Week 11-12
The assessment helps us to understand the person's skills so during treatment we can organize their __________.
"ENVIRONMENT to fit the person's skills"
When an individual gets stuck, what can you do?
"You can make it simple and give them things they used to like"
Mild Cognitive Impairment MCI
*mild cognitive impairment is a transition stage or condition of intermediate symptoms between the congitve changes associated with healthy aging and then the salient cognitive impairment seen in the Alzheimer's dementia or the other dementias. *it that in between stage of expected decline in nomral aging and that more serious delcine of dementia. *characterized by: memory, thinking, judgment and individuals may be aware that their memory or mental function is slipping, become more impulsive *in between stage!
Dementia With Lewy Bodies (DLB) symptoms
*symptoms are similar to those of Parkinson's and can be misdiagnosed or underdiagnosed *it is a disease where there are abnormal deposits of a protein called alpha-synuclein in the brain. These deposits are called lewy bodies, and they affect the chemicals and the function of the brain and, in turn, can lead to problems with thinking and movement behaviour, and mood. *Typically associated with a loss of two neurotransmitters and those are acetylcholine and dopamine. - these two act as messengers between brain cells. *Typcaly see: persistent and complex visual hallucinations, or other sensory hallucinations. visual spacial imparments, sleep disturbance, fluctuating attention and vigilance. gain, imbalances and parkinsons like movements, reduced speech and fluency, executive funtion deficits, cognitive inflexibility
What other information should you look for during the assessment? (Mark all that apply.)
- Agitation - Baseline functioning - Premorbid intelligence - Affective status
What domains did Dr. Hyer mention that you should assess?
- Executive function - Attention - Language - Visual spatial - Memory
Which of the following changes should be documented?
- Increased confusion - Disorientation - New onset of wandering through the house - Coughing and choking with a meal - Increased agitation - Change in functional communication
More Goals
- Patient will demonstrate auditory comprehension of simple yes/no questions with 70% accuracy in order to communicate functional thoughts, needs, wants and/or feelings. -Patient will demonstrate recall for recent experiences 70% of opportunities using visual aids (ex: digital photos of a picnic)/ AAC with moderate assist to increase episodic memory. - Patient will demonstrate functional problem solving with 50% AAC and mod cues in order to increase safety and reduce fall risk during daily living tasks (ex: showing a picture of floor with split water split, "what do you have to do when this happens"? mealtime (how to elicit safety and problem-solving) - self-advocate needs (need spoon) - knowing what the utensils are used for (not eating with a knife) - someone living at home with a caregiver and smokes cigars and flicing ashes in carpet
Montessori, Part III
- Present freedom in their environment - Facilitates independence, creativity, spontaneous thinking - let them explore the surroundings and choose their favorite activities. - The person with dementia determines what is meaningful to them. Sense of belonging: - regaining the full joy of being together Power of joint activities.
All goals should be __________.
- Stage appropriate - reasonable - reasonable - functional for their daily activities
Assessment Tools
1. ABCD: Arizona Battery for Communication Disorders of Dementia 2. Clinical Dementia Rating Scale (Hughes, Berg, Danziger, Coben, & Martin, 1982) 3. FLCI: Functional Linguistic Communication Inventory 4. Global Deterioration Scale (GDS) 5. FROMAJE: Function, Reason, Orientation, Memory, Arithmetic, Judgment, and Emotional Status 6. FAST: Functional Assessment Staging Test 7. Barthel Index of ADLs 8. Kohlman Evaluation of Living Skills (KELS): $99.00 9. Allen Cognitive Levels 10. Boston Naming Test (Kaplan, Goodglass & Weintraub, 1983) 11. Western Aphasia Battery-R (Kertesz, 2006)
Treatment by SLP
1. Dementia affects a variety of cognitive functions (memory, attention, EF, visual perception, impaired judgment, disorientation, depression 2. Primary goals of service by SLP - Optimize retained abilities for performing ADL: speech, thinking, eating, bathe selves, brush hair, brush teeth, cook a meal - Maintain a level of independence for longer: -Stimulate cognitive ability through creative, customized activities for each underlying cognitive domain. - Compensate for their deficits: teaching the use of memory aids and strategies (external aids) -Modify their environment: to maximize their QoL - Care partner training (family education): caregiver can get burnt out - can effect how that individual with dementia will function. Make sure they take time for themselves -Interprofessional approach: OT (physical independence)- want to involve all the other disciplines **goal = independence, want to get them where they can function and maximize those independents even though those skills are going to be becoming progressively worse.
