Med Con.: Test One- Dementia Lecture

Stage 3: Mild cognitive decline

Early-stage Alzheimer's can be diagnosed in some, but not all, individuals with these symptoms •Friends, family or co-workers begin to notice deficiencies. Problems with memory or concentration may be measurable in clinical testing or discernible during a detailed medical interview. Common difficulties include: Word- or name-finding problems noticeable to family or close associates Decreased ability to remember names when introduced to new people Performance issues in social or work settings noticeable to family, friends or co-workers Reading a passage and retaining little material Losing or misplacing a valuable object Decline in ability

Reisberg Global Deterioration Scale: 1 thru 3 : Early/Mild Stages

Stage 1: No impairment Stage 2: Very mild cognitive decline Stage 3: Mild Cognitive Decline

Creutzfeldt-Jakob disease (CJD)

• is a rare, rapidly fatal disorder affecting about 1 out of 1 million people per year worldwide. It usually affects individuals older than 60.

•Research has shown:

• that individuals with MCI have an increased risk of developing Alzheimer's disease over the next few years, especially when their main problem is memory. •Not everyone diagnosed with MCI goes on to develop Alzheimer's. •results of a large, federally funded trial showed that 10 milligrams of donepezil (Aricept) daily can reduce the risk of progressing from amnestic MCI to Alzheimer's disease for about a year, but the benefit disappears within three years.

Symptoms of frontotemporal dementia

•A more rapid onset than in Alzheimer's disease. •The first symptoms often involve changes in personality, judgment, planning and social functioning. Individuals may make rude or off-color remarks to family or strangers. They may make unwise decisions about finances or personal matters. •Individuals' feelings may seem disconnected from the situation. They may show apathy and loss of interest or excessive happiness and excitement. •Individuals may have a strong desire to eat and gain weight as a result.

Middle Stage •individual will have even more of a decline in memory and high level cognition. •At this stage, most people begin needing assistance with basic self care tasks like getting to the bathroom in time. They may show decreased sequencing ability and motor planning of basic ADLs.

•ADL retraining along w/ balance retraining and functional mobility •At this stage, the patient's caregivers might start jumping in and doing everything for them. w/ cues and prompting the pt. can still physically assist with this, & they should be encouraged to do so (especially w/ ADLs) not allowing pt. to continue routine may lead to a loss of basic self-care skills. may be due a legitimate lack of time or simply a lack of education of the caregivers •Performing basic ADL retraining (toileting, dressing, self-feeding increased verbal or visual cues, demonstration, physical guidance, partial physical assistance and problem solving to improve the outcome repeated ADL retraining using same activity, same sequence, same time, and same place will help to increase retention. Pts. own personal living area is more beneficial than doing simulated activities in the gym, when possible

Common OT interventions in dementia care

•ADL's •IADL's •Daily Structure •Family •Adult Day Care •Support groups

Irreversible dementias

•Alzheimer's disease •Parkinson's Disease •HIV •Multiple Sclerosis •Huntington's Disease

Dementia

•Any group of symptoms characterized by: a decline in intellectual functioning severe enough to interfere with a person's normal daily activities and social relationships. •A memory deficit with one or more of the following: agnosia, apraxia, aphasia, impairment in executive functioning •Is a progressive and fatal brain disease.

•Stage 4: Moderate cognitive decline(Mild or early-stage Alzheimer's disease)

•At this stage, a careful medical interview detects clear-cut deficiencies in the following areas: Decreased knowledge of recent occasions or current events Impaired ability to perform challenging mental arithmetic-for example, to count backward from 75 by 7s Decreased capacity to perform complex tasks, such as planning dinner for guests, paying bills and managing finances Reduced memory of personal history The affected individual may seem subdued and withdrawn, especially in socially or mentally challenging situations

Symptoms of Wernicke-Korsakoff

•Confusion, permanent gaps in memory and problems with learning new information. •Individuals may have a tendency to "confabulate," or make up information they can't remember; they are not "lying," but may actually believe the invented explanation. •Unsteadiness, muscle weakness and lack of coordination. •Recent research suggests a genetic variation called APOE-e4 may be associated with a higher risk of Wernicke-Korsakoff in individuals who drink heavily. APOE-e4 is also linked to a higher risk of developing Alzheimer's disease.

Symptoms of NPH

•Difficