Dementia

Dementia is characterized by impairments in

Memory Intellect Cognition

There are several types of

Dementia

Dementia is classified as

a neuro-cogntive disorder

Dementia incidence increases with

age

Dementia

Brookshire 2015 DSM-IV Impaired short term & long term memory At least one of the following characteristics: Impaired abstract thinking Personality change Impaired judgement Impaired constructional abilities Impaired language Impaired praxis Impaired visual recognition

Alzheimer's Disease Medical Management

Cause is not known • Symptoms develop differently in individuals • Treatment may include: • Medication for aggression and/or depression • Monitoring of nutritional intake and hydration • Manipulation of the environment for stimulation and social contact • Counseling for the individual and his/her family • Drugs reported to improve cognition are tacrine (Cognex) - side effects of liver damage and donepezil (Aricept) - fewer side effects • Rivastigmine and glantamine are under review by the FDA

Parkinson's disease

Caused by deterioration of dopamine-producing neurons in the basal ganglia (especially in the substantia nigra) and the brain stem • Dopamine - neurotransmitter • Inhibits neuronal activity and prevents unintended movements • Symptoms surface when 60% or more of the dopamine-producing neurons have been destroyed •

Dementia occurs when brain nerve cells

Cease working Loose connections with other brain cells and die

Dementia

Is the name for a group of symptoms caused by disorders that affect brain. It is not a specific disease. People with dementia: May not be able to think well enough to do normal activities such as getting dressed or eating May lose their ability to solve problems or control their emotions. Personalities may change May become agitated or see things that are not there

Three subgroups of multi-infarct dementia

Lacunar state Multiple cortical infarcts Binswanger's Disease

Montreal Cognitive Assessment MoCA

One page • 30 point test • Administration time is approximately 10 minutes • addresses the following cognitive areas: • Ability to process and understand visual information about where objects are • Executive functions - ability to manage cognitive processes • Language • Short-term memory recall • Attention • Concentration • Working memory • Awareness of time and place • Training and certification are recommended • There is an APP

• Lacunar state

Primarily subcortical pathology • Due to small multiple infarcts in the arteries providing the basal ganglia, thalamus, midbrain and brain stem. • Initial symptoms are subcortical • Initial symptoms include dysarthria, swallowing impairments, pseudobulbar palsy, weakness, and at times tremor • Late stage shows problems with intellect and language • 70% to 80% of individuals develop Dementia

Parkinson's Disease symptoms

Primary symptoms include • Disturbances of movement • Muscle rigidity • Tremor • Slowness or elimination of movement • Loss of balance • Incidence • Affects approximately 1% of adults in the United States • Affects more men than women • Usually surfaces between 50 - 65 years of age (Brookshire, 2015)

Alzheimer's Disease

Progressive deterioration of intellect • First signs are sudden and may include problems with memory, reasoning, poor judgment, disorientation in unfamiliar places, mood changes and withdrawal from social contact • Mental impairment increases as disease progresses • Intellect and cognition become more impaired as the disease progresses • Language and communication become more impaired as the disease progresses • Agitation and incontinence emerge. • Symptoms become progressively worse as the disease progresses • During the final stages individuals may exhibit profound motor impairments, total incontinence, and substantial loss of intellect and cognition

Vascular Dementia

Second most common cause of dementia in the United States • 15 to 20% of all dementia cases • Prevalence increases with age • The presence of cerebrovascular disease and dementia are the requirements for diagnosis • Most individuals have a diagnosis of this disease and Alzheimer's. The occurrence of this disease solo is rare.

Parkinson's Disease

Slowly progressive deterioration of motor and mental functions • First symptom is usually tremor, but may be immobility • Problems in memory, problem solving, abstract reasoning and other mental functions occur as the disease progresses • Significant dementia occurs in 15% to 20% of individuals

Dementia criteria

Subtle onset Not caused by other psychological manifestations Acquired Continual 2 or more brain tasks Impedes social, occupational and activities of daily living

Dementia often occurs as the only

Symptom of neurological disease

Pseudodementia

Symptoms of depression resemble those of dementia • Cognitive impairments • Loss of appetite • Problems sleeping • Social withdrawal • Apathy

Dementia is a loss of cognitive functioning (ex remembering, thinking reasoning)