And Last of All... Some Striking Facts
1. Dementia: the "ticking time bomb" (Dr. Peter Piot) 2. The WHO reports that every four seconds a new case of dementia occurs 3. Around 95% of the general public believes that they could develop dementia in their lives 4. 35% of CGs have reported concealing their loved one's diagnosis of dementia • Denial, privacy, protection 5. 62% of healthcare practitioners believe that dementia is "normal aging"
Tau-proteins produce "neurofibrillary tangles"! (Protein Causing alzheimer's disease)
1. Healthy brains • Healthy neurons have lots of microtubules that guide nutrients from the cell body to the axon and dendrites • In normal brains, tau-protein normally binds to microtubules 2. Alzheimer's disease • Abnormal chemical changes happen to tau. • Detach from microtubules and stick to other tau molecules, forming tangles inside neurons called NFT - or neurofillary tangles. • These tangles block the neuron's transport system and harms the synaptic communications *abnormal chemical changes, those abnormal microtubules detach from the microtubules, these plaques detach from the microtubules and stick to the other tau molecules forming tangles inside the neurons called NFT (neurofibrillary tangles)- these tangles get into these neurons and they black the transport of the firing of that neuronal signal. and so they cant go form neuron to neuron
SLP's Communication Strategies
1. Increase of sense of accomplishment and self worth - when their more confident and the more they feel like they are being successful, the better the quality of life and the more they are going to participate and the more effective you can make your therapy. 2. Positive, encouraging, simple tasks, error free learning -their performance is successful, because when they do make errors they may propagate those errors 3. Decrease undesirable behaviors by displaying socially appropriate behaviors In those later stages, trying to orient them will be challenging and they may not get it. - try to mitigate those things that cause those behaviors. 4. Eliminate distractions (turn off TV or radio, limit number of speech in a room 5. Establish and maintain eye contact 6. Use short, simple sentences and speak slowly 7. Verify that you've understood what the person told you 8. Repeat! if the person does not respond, repeat using the same wording 9. Avoid interrupting the person: allow plenty of time to respond 10. Ask one question or give one instruction at a time 11. Use materials (books, pictures, magazines, games) and gestures 12. Use yes/no questions instead of open ended questions -decreases the cogntive demand of that instruction. 13. Show a spirit of being with : I am not alone: we are in this together.
Sample Reminiscence questions
1. Let us begin with you describing your earliest memory. Describe what life was like for you when you were young. 2. Describe your family, parents, and siblings as you saw them as a child 3. Was religion important to your family as you were growing up? if so, talk about how it was important. was your faith been important to you over the years? In what way? 4. Describe what it felt like the first time you rode in a car, a train, a plane. 5. Did you have any special aspirations or dreams for your life when you were younger? Did they become true? 6. Over the years you have seen many changes in the way people live. How do you feel about the changes? What do you like about the changes? What do you dislike about the changes? 7. What change in your life brought about the most pleasure? 8. Do you have any regrets about your life? Describe. 9. What advice would you give to young people to help them enoy life more? 10: Describe your favourite memory.
PD vs. DLB
1. Lewy bodies found in the brain 2. Both will display the typical motor issues and cognitive issues 3. PD • Typical motor problems are seen first (B, R, T, P) and cognitive deficits follow • 5-10 years post-diagnosis • LB are found mainly in the SN: ____________ 4. DLB • Cognitive symptoms/dementia are seen first or around a year prior to the onset of movement issues • LB are found throughout the cortex, which leads to cognitive issues before motor issues
Mild Cognitive Impairment MCI
1. Moderate, subtle cognitive declines in the six thinking domains (DSM-5) • Gradual decline in memory: forgetfulness as the hallmark • A syndrome with subtle onset of memory issues • Later, a noticeable decrement in cognitive functioning follows that is not typically seen in normal aging • You can still show normal ADL skills • Sometimes referred to as the zone between normal aging and AD • People with MCI are at a greater risk for progressing to dementia → 1. About 50% of patients with MCI will progress to AD over four years → 2. 80% with MCI develop AD within seven years → 3. Not all will have dementia difficult to predict → 4. May not be reversible if it leads to AD • DSM-5: MCI—"mild" NCD; cf. dementia: major NCD *in between stage!
