belligerence.
- Psychosis, Paranoia
- Insomnia
AD Moderate Stage (Safety Concerns):
- Elopement
- Eating and drinking
- dependence
- cognition
- deconditioning
- socialization
- abandonment
AD Moderate Stage:
- How long does it usually last?
- Often have a _______ gait pattern.
- Often found wondering around with no purpose unless what?
- What is sundowning?
- 2-10 years
- shuffled
- they have found a way to escape
- significant decline in cognition, stress tolerance, and orientation that occurs
AD Severe Stage (Memory and Thinking):
-memory __________ compromised
AD Severe Stage (Language):
-significant limited ________ output
AD Severe Stage (Mood):
- agitation, irritability
- lability
- apathy
- delusions, hallucinations
- sleep and appetite changes
- severely
- verbal output
AD Severe Stage (Function):
- ADL _________
- incontinent bowel/bladder
- ineffective swallow
- functional ___________
- progressive __________
AD Severe Stage (Behavior):
-still recognizes _________
AD Severe Stage (Safety Concerns):
- high rates of ____________ and ________ pneumonia
- __________ may occur
- dependence
- dependence
- fatigue
-comfort
- dehydration, aspiration pneumonia
- seizures
AD Severe Stage:
- How long does it usually last?
- How long does end-stage last?
- What is often used to deescalate situations in this stage?
- 1-3 years
- 1-6 months
- comfort items (baby doll)
AD Diagnosis:
- What is the gold standard for diagnosis?
- What can we do before death to help with diagnosis?
- What can be seen on a MRI and PET scan to help with diagnosis?
- postmortem autopsy
- diagnosis of exclusion, diagnostic imaging
- MRI (hippocampal atrophy), PET (temporal and parietal hypometabolism)
AD Treatment:
-Is there a curative treatment for AD?
No, but there are some medication found to slow the process of cognitive decline.
AD Prognosis:
- __-__ years to mortality from diagnosis.
- ____ leading cause of death.
- What are the main causes of death in this population? (4)
- 6-15 years
- 6th
- pneumonia, infection, dehydration, malnutrition
PART 3: VASCULAR DEMENTIA AND FRONTOTEMPORAL DEMENTIA
PART 3: VASCULAR DEMENTIA AND FRONTOTEMPORAL DEMENTIA
- Vascular Dementia is the _____ most common cause of dementia.
- It is a unique type of dementia in that it has ________ and _________ undertones.
- It results from multiple cortical and/or subcortical ________ or __________ strokes over time.
- 2nd
- cardiovascular and stroke
- ischemic or hemorrhagic
What are the 4 most closely linked risk factors to VD?
- ) Age
- ) Diabetes
- ) HTN
- ) Metabolic syndrome (presence of 3/4: obesity, HTN, dyslipidemia, insulin resistance)
Treatment/management of VD is largely focused on ______ management.
CVA management
How is VD diagnosed?
clinical examination + neuroimaging
VD is dementia + ____________ deficits.
neurological
VD:
- Abrupt onset, with a _________ regression.
- Unlike AD, will often see SxS of _____ injury, ______ deficits, and _________.
- Severe ________ is often predominant feature.
- stepwise
- UMN injury, sensory deficits, aphasia
- depression
What is the main characteristic of cognitive impairments with VD is early and severe ___________ ___________ loss over everything else.
executive function loss
What is the average years to mortality from initial infarct.
5 years
Frontotemporal Dementia:
- Average age of onset: mid ____ to ____.
- Commonly misdiagnosed as __________ disorders.
- 50s to 60s
- psychiatric disorders
What is the cause of frontotemporal dementia?
- genetic mutations linked to FTD
- unknown for ~50% of cases
FTD Pathophysiology:
- Variability, not entirely understood.
- _________ build up is thought to be occurring, but not seen consistently with these patients and various involved __________ have been suggested.
- Ultimately, see _________ and ________ _______ in frontal and temporal lobes of the brain.
- protein
- atrophy and neuronal death
Are temporal or frontal SxS seen most prominently in FTD?
frontal SxS
What frontal SxS are seen with FTD?
- disinhibition
- apathy
- loss of sympathy/empathy
- repetitive/compulsive/ritualistic behavior
- changes in eating/bathing habits
What temporal SxS are seen with FTD?