That interferes with a person's ability to perform activities of daily living

Assessment - comprehensive

The Arizona Battery for Communication Disorders of Dementia (ABCD) • Boston Diagnostic Aphasia Exam (BDAE) • Western Aphasia Battery (WAB) • Communication Activities in Daily Living (CADL)

Vascular dementia

The focus of medical management is the prevention of subsequent CVAs • Medications and management may include: • Anticoagulants to help decrease blood clots • Controlling hypertension • Controlling cholesterol levels • Controlling diabetes • Quit smoking • Some drugs that help manage Alzheimer's disease may be useful for managing vascular dementia

Dementia categories

Three major categories based on location of pathological change Cortical dementia Subcortical dementias Mixed dementia

Delirium

Usually transient • Rapid onset • Rapid progression • Individual experiences confusion, agitation, disorientation, hyperactivity, confused thinking, distractibility, and possible hallucinations and/or delusions • May be caused by • Medication • Infections • Metabolic disorders • Surgery, anesthesia • Substance withdrawal • Kidney or liver disease • Toxins • Sudden environmental changes

Parkinson's Disease Cognition and Communication

Voice becomes weak • Speech rate increases as the disease progresses • Articulation becomes less distinct • Rapid stuttering-like repetition of syllables, words and phrases may prevail • Micrographia may occur in early stages • Swallowing and drooling may occur in middle stages • Problems with vocabulary, syntax and understanding of complex verbal material may be seen in the late stages

Mini-Cog

a 3-minutes instrument that can increase detection of cognitive impairment in older adults. It can be used effectively after brief training in both healthcare and community settings. It consists of two components, a 3-item recall test for memory and a simply scored clock drawing test. As a screening test, however, it does not substitute for a complete diagnostic workup

In dementia changes in behavior

and personality may occur

Dementia

as classified by ICD 10 WHO A syndrome due to disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple higher cortical functions, including: Memory Thinking Orientation comprehension Calculation Learning capacity Language Judgement Consciousness is not clouded. Impairments of cognitive function are commonly accompanied and occasionally preceded by deterioration in: Emotional control Social control Motivation Dementia produces an appreciable decline in intellectual functioning and usually some interference with personal activities of daily living such as: Washing Dressing Eating Personal hygiene Excretory and toilet activities

Cortical dementia

caused by changes in the cerebral cortex Alzheimer's Disease • Pick's Disease (Frontal Lobe Dementia) • Primary Progressive Aphasia • Alzheimer's Disease and Pick's Disease are the most common causes

Global Deterioration Scale (GDS)

describes seven levels of dementia with increasing severity of intellect • Utilizes interview with the individual, family members, and/or caregivers to assess the severity of intellectual impairment

Dementia prevention

healthy diet exercise active social life stress management mental stimulation sleep

Subcortical dementia caused by changes

in the thalamus, basal ganglia and brainstem

The Instrumental Activities of Daily Living Scale (IADL)

• Addresses functional abilities in activities of daily living • Caregiver rates the individual in eight areas of daily living addressing independence in activities

Mixed dementia

• Caused by changes in both cortical and subcortical structures

Binswanger's Disease

• Primarily subcortical pathology • Rare disease • Caused by multiple infarcts in subcortical white matter due to thrombotic or embolic occlusion • Initial symptoms are focal • Multiple infarcts show significant mental and physical impairment

Managing Dementia Late stages

• Provide assistance to caregivers (i.e. behavioral issues) • Ensure the individual's health • participation in activities of daily living as appropriate

Human Immunodeficiency Virus Encephalopathy

Acquired immunodefiency syndrome (AIDS) conglomerate of symptoms secondary to infection with human immunodeficiency virus (HIV). • Transmission occurs through body fluids primarily blood and semen • The immune system is weakened by the virus allowing bacterial, parasitic and fungal infections and certain cancers to enter the body • The World Health Organization reports that approximately 22 million adult individuals in the world are living with HIV infections • The majority of individuals with AIDS are younger than 35 years. • Greater than 90% of deaths from AIDS happen in individuals younger than 50 years of age.