Alzheimer's Dementia (AD)
1. Most common neurodegenerative and dementing disease *accounting for about 60% to 80% of all dementia diagnoses - 5.7 million Americans over the age of 65 **earliest symptoms include: deficits in episodic memory, working memory, attention, and executive function. Language and commutation impairments adversely affecting lexical retrival and discourse are seen 2. Brain volume reduction: significant loss of brain mass! 1. Normal adult brain: roughly 3 lbs (1,300-1,400 grams) 2. Autopsy: cortical shrinkage leads to fewer nerve cells and synapses than healthy brains • Typically, 10% less than normal volume (117-1,260 grams) 3. Ventricles get larger
Dementia in DSM-5 define
1. Officially called a "major neurocognitive disorder" *which is also recognized as earlier stages of cognitive decline as mild neurocognitive disorders. 2. Dementia in itself: • Not a specific disease; memory is typically considered the primary loss of function • The Diagnostic and Statistical Manual of Mental Disorders (DSM) handbook used by healthcare professionals as the authoritative guide to the diagnosis of mental disorders (contains descriptions, symptoms, and other criteria for diagnosing mental disorder)
What are three external strategies that can be used to support memory in dementia therapy?
1. Signs, labels, notes 2. Shopping list, newspaper 3. Audio recording 4. Reminders, sticky note 5. Calendar, planner, diary 6. Watch, timers 7. Shopping lists 8. Putting things in a special place 9. Memory games
Montessori, Part II
1. Sorting buttons 2. Sorting sugars 3. Sorting nuts and bolts 4. Rolling balls of yarn 5. Sorting fabrics 6. Flower arrangements 7. Sorting socks 8. Clipping coupons
Why Is Dementia Important?
1. The world is now aging! (Aging world!) *it is only when the disease progresses to a more severe state that the family seek a medical diagnosis. 2. The U.S. Administration on Aging reports the following. • 2010: 40.3 million over age 65 (social security age!) in the U.S. • 2019: there are over 54 million people living in the U.S. → In the past decade, the population over age 65 has increased by 34% • Elders (aged 65 and over) represented 1 in every 7 Americans
The Purpose of the Assessment 1-3
1. To identify cognitive‐linguistic Strengths and weaknesses *when do they occur, what time of day, how often, what is the consequence of the problem, what is causing the problem, can it be removed, what impact does this problem have on the quality of life? 2. To determine Preserved skills and defits *want to know what is it that they CAN still do. what are their current abilities so that you can build apon it. 3. To document desired activities and participation (patient, family) *want to have a good intake interview and talk to those families about what is their edngame? what is their long term goal? - you want to know their desired activities and participation
Alzheimer's Dementia (AD) (cont)
3. Brain change 1. AD typically begins in the hippocampal area (forming new episodic memories) • Leads to difficulties recalling recent events 2. Damage will progress to the frontotemporal-parietal regions (leads to semantic memory loss, word/facts retrieval problems) *AD typically begins in the hippocampal area, and it will progress through the frontotemporal parietal regions, which leads to semantic memory loss and word finding and word retrial deficits. 4. Hallmark presentation 1. Gradual onset and continuing decline of memory and cognition 2. Typically, motor cortex is persevered: no significant speech disorder is found
The Purpose of the Assessment 4-6
4. To provide a baseline measure of cognitive communicative functioning against which to measure progress *want to do some testing and have numbers where you can monitor how they have progressed- are they declining? is therapy helping making improvements? *WANT a baseline measure of cognitive communication so that you can measure progress. 5. To provide a diagnosis and prognosis when possible *were not diagnosis dementia but you can diagnose the cognitive lingusitc deficits of the dementia. 6. Dynamic assessment: assessment should take place both pre- and post-treatment
SLP Assessment tools
A number of assessment tools have been standardized on individuals with dementia. 1. The severity of dementia needs to be taken into consideration when selecting tests you will get this from your chart or from family history 2. Some tests are too difficult for individuals with severe dementia and do not yield useful information you'll have to choose bits and pieces that you want to look at and informal tests 3. Always factor in the client's cultural and linguistic background • Use tests that have normative samples of culturally and ethnically diverse groups. • Standard scores should not be reported if the normative sample is not representative of the individual being assessed.