- progressive aphasia (most common: progressive nonfluent aphasia)
- speech apraxia
As dementia progresses, we can start to see widespread _________ involvement leading to things such as coordination, motor control, balance impairments, EOM dysfunction, and dysphagia.
cortical
FTD Clinical Course And Prognosis:
- Does it usually start with frontal or temporal SxS?
- ___-___ years to mortality from onset of symptoms.
- frontal, but can start with temporal
- 10-15 years
PART 4: TREATMENT CONSIDERATIONS
PART 4: TREATMENT CONSIDERATIONS
Anti-Dementia Therapy:
- ____________ inhibitors: slow progression and increase function in Alzheimer’s disease, DLB, and vascular dementia.
- ________/_________: manage compulsive behaviors in FTLD and Alzheimer’s disease.
- _____, mood stabilizer, antipsychotics for behavioral symptoms and depression in FTLD and vascular dementia.
- Currently no FDA-approved medications for ________ and _________ seen in dementia.
- Cholinesterase
- Namenda/Memantine
- SSRIs
- agitation or psychosis
List some cognitive outcome measures used for dementia.
Global Functioning
- MMSE
- Alzheimer’s Disease Activity Scale-Cog
- Severe Impairment Battery
- MOCA
Executive Functioning
- Verbal Fluency Test-Category
- Verbal Fluency Test- Letters
- Clock Drawing Test
List some physical outcome measures used in dementia to address mobility, endurance, balance/fall risk, and muscle strength.
Mobility
- TUG, TUG-cog, TUG-man
- 6 meter walk/gait speed
Endurance
-6MWT
Balance/Fall Risk
- Berg Balance scale
- Mini-BESTest
- Groningen Meander Walking Test
Muscle Strength/Power
- 5x Sit to Stand
- 30s chair rise
What is the most common cognitive outcome measures used for dementia?
MMSE
MMSE:
- Brief screening tool, provides quantitative assessment of _________ impairment.
- ___ simple questions, __ domains (total: __ points)
- cognitive
- 11 questions, 7 domains, (30 points)
- orientation to time, orientation to place, registration of 3 words attention and calculation, recall of 3 words, language, visual construction
What are the cutoff scores for the MMSE?
- > /=24- no cognitive impairment
- 18-24- mild cognitive impairment
- 0-17- severe cognitive impairment
One of the biggest underlying factors to a patients cognitive status getting in the way of a PT treatment session is they have a progressively lowered _______ threshold.
stress
What are the 6 notable points to help define difficulty? (Progressively Lowered Stress Threshold Theory)
- ) People with dementia prefer to lead a lifestyle as close as possible to what they have lived across the lifespan.
- ) Person with dementia will become progressively disabled in coping with stress.
- ) Secondary behavioral symptoms occur when stress exceeds the person’s capacity: like panic attacks
- ) People experiencing secondary behavioral symptoms are uncomfortable.
- ) Prior to this reaction, the patient experiences anxiety and often tries to relieve stress prior to the incident.
- ) Factors triggering these episodes can be controlled or modified to prevent excess disability and can occur up to 36 hours prior to the stress-related event.
What are the 3 main categories for treatment considerations?
- Fatigue
- Engagement
- Communication
Fatigue:
- _________ is often a primary factor contributing to behavior challenges.
- What are some treatment strategies to address this?
- _________ activity has been shown to help cognitive fatigue. (3-5x/week, 20-30min/day)
- fatigue
- frequent cognitive (and motor) rest breaks, strategic scheduling, established routines, consider environment
- aerobic activity
Engagement:
- Find activities and create environments that create __________ experiences for your patients.
- Maximize success through adaptations and supportive cues.
- __________ activities often elicit more positive responses than new or _________ ones.
- Use _________ to your benefit as able.
- meaningful
- familiar, unfamiliar
- family
Communication:
- Important to consider that these patients have poor _________ and ____-____ memory, repetition, understanding, and issues with identification of words and names. Also, language is often vague, tangential.
- Try to avoid arguing, reasoning, over-explaining, or coercing when a patient has inappropriate or incorrect thought. Avoid making the patient feel _______ for not remembering. Avoid
-immediate and short-term memory
-
With these patients, what do we need to do?
- Reassure, agreement
- Apologize
- Avoid yes/no
- Defer when needed
- Redirect, distract
- Praise and thank
Enter their reality.