Human Immunodeficiency Virus Encephalopathy

AIDS dementia complex aka HIV encephalopathy • Most common neurologic outcome of AIDS • Up to 70% of individuals with AIDS contract AIDS dementia complex • Due to infection of the brain with the HIV • Infection causes changes in the brain in the subcortical white matter and basal ganglia • Changes eventually progress to the cortex • Early symptoms of infection in the brain include weakness, slowness, rigidity and dyskinesia (extrapyramidal pathology) • Later symptoms include impaired perception, memory, intellect and language (cortical impairment) • Cause for changes is unknown, however, neurotoxins triggered by the virus are suspected • AIDS dementia complex usually appears in later stage, however, may appear in early stage signifying AIDS

Alzheimer's Disease

Additional abnormalities in the brains of individuals include: • lower levels of the neurotransmitter, acetylcholine. • Abnormal levels of aluminum in neurofibrillary tangles and neuritic plaque • Neuropathologic change usually affects the temporo-parietal-occipital junctions and the inferior temporal lobes.

Frontotemporal Dementia

Described in the 1990s • Dementia following pathologic changes in the frontal and temporal lobes of the brain • Abnormal neuronal occlusions, neuron loss, and structural abnormalities in brain tissues • Subcortical, cortical and subcortical-cortical pathologic conditions • Subtypes include Pick's Disease (Behavioral Variant Frontotemporal Dementia) and Primary Progressive Aphasia among others (National Institute on Aging, 2015)

Dementia may be caused by

Different diseases

Dementia Symptoms

Difficulty with everyday tasks Confusion in familiar environments Difficulty with words and numbers Memory loss Changes in mood behavior

Diseases that can cause symptoms of dementia

Disease Vascular dementia Lewy body dementia frontotemporal dementia Huntington disease Creutzfeld-Jacob disease

Progressive Supranuclear Palsy Symptoms in Stages

Early Symptoms Paralysis of muscles responsible for downward gaze • Rigidity in neck muscles • Weakness in facial muscles • Difficulty walking secondary not being able to see their feet • Frequent falls Advanced symptoms • Loss of vertical and lateral eye movement • Limbs become stiff and rigid • Dysarthria • Dysphagia • Person may show apathy and euphoria or may appear restless and irritable • Middle to late stages • Dementia characterized by slowing of mental processes and forgetfulness • Final stages • Person becomes mute, immobile and requires increased help

Human Immunodeficiency Virus Encephalopathy

Early stages show speech and language to be within normal limits • Subtle impairments in word retrieval or understanding complex printed material may be observed through testing • As the disease progresses, speech becomes labored, slow, sparse and dysarthric. • Individuals are not able to keep up in conversations and understanding of complex printed material is reduced • During later stages spontaneous speech is limited to words or short phrases. The individual is unable to understand simple printed material and understanding of speech is limited to short and simple utterance.

Assessment - rating scales

Enable the examiner to differentiate between severities of dementia • May be insensitive to sudden intellectual decline • May be insensitive to competencies in activities of daily living • Completed through administration, observation and interview of caregivers and/or family members

If an individual has memory loss

He/she doesn't necessarily have dementia

Subcortical dementia

Motor impairment is prominent in early stages • Late stages affects memory, intellect and language • First signs of dementia in individuals appear months to years following motor impairment • Caused by changes in the thalamus, basal ganglia and brainstem • Parkinson's disease and Vascular disease are the most common causes

Human Immunodeficiency Virus Encephalopathy Medical Management

No cure for AIDS or AIDS dementia complex • Medications may prolong lives and possible lessen the degree of severity of the dementia • A combination of HIV antiviral drugs is thought to be the best course of action

Dementia - other causes

Normal Pressure Hydrocephalus Creutzfeldt-Jakob Disease Late stages of amyotrophic lateral sclerosis (ALS) • Multiple sclerosis (MS) • Brain tumors • Chronic subdural hematomas • Bacterial or viral infections of the brain (i.e. meningitis, encephalitis) • Prolonged hemodialysis

Pick's Disease

"characterized by two neuronal abnormalities: proliferation of enlarged neurons (Pick cells) and the presence of Pick bodies within neurons. (Pick bodies are dense globular formations in the neuron cytoplasm. They are about the same size as the cell nucleus and contain numerous neurofibrils" • Pick's disease progresses through brain shrinkage usually occurring in the posterior inferior frontal lobes and the anterior superior temporal lobes in conjunction with neuronal loss and increased production of glial cells in the cortex • Cause is unknown and a genetic component is thought to exist as familial cases may occur in 20% to 50% of the individuals No cure • Treatment is symptomatic • Medication is administered to address changes in mood and depression

Individuals with dementia exhibit problems with

2 or more brain tasks (ex lang & memory)

Lewy Body Dementia

Aka Dementia with Lewy Bodies, Lewy body disease, and senile dementia of the Lewy body type • First described in 1996 • One of the most common progressive dementias • Accounts for 10% - 15% of all dementia cases

Parkinson's Disease

Aka paralysis agitans • Aka primary parkinsonism • James Parkinson in 1817 first described Parkinson's disease • Cause of the neural degeneration is unknown (idiopathic) • Degenerative disease that affects nuclei in the midbrain and brain stem

Rating Scales

Blessed Dementia Scale (BDS) Global Deterioration Scale (GDS) Clinical Dementia Rating The Instrumental Activities of Daily Living Scale (IADL)

Mini-Mental State Examination (MMSE)

Common screening tool for dementia • Administration time is approximately 10 mins • Consists of 30 questions, each worth 1 point. • The test addresses memory, orientation, and math skills. • The MMSE looks at the following: • sense of date and time • Sense of location • Ability to remember a short list of common objects and later, repeat it back • Attention and ability to do basic math, like counting backward from 100 by increments of 7 • Ability to name a couple of common objects • Complex cognitive function, like asking someone to draw a clock • The grading scale is: • 25 or more points = no problem • 21-24 points = mild cognitive impairment • 10-20 points = moderate cognitive impairment • 0-9 points = severe cognitive impairment • If someone gets a score in the 0 to 20 range, it can indicate cognitive issues. It doesn't mean that they have dementia. It does mean that more extensive physical and cognitive testing should be done.

What is the cause of dementia?

Conditions that affect the brain such as Alzheimer's disease, stroke or head injury

Pick's Disease (Frontal Lobe Dementia)

Dementia caused by pathological changes in the Frontal lobe • Arnold Pick, a professor of psychiatry in Prague, described Pick's disease in 1892 • Rare disease • Originates in the cerebral cortex of the frontal lobes. • Incidence is <1% of the U.S. population • Incidence is approximately 2% of dementia patients • Onset is usually between the ages of 40 - 60 years of age, however it has occurred in those younger and older

Vascular dementia

DSM-IV criteria require : • Memory impairment plus one or more associated cognitive disturbances • Cognitive deficits create significant impairments in social and occupational tasks and significantly impact these areas • Cognitive deficits show a significant decline from prior level of function • There is presence of focal neurologic signs and evidence of cerebrovascular disease(latter related to the occurrence)

Alzheimer's Disease

First described by a German professor of neuropathology in 1906 following autopsy findings on a 56 year old patient with severe dementia. He explained three microscopic variances in neurons of the brain that are only visible by direct examination of brain tissue. It is thought that the abnormalities interfere with normal neuronal function in the brain. The abnormalities are: • Neurofibrillary tangles - " Neurofibrils are threadlike structures normally found in the cell bodies, dendrites, axons and sometimes in the synaptic endings of neurons in the brain. In the disease, the neurofibrils become twisted, tangled, contorted, and dumped together" • Neurofibrils may also be seen in the brains of individuals with Parkinson's disease, Progressive supranuclear palsy and at times in elderly individuals with no apparent neurologic disease Neuritic plaques - aka senile plaques or dendritic plaques. Are miniscule spots of tissue degeneration encompassing granular deposits and remains of neuronal processes. Also seen in the brains of individuals with Down's syndrome or Creutzfeldt-Jakob and in the brains of normal elderly individuals. • Granulovacuolar degeneration - a process whereby granular debris is seen inside nerve cells. Pyramidal neurons in the hippocampus are affected most frequently which explains in part the deterioration of memory in the individual