Alzheimer's vs. Dementia
Alzheimer's unknown cause: "amyloid cascade hypothesis" is most widely discussed and researched hypothesis today Irreversible: There are no rugs that can cure Alzheimer's, can can only improve symptoms or slow progression Dementia Many causes: Diseases, stroke, thyroid issues, vitamin deficiencies, reactions to medications, and brain tumors Potentially reversible: some form of dementia can be reversed and managed, such as those caused by drugs/alcohold and metabolic disorders Dementia is the decline in mental functions- it's usually irreversible, its a syndrome, not a disease. it is the umbrella phrase that's encompasses several disorders (chronic memory loss, personality changes, impaired reasoning, and Alzheimers) Whats the difference? - Alzheimer's disease is a form of dementia
Keeping attention over time, keeping attention despite distractions, being able to focus on two different tasks at once
Complex attention
DSM-5 Criteria for *Major Neurocognitive Disorder ^ DSM-5 definition
DSM: Diagnostic and Statistical Manual of Mental Disorders. *Evidence of decline is based on concern of the individual, a knowledgeable informant, or the clinician that there has been a significant decline in cognitive function and a substantial impairment in cognitive performance, preferably documented by standardized neuropsychological testing or, in its absence, another quantified clinical assessment. *has to interfere with your independence - they do not occur solely within the context of delirium. (aka its, not a confused state or under a medication. It has to be outside of the context of any delirium, and they are not better explained by another mental disorder such as schizophrenia or depression.
Early Stage
Early symptoms develop in one of three domains. 1. Personality and behavior 2. Language and communication 3. Movement and motor skills *Problems almost unnoticed *Mild memory issues; forgetfulness *Decreased awareness of recent events *Irritable, personality changes, mood swings *Mild semantic anomia (apple for pear, pen for pencil, and other like confusions) *Mini-Mental State Exam (16-24 of 30)
What Happens to the Brain With alzheimer's disease AD?
Even normally aging brains shrink to some degree, but they don't lose neurons in large numbers. AD: Neuronal damage is widespread. • Early stages: AD first destroys neurons in parts of the brain involved in memory (medial temporal lobe): the entorhinal cortex and hippocampus • Important for forming episodic memories and storing LTM (declarative memory) • Issues with recalling recent events and past memories *in this process there is a striking loss of synapses in neurons with alzheimers disease. *The major comments of neuronal loss are those larger neurons. - as the neurons die, additional parts of the brain are affected and also begin to shrink. *So There is a big brain anatomy atrophy
Montessori, Part IV
Invite them to work 1. Real work for meaningful goals - ex: certain areas of the backyard - freedom of choice -more meanings Socializing Environment 1. Doing things together - We live much better as a group - Social being: a being of fellowship 2. Compassion and empathy for other 3. Work, play, eat, rest in groups
List five treatment suggestions for dementia.
It is best to: - Talk about "here and now," especially concerning objects in view. - Eliminate distractions: Reduce number of people in conversations. - Try not to talk about past time ("What did you do yesterday?"). - Do not call attention to the person's difficulties. - Reduce speech rate: Speak clearly and directly, making eye contact. - Allow for time to process information and respond. - Use gestures and expressions to accompany language. - Stay within the patient's view when approaching. - Avoid use of pronouns or other unclear terms. - Use simple, declarative sentences as much as possible. - Use yes/no questions instead of wh-type questions ("When did you go to the bathroom?"). Restate information. - Use touch to gain the person's attention and focus. - Gain the emotional support and respite care for caregivers of patients with dementia—this is critical for continued stamina. - Improve the patient's ability to read signsand find locations of important places, including objects needed in the home. - Say goodbye or signal when leaving.
She called the pen a pencil. This would be deficits in which area?
Language
What Should Goals Look Like for Dementia Patients?
Long term goal: - Pt will utilize a communication system compatible with spared skill to ensure functional expression of basic and medical needs by mastery of the objectives/ STG's [What can "functional expression" be? Could be speech, pointing to picture/symbols/word/phrase/gesture..] Short term goals: - Pt. will appropriate communication exchanges 8 out of 10 opportunties in a session to facilitate expression of basic needs using a picture board (or an iPad) Daily Note: - AAC treatment was provided (ex: memory book was used to cue episodic memory to increase the patient's commutation to 5 of 10 targeted questions: "tell me about your dog"
Memory Support
Memory strategies can be... Internal strategies 1. Mnemonics 2. Face-Name associations 3. Regular recalling of decent events 4. First letter associations 5. Putting things in a special place External Strategies 1. Signs, labels, sticky notes 2. Shopping list, newspaper 3. Audio recording 4. Reminders, sticky notes 5. Calendar, planner, diary 6. Watch, timers 7. Shopping lists 8. Putting things in a special place 9. Memory games
Memory Support
Memory strategies can be... Internal strategies Mental strategies 1. Inside the brain 2. internal monitoring 3. Effortful, conscious processing 4. Active memory search to recall External Strategies (external aids) 1. Physical, permanent products 2. In the enviroment 3. interactive -things like the pill box -When it comes to internal vs external, with dementia, we know that this is a neurologically fragile disease. So the internal strategies are probably not necessarily going to be your first go to. You're going to be going to use those EXTERNAL aids.
Vascular Dementia VaD: Risk Factors
Risk factors are: • Hypertension • Hypercholesterolemia • Type II diabetes mellitus • Prior history of stroke • Smoking *same risk factors you see with stroke.
Sensory Activities
Sight (visual stimulation) - Vision is our most important sense, the one through which we gain most of our information Hearing (auditory stimulation) - Our ears probably provide us with our second most vibrant source of sensory stimulation Smell (Olfactory Stimulation) - Some of our strongest memories, our most potent associations, are triggered by odor Taste (Gustatory Stimulation) - In many ways taste is the most pleasurable of our senses Touch (tactile stimulation) - anything touched and anything that touches us can be stimulating. Every solid object has texture, temperature, and shape. -What you are doing is just using multi-sensory modalities to increase their activities. So using things that are very visually engaging for them.
Maintaining behavior within social norms
Social cognition
Reminiscence Therapy (RT) STEPS:
Step 1: Choose a topic/ question from their childhood, or early adulthood taht will likey have positive memories -ex: first care, wedding day, first job, first home, favorite music) Step 2: Use props or items that can help with the conversation (wedding picture, antique car model) Step 3: Ask questions about the topics (that can hit all 5 senses if possible) -ex: wedding ring, bouquet, old wedding pictures, prompting questions -This is that process of building that collection of memories.
Spaced Retrieval STEPS:
Step 1: Choose one functional target - Today we are going to practice remembering your room number. your room number is 3429 - then going to have a delay and ask them again in 5 minutes,.... Step 2 (no delay): ask a question to elicit the target reponse - Mr. XXX what is your room number? - if correctly answered, move to step 3 "thats right. I am glad that you remembered." - if incorrect, tell them the right answer and have them repeat it back. repeat step 2 Step 3 (short delay): - Ask again 15 seconds later (if they can't recall, give the answer and have them repeat it back. Repeat step 2) Step 4 (long delay): - When the answer is given correctly in step 3, increase the time interval (30 seconds, 1 minute, 2 minutes, etc.) and ask the question again. - repeat this step each time the answer is correctly given. its an immediate response, and want to hold it for 5 minutes then. Having their 10 min delay and then 20 minute delay
A short delay would be considered approximately 15 seconds.
TRUE
Spaced retrieval is a technique that can help improve memory with someone who has Alzheimer's dementia.
TRUE
Spaced retrieval is intended to assess increasing memeory
TRUE
SLP Assessment
The SLP determines the most appropriate assessment protocol based on the stage of dementia and the individual's communication needs. 1. Standardized or non-standardized tests 2. A variety of other data sources 3. Clinical observations in the home or long-term care setting whatever settings they are currently at and how they are functioning there. 4. Conversations with the individual and his or her family and caregivers
Short Term Examples of Functional Change
The person's functional change should be documented: - Change in swallowing safety - Increasingly confused -Change in memory - Impaired safety and judgment - non purposeful chewing - Disorientation - Increased confusion - New or increased wandering without purpose *These are the things that you are looking for that you might notice the decline in.
Two Proteins Causing alzheimer's disease AD
Two assumptions: β-amyloid and tau-protein 1. β-amyloids are known to produce amyloid plaques outside the neurons - build up between the neruons and cause plaques *there is an imbalance - found in too great a quantity because no longer regulated, forming that insoluble plaque 2. Tau-proteins are known to produce neurofibrillary tangles inside the neurons - build up inside the neurons, forming dense tangles * the tau protein stabilizes the microtubes. Tau protein becomes defective and detaches from microtubes. Tau protein becomes defective and detaches from microtubules. Then assemble to for filaments in neuron-neurofibrillary tangles. without the tau skeleton- the neuron degenerates and connection between the neurons is the log. The NT eventually cause the death of a neuron *This is the accumulation of a toxic beta-amyloid protein that forms a hard mass on the brain and includes neurofibrillary tangles, which are twisted fibres and abnormal tau-proteins that accumulate inside of the brain cells, leading to loss of the synapses and eventually cell death. ' *remember: these beta-amyloid proteins just begin to attach to these neurons and begin to impair the synaptic abilities in that firing ability of these neurons. The amyloid plaques and neurofibrillary tangles contribute to the degradation of neurons and lead to Alzheimer's disease. *their symptoms will progressively get worse and decline. And how that decline is patient-specific- but will all have these neurofibrillary tangels and amyloid plaques.