Progressive Supranuclear Palsy

First signs are subtle - person may have frequent falls and state complaints of neck and trunk rigidity • Double vision due to ocular muscle weakness as the disease continues • Changes in mood • As the disease progresses further individuals experience loss of vertical eye movement, muscle rigidity in the arms and legs and pseudobulbar palsy (overstated palatal and laryngeal reflexes, drooling and swallowing impairments • Late stages of the disease show loss of side to side eye movement, rigidity in facial muscles, and increased difficulty walking or unable to walk. • Death usually occurs 4 to 7 years post diagnosis from either respiratory failure or aspiration pneumonia due to central nervous system dysfunction • Dysarthria emerges early and may be severe in the early stages • Speech is slow and contains stuttering-like repetitions • Voice intensity diminishes • Progressive dementia begins slowly usually in the middle to late stages • Language is intact until very late stages when the individual becomes unintelligible and at time mute

• Communication Activities in Daily Living (CADL)

Functional communication • Communication in daily life • Baseline measure to track language abilities over time

Depression Scales

Geriatric Depression Scale The Cornell Scale for Depression in Dementia

Primary Progressive Aphasia

In 1982, Mesulam described symptoms of six patients who showed slow progressive language impairments without behavioral and mental impairments of dementia. Mesulam termed the disease slowly progressive aphasia. • In 1987 the term primary progressive aphasia replaced the old term. • A variant of the disorder is characterized by impaired programming and sequencing of movements of speech and has been termed primary progressive apraxia of speech by Duffy in 2005. • Brain autopsies of these individuals reveal nonspecific degeneration of brain tissues usually located in the temporoparietal region of the language dominant hemisphere Granulovacuolar degeneration, neurofibrillary tangles, or Pick's bodies are found infrequently Many individuals develop impairments in memory, attention, reasoning and executive function 2 to 10 years post diagnosis (average is about 5 years). Onset is gradual with word retrieval difficulties in speaking and writing. • Progression of the disease shows increased word retrieval problems, deterioration of the understanding of spoken and written language, and ability to perform mathematical computations are reduced. • Many individuals are able to carryout activities of daily living that do not necessitate language, if cognition is intact

Huntington's Disease

Inherited, degenerative neurologic disease • Discovered in writing by an American general practitioner in 1872. • Previously called Huntington's chorea (movement disorder of the disease) • Originated in Britain in the 17th century • Affects approximately 1 in 20,000 people

HD symptoms

Initial symptoms of involuntary movements (chorea) • Clumsy, restless, fidgety

Parkinson's Disease Medical Management

Levadopa (L-dopa) • Chemical precursor to dopamine • Body converts to dopamine • Suppresses tremors and slows mental deterioration in approximately two thirds of individuals • Deprenyl • Slows the breakdown of dopamine in the body • Bromocriptine • Mimics the effects of dopamine • Surgical intervention • Relatively new • Pallidotomy- tissue in the basal ganglia(globus pallidus) is surgically destroyed to relieve tremor and rigidity • Fetal tissue transplantation - controversial experimental - dopamine producing tissue from human fetuses are transplanted in to the brains of individuals to replace lost dopamine-producing neurons

Parkinson-plus diseases

Major symptoms of Parkinson's disease are accompanied with other symptoms of central nervous system pathology

Vascular Dementia

Majority of individuals have a history of hypertension and/or heart disease. • It is common for individuals to have a history of multiple strokes. • Initial symptoms are usually abrupt and produce focal neurologic signs such as perceptual, motor, or sensory impairments. • The slow gathering of subsequent neurologic events yields dispersed cerebral involvement and dementia • Depression, irritability, and emotional lability may appear early on. • Later in the progression may yield personality changes and intellect impairments may be sequelae following heart attack causing brain ischemia • may occur after chronic subdural, subarachnoid or intracerebral hematomas •may be associated with autoimmune disease or infection, however, it is rare •

Boston Diagnostic Aphasia Exam (BDAE) • Western Aphasia Battery (WAB)

Measure general language abilities • Track language abilities over time

Dementia is characterized by a decline in

Memory Language Problem-solving and other cognitive skills that affects a person's ability to perform everyday activities

Managing Dementia - middle stages

Memory and attention problems become more severe • Awareness of impairments decrease as the severity increases • Caregivers may have issues of loss, anxiety and anger • Caregivers may become resigned and despondent • Increase in confusion • Increase in self-care neglect • Decrease sleep • Incontinence • Problems with judgment, insight and orientation • Increase in physical dependence • Individual needs more supervision • Individual takes a passive role in conversation • Produces automatics