Memory Support/ Visual aids and daily schedule
Visual aids 1. Written cues: Notes, labels, lists, signs,(i.e., inside of the car door to remind to the key out) 2. Orinizational Cues: Planners, medical boxes, shopping lists, memos on the wall, digital photo frame 3. Environmental cues: color coding, special places 4. A smart home for people with dementia
Planning, decision-making, working memory, using feedback to solve a problem, overriding habits and inhibition, mental/cognitive flexibility
executive function
What are two internal strategies that can be used as memory support in dementia therapy?
i. Mnemonics ii. Face-name association iii. Regular recalling of recent events iv. First letter associations v. Putting things in a specific place
Speaking and understanding language
language
Learning new information and remembering that information at a later time
learning and memory
Hand-eye coordination, following nonverbal behaviors, recognizing faces, seeing everything in the environment correctly
perceptual motor
error free or errorless learning with spaced retrieval
spaced retrieval - those with explicit memory issues do not will not eliminate errors during learning. - explicit memory issues prevent them from remembering previous errors and their consequences -repetition of errors will strengthen the errored responses. **So we rely on the preserved implicit memory to function - therefore, we must eliminate the interferences of the errored response. - every learning trial must end with a correct response. so you design a task with uces and support to prevent any errored response Implicit = habitual (brushing your teeth, riding a bike)P those things that you can do without conscious effort Explicit. = those things that require conscious effort. idea of errorless learning = don't make those errors - its strengthening that error response - you want to make it as automatic and error-free like brushing. your teeth - idea of errorless learning is that every learning trial must end with a correct response. So you design a task with queues and support to prevent any arid response. because those errors will be come apart of their function *error-free learning just means creating a task That, and getting enough queues and support. So that they don't make the air because then that error becomes strengthened the more that they do it
Frontotemporal Lobar Degeneration (FTLD)
• Accounts for 10% of dementia cases, most diagnosed before the age of 65 (Alzheimer's Association, 2018) *more rare form of dementia *has a greater impact on work and family fincences • FTLDs are a heterogeneous group of rare neurodegenerative disorders that result in significant impairments of behavior, personality, and distinct types of language impairment (NIA, 2012) • Hallmark presentation • Changes in personality • Changes in behavior • Changes in speech and language • Changes in movement • Rare • Frontal anterior temporal regions of the brain • Pick's disease * Core pathology is progressive atrophy of the frontal and anterior temporal regions of the brain. so you will typically see personality changes, like impulsivity, selfishness, apathy, loss of sympathy, loss of empathy, lack of motivation or lack of spontaneity. more withdrawn, disinhibited, become inappropriate. more confrontation, making hurtful or insensitive remarks, verbally aggressive
Goals for Dementia
• Always relate to functional outcomes • All goals should be: • functional for the patient's capabilities according to stage • measurable • necessary • reasonable
Types of Dementia
• Alzheimer's disease (AD) • Vascular dementia (VaD) • Dementia with Lewy bodies (DLB) • Frontotemporal lobar degeneration (FTLD)
Non-Reversible define and examples
• Can NOT be treated • Symptoms DO NOT resolve or improve • Examples • Alzheimer's Disease • Lewy Body Dementia • Parkinsons' *causes that medically cannot be reversed *examples: irreversible brain damage , Alzheimer's disease, primary progressive aphasia, progressive dementia, vascular dementia, Lewy body dementia, frontotemporal lobe dementia and Parkinsons' disease
Reversible define and examples
• Can be treated • Symptoms may resolve or improve • Examples • Normal pressure hydrocephalus • Vitamin B12 deficiency *those that can be treated are those that have an underlying cause that you can fix Examples: normal pressure hydrocephalus, a vitamin deficiency, dementia due to too much alcohol consumption, smoking or lung issues or metabolic diseases, or stress, sleep problems, or depression *so when those are dealt with, the cognitive symptoms will improve so they can resolve. Those are reversible.