Managing Dementia Early Stages

Memory impairments - declarative, procedural and perspective • Attentional impairments • Confusion • Retention of spoken or printed material may be compromised • Word retrieval impairments • Identification of important targets • Effects on communication for individual and family • Creating strategies to aid in communication • Anxiety • Depression • Denial • Excess disability due to co-existing illness, environment, medication, co-existing emotional or psychological problems • Sleep disturbances • Health - nutrition may be compromised

A common symptom of dementia is

Memory loss

Early signs of dementia

Memory loss Disorientation Lapses in judgment Problems executing daily living activities Problems with mentally demanding activities Placing things in the wrong areas or places Apathy Mood changes

Human Immunodeficiency Virus Encephalopathy

Onset is variable from insidiously with slow progression to abrupt with rapid progression • In the beginning, the individual may be forgetful, apathetic, have difficulty concentrating and performing complex mental tasks. • Motor impairments emerge as the disease progresses due to cortical ( i.e. spasticity, hyperreflexia and primitive reflex) and subcortical (i.e. weakness, rigidity and ataxia)pathologies • Seizures and incontinence surface following motor impairment progression • The individual shows cognitive impairments (i.e. visuospatial abilities, abstract thinking and reasoning) and is not able to sustain a job or run a household • During the final stages the individual becomes mute, disoriented, incontinent, immobile and requires 24/7 care. • Without medication death occurs within 6 months post onset of central nervous system pathology usually due to aspiration pneumonia or infection

Subcortical dementia

Parkinson's Disease • Huntington's Disease • Progressive Supranuclear Palsy • Human Immunodeficiency Virus Encephalopathy

• As HD progresses

movements become more obvious and personality changes occur • Persons may show irritability and have emotional outbursts • Mental deterioration follows • memory usually affected first • Intellectual functions slow down • Attention is compromised

Dementia is not

part of the normal aging process

Other conditions that can cause dementia or dementia-like symptoms:

reactions to medications • metabolic problems and endocrine abnormalities • nutritional deficiencies • Infections • Poisoning • brain tumors • anoxia or hypoxia • heart and lung problems

Multi-infarct dementia is

the most common vascular dementia syndrome.

Geriatric Depression Scale

to help estimate level of severity of depression in normal elderly adults and adults with mild dementia • 30 questions related to feelings and mood • Respondents are classified as normal, mildly depressed, or severely depressed

Lewy Body Dementia

• "Caused by proliferation of Lewy bodies (the development of abnormal protein deposits in neuron cell bodies" (Brookshire, 2015, p.359) • Results in: • loss of dopamine-producing neurons in the substantia nigra • Produces motor impairments such as rigidity and decreased spontaneous movements • Loss of acetylcholine-producing neurons in the brain • Causes mental deterioration • In addition, Lewy bodies are seen in individuals with Parkinson's Disease and Alzheimer's Disease • Early stage Lewy body dementia is often mixed up with Alzheimer's secondary to granulovacuolar degeneration and neurofibrillary tangles that are present • No cure • No way to slow progression • Palliative management • Focus is on the management of the cognitive, motor and psychological effects • Pharmalogical treatment for motor symptoms may be effective, however, it may cause cognitive impairments, psychosis and/or hallucinations and vice a versa • Prescription treatment for cognitive impairment may include cholinesterase • Prescription treatment for muscle rigidity and spontaneous movement may include levodopa

Coping with Dementia Clinicians need to:

• Address safety issues • Provide support to the individuals, caregivers and family members • Reduce the negative impact and effect that the disease has on the individual • Need to understand what the individual and his/her family and/or caregivers are experiencing • Provide counseling to the individuals, caregivers and family members in dealing with grief, frustration, anger, anxiety and stress

Normal Pressure Hydrocephalus

• Caused by circumstances that impede with the resorption of cerebrospinal fluid (CSF) from the spinal cord and ventricles of the brain • Buildup of CSF in the ventricles of the brain and spinal cord cause increased intracranial pressure and the enlargement of the ventricles • Medical procedure to remediate is shunting • Approximately 2/3 of the individuals treated improve. • Symptoms include: • dementia • Observed as slowing of mental functions, problems with memory, decreased emotional responses, mild attentional difficulties • gait disturbance • Individual is unsteady in a standing position and has problems initiating walking movement • urinary incontinence

• HD triad consists of:

• Chorea • Cognitive decline • Neurobehavioral symptoms • Personality changes, agitation, depression, paranoia, and delusions

The Arizona Battery for Communication Disorders of Dementia (ABCD)

• Clinical assessment that identifies and qualifies communication impairments in individuals with dementia • Addresses speech discrimination, visual perception, visual agnosia, mental status, linguistic expression, verbal memory, linguistic comprehension, and visuospatial construction

Alzheimer's Disease Communication and Cognition Middle stages

• Communication impairments are more noticeable • More and frequent word retrieval problems • Spontaneous production shows more sentence fragments and grammatical errors • Reading rate declines and most individuals discontinue recreational reading • Conversational speech declines (apathy and withdrawn) • Individuals become passive partners during conversation • Increased repetition of ideas and statements • Problems with turn-taking skills • Increased difficulty understanding non-literal material

The Cornell Scale for Depression in Dementia

• Depressive signs for individuals with dementia • Uses ratings from caregivers and family members based on observations during the prior week

HD

• Dysarthria may appear in the early to middle stages secondary to chorea • As chorea increases intelligibility decreases and dysphagia may develop • Sustained attention, memory and judgment may be affected • Language may be affected in last stages

Pick's Disease Cognition and communication

• Early stages Memory and orientation are usually intact • Language breakdown occurs • Middle to Late stages • Language breakdown continues • Word retrieval problems • Difficulty with confrontational naming • Circumlocutions • Generic word substitutions • Echolalia • Verbal stereotypes • Repetition of same idea or story • Impairments in comprehension for spoken and written language are progressively worse • Individuals are mute, have profound dementia, severely impaired memory, decreased orientation, decreased cognition and may show motor rigidity • Death usually occurs 6-12 years post diagnosis secondary to aspiration pneumonia or infection

Coping with Dementia middle to late stages

• Focus of reality declines • Hyperactivity • Wandering • Repetitive behaviors • Incontinence

Coping with Dementia • Early stages

• Inconvenience • Adjustments • Modification • Memory impairments

Coping with Dementia • Middle stages

• Increasing severity in mental impairments • Unpredictable changes in mood • Apathy

Causes of secondary Parkinsonism

• Influenza epidemic in 1918-1919 • Poisoning with heavy metals (manganese, lead and mercury) • Poisoning with aluminum, carbon monoxide or cyanide • Heroin contaminated with a neurotoxin called MPTP • Pugilistic parkinsonism - Parkinson-like condition caused by repeated minor head trauma (boxers)

Neurologic conditions that may resemble dementia

• Intracranial tumors • Hydrocephalus • Infections • Toxemia • Nutritional disorders • Metabolic disorders

HD

• Loss of neurons in the caudate nucleus and the putamen • Some loss of cortical neurons in the frontal and temporal lobes • May have some neuron loss in cerebellum

Pick's Disease

• May be first diagnosed as Alzheimer's, depression or stress • Diagnosis changes with subtle symptoms becoming more dramatic • Alterations in personality and emotion appear first, followed by apathy and indifference towards activities and interests • There is a decline in a person's ability to independently plan, initiate and complete an activity • Social behavior shows deterioration characterized by impulsivity, disinhibition, and inappropriate jocular, inappropriate comments, inappropriate laughter, talking with strangers. • Individual may become hyperoral thus showing a gain in weight • Increased apathy may be observed • Some individual show restlessness, are fidgety and pace increasingly

Coping with Dementia Early to Middle stages

• Memory impairments increase • Self-care is neglected • Impairments in judgment • Increase in anxiety, depression, aggression and irritability • Wandering at night due to daytime napping • Decrease appetite and/or indifference to food or eating

Alzheimer's Disease Communication and Cognition Early Stages

• Mild word retrieval problems • Verbal paraphasias • Subtle problems in comprehension • Reading rate may be slow with difficulty retaining information read • Sustained attention and mental flexibility are impaired • Phonology, syntax, and voice are intact • Automatic, practiced speech responses are intact • Conversation is adequate, however verbose and individuals tend to go off topic

HD Medical management

• No cure • Medication is most effective for controlling the movement, psychological and emotional sequel lea (anti-depressants, anti-psychotics, and anxiolytics) • High doses of said medication may cause parkinsonism symptoms to appear