Screening for Cognitive Impairment
• Conducted by an SLP or other member of the interdisciplinary care team • Standardized instruments with high reliability for dementia screening are available 1. Mini-Mental State Exam (Folstein, Folstein, & McHugh, 1975): screen attention, concentration, language, and memory 2. MOCA: Montreal Cognitive Assessment: increasingly popular; designed for vascular dementia 3. SLUMS: Saint-Louis University Mental Status Examination • Prior to screening: check the patient's sensory impairment (hearing and vision), depression, and current medications on cognitive functioning
Vascular Dementia (VaD) (non reversable)
• Considered the second most common cause of dementia— irreversible • Caused by ischemic or hemorrhagic cerebrovascular disease, cardiovascular disease, or circulatory disturbances that damage brain areas vital for memory and cognitive functions • Hallmark presentation • Step-wise decline within each stroke • Memory deficits not always present • Symptoms may vary per blood flow interruption *caused by brain damage from ischemia or occlusion of those fine capillaries of the brain - this ischemia is generally impaired blood flow to the brain which is depriving that brain of oxygen (aka stroke) - it is multiple vascular incidences or vascular accidents, strokes, happening over time that eventually begin that dementia process due to all of the vascular changes and vascular incidences.
Dementia With Lewy Bodies (DLB)
• DLB is biologically related to PD *3rd most common form of demential • Both conditions share pathological hallmark of the presence of Lewy bodies • DLB symptoms • Lewy bodies are abnormal clumps of the neuronal protein, alpha-synuclein
Beta-amyloid plaques (Protein Causing alzheimer's disease)
• Healthy, normal body produces protein called amyloid (soluble and cleared): helps synapse formation, neural plasticity, antimicrobial activity • Beta amyloid is a small fragment cut from the amyloid protein (aka, APP) • In healthy brains, β-amyloid fragments are dissolved and eliminated • Larger than normal and sticky • Sometimes these fragmented β-amyloid particles may not be dissolved • These undissolved protein clump together to form "amyloid plaques" • Blocks neural connections—neurons die out *Remember: these plaques are aggregates of misfolded proteins that form in those spaces within the nerve cells. and they begin to dissolve and then become sticky, and they begin to attach to these neurons.
How Is Dementia Diagnosed?
• History • Physical exam and tests *ex: blood test - going to exclude b12 deficiencies. or they are going to do MRI's to exclude the possibility of any other neurological issues like a tumor or maybe even do imaging to test for a CVA- want to rule those things out *blood tests are going to include tests for liver function, kidney function, thyroid function, haemoglobin A1C levels and b12, folate levels • Test of mental abilities *can be simple tests - typical questions to see how things are going • Instrumental exams of the brain structures *scans of the brain; MRI, CT, PET scan
What Happens to the Brain With alzheimer's disease AD?
• Later stages: lateral temporal, frontal lobe, parietal lobes are affected • Affect cerebral cortex responsible for language (semantic memory, recalling/accessing words), reasoning, social behaviors • Eventually, many other areas of the brain are damaged *Hallmark = losing independence, losing the ability to live and function independently • Last stage • A person with AD loses the ability to live and function Independently • Ultimately, the disease is fatal
MOCA: Montreal Cognitive Assessment
• MMSE vs. MOCA • MOCA has subtests for executive function and more demanding visuospatial construction • Better predictor of PSCI in chronic or midterm post stroke cases • Screener • A 1-page, 11 tests for 30-point test, 10 minutes • A score of 26 and above: normal • Average score for MCI: 22.1 (range 18-25) • Average score for mild Alzheimer's disease: 16.2 (10-17) • Tests • Visuospatial abilities, executive functions, short-term memory, attention, working memory, language, orientation to time and space
Montessori, Part I
• Maximize their engagement in real-life activities (let them do the work). • A good center will offer a variety of activities as well as movement. • It will present free in their environment. Let's take a look at different ways caregivers can put Montessori into practice. 1. For advanced dementia, people may take comfort in holding dolls; a series of dolls and doll clothes can make for a pleasurable activity 2. For those who enjoy baking or cooking, baking ingredients, and a safe kitchen environment 3. Have a basket of clean socks that need to be matched and folded 4. Lay out a basket of clean towels to fold 5. Prepare tables with materials for activities such as puzzles, sorting exercises, and other games 6. Put out a bin of plastic plumbing tubes that can be connected and put together -Focueses on rediscovering and supporting the person behind the dementia. -So activities with meaning and purpose, they're put back into their lives. - its based on their needs, skills and interests and abilities. - People with dementia always feel like their always being told what to do. So these adults often don't need to be told what to do but they need to feel useful, productive, doing something meaningful. Montessori method is about providing way to connect with those long term memories. **So presenting with fresh flowers and an empty vase may give them a way to step out of a sense of isolation and into a beautiful spring day and because of the experience of putting the flowers in a case is enough and my powerfully call forth the memory of cutting fresh flowers from the past.