Progressive Supranuclear Palsy Medical Management

• No effective medical treatment • Temporary, short term improvement seen with Levodopa and similar medications • No medicinal regimen for long term effects at this time • Medications may be given to manage psychological and neurobehavioral manifestations

Multiple cortical infarcts

• Primarily cortical pathology • Due to thrombus or embolism occlusion of cortical arteries • Symptoms are secondary to area involved • Include those symptoms that usually manifest from cortical damage such as apraxia, aphasia and neglect

Creutzfeldt-Jakob Disease

• Rare disease - affecting 1 in 1 million individuals in the U.S. • Most occurrences are seen in adults in their 50s to 60s, however, it can emerge at any age • No effective treatment • Fatal • No known source of infection • In the early 1990s an increase in the disease was seen in England. Scientists attribute this to the consumption of beef from infected cows • Causes rapid progression of dementia and neuromotor disorders • Due to attack of protein particles (prions) into the central nervous system Prions change normal healthy proteins in the brain into infectious and deadly through the changing of the shape of molecules • Infection with the prion causes neuron loss and the production of glials • Appears similar to some diseases in animal such as bovine spongiform encephalopathy in cattle, aka mad cow disease • Symptoms include dementia, memory problems, slowing of mental thought (intellect), problems with reasoning, difficulty with problem solving, insomnia, flat affect, neuromuscular impairments such as cerebral ataxia and myoclonus, hallucinations and confusion • Symptom progression is rapid as disease progresses

Clinical Dementia Rating

• Ratings in six domains of cognition and function • Ratings made based on interview with the individual and a reliable informant

Alzheimer's Disease Communication and Cognition Late stages

• Reading and writing are non-functional • Comprehension of spoken content is limited to familiar words or phrases • Spontaneous speech is characterized by single words and sentence fragments that are bizarre, have no meaning and are repetitive • Neologisms are observed • Individuals are unaware of errors • Insensitivity to rules of conversation and social conventions • May become echolalic • Decreased orientation to self and surroundings • Unable to utilize language in a meaningful manner

Progressive Supranuclear Palsy

• Steele et al. first described in 1964. • Cause is unknown with suspicion of slow acting toxins or viruses as a possible cause . • Recent studies suggest possible genetic origin. • Rare disease affecting approximately 1 in 20,000 adults • Onset is usually between the ages of 50 to 80 years with peak incidence at 60 years of age • Presents with similarities to Parkinson's in rigidity and slowness of movement, but is void of tremor and rigidity affects the muscles of the neck and trunk rather than the limbs • Approximately 12% of individuals are first diagnosed with Parkinson's • Incidence is slightly greater for men Caused by neuronal loss, abnormalities in neurons and production of glial cells in the brain stem and basal ganglia

Vascular dementia

• Symptoms may look like Alzheimer's Disease, however it differentiates by the following: • Acute onset of symptoms • There is a fluctuation in the severity of the symptoms • There is a history of hypertension and stroke • Patterns of impairment is scattered • Individuals are aware of their disorder • Open to depression • Difficulty with recent memory • Difficulty with problem solving • Problems with reasoning • Problems with abstract thinking • Motor speech may be affected secondary to site of lesion (gait, bowel and bladder affects depend of site) • Language and comprehension may be affected if sites in cortical regions • Apathy and lack of initiation may show if frontal lobes are affected.

Lewy Body Dementia

• Typically emerges after 75 years of age, but may develop earlier (age 40 ) • Males and females are affected equally • Initial symptoms vary in severity and include impairments of memory, visuospatial abilities, and attention • Early on in the disease individuals may experience visual hallucinations, frequent falls and fainting • Muscle rigidity and difficulty with spontaneous movement may appear early on in the disease • If decline in cognition within 1-2 years of diagnosis of Parkinson's, this Dementia is suspected • Cognitive and motor impairments decline as the disease progresses • Survival rate following the diagnosis of Lewy Body dementia is approximately 8 years Studies suggest impairments with: • Visuospatial abilities • Language • Attention • Working memory • Executive function

Blessed Dementia Scale (BDS)

• Utilizes family/caregiver information and medical records to estimate an individuals ability to perform activities of daily living

Mixed Dementia

• Vascular Dementia • Lewy Body Dementia • Frontotemporal Dementia