Middle Stage
• Problems more obvious, diverse, frequent, and difficult to manage • Difficult to perform most ADLs • Assistance is needed with ADLs • Relationships are affected • Emotional difficulties: anger, irritability, frustration, conflicts, agitation, anxiety • Restlessness and distractibility • Poor episodic memory and lack of awareness for recent events • Encoding and lexical retrieval impairments • Visual perceptual and constructional deficits • Executive function/forgetfulness deficits worsen • Reading and writing are impaired • Mini-Mental State Exam (8-15 of 30)
Who Diagnoses Dementia?
• Psychiatrist: a mental health specialist • Geriatrician: a doctor specializing in the physical health of older people • Neurologist: someone who concentrates on diseases of the nervous system • Neuropsychologist: someone who specializes in understanding the relationship between the physical brain and behavior; their goal is understand how brain structures and systems relate to behavior and thinking • Trained GPN: __ (general practice nurse) or specialist nurse depending on their expertise and training; with the right training a general practice nurse can be well-positioned to provide comprehensive dementia information and support that so that people living with dementia are better equipped to self-manage their health and live well with dementia SLP don't do diagnosis
Spaced Retrieval
• Purpose: recalling information over "progressively" longer periods of time • Evidence supports use with Alzheimer's disease, Parkinson's disease, TBI, and aphasia • Very simple manipulation of recall tasks • Choose targets that are: • Personal • Functional • Important • Familiar • Involve the patient's immediate needs - You will have something to recall, an event. But then you have to recall it after 5 minutes, after 10 minutes, and you increase that space. -This is really good to use with Alzheimer's disease. Also you can use with TBI.
Reminiscence Therapy/ Reminiscence therapy (RT)
• Reminiscence therapy (RT) refers to a guided collection of memories from the past • Engages long-term memory • Think back • Do you like music? • What were doing at 21? • What was your first car? • What did you do for a living? • Who was your favorite comedian? -Reminiscent therapy involves discussing events and experiences from the past. It aims to envoke memories and stimulate mental activity and improve their overall well being. -It uses props like videos, pictures, and objects. -it can take place in a group or done on their own - It often results in some form of life storybook. You get that persons life in creating this story of their whole history. - It can help with depression, and helps tap into that persons well learned past memories because you're pulling al those back in. - So its a guided collection of memories from the past *basically creating a memory journal and locking in some of their memories.
Interventions
• Sensory • Reminiscence • Spaced retrieval • Montessori • Memory support . These are all types of interventions that you can implement
Late Stage
• Severe-profound cognitive deficits noted. • Patient may be non-ambulatory or bed- bound • Verbal output: extremely diminished speech • Common language deficits are: • Mute: verbal abilities may be lost • Perseverative • Echolalic • Severe impairment in memory • STM, WM • LTM: episodic (past event) semantic (factual information) • Disoriented to person, place, and time • MMSE scores 0-9 of 30
SLUMS: Saint Louis University Mental Status Exam
• Tests: orientation, STM, calculations, naming of animals, clock drawing, and recognition of geometric figures • SLUMS scores • Scores between 27 and 30 are considered normal in a person with a high school education. • Scores between 21 and 26 suggest a mild neurocognitive disorder. • Scores between 0 and 20 indicate dementia. it was designed as an alterative screening to that widely used MMSE *so the SLUMs consists of 11 items *more difficult test
Mini-Mental Status Exam MMSE
• The Mini-Mental State Exam (MMSE) is a widely used test of cognitive function among the elderly; it includes tests of orientation, attention, memory, language, and visual-spatial skills • The MMSE asks questions to ascertain cognitive status; responses are scored as follows: 0 = incorrect 1 = correct + item administered, participant does not answer 9 = test item not administered, unknown • Scores range from 0 to 30 • Example questions • What is the date today? (3 = 1 point for month, 1 point for day, 1 point for years) • What is the season? • What day of the week is it? • What town, country, and state are we in?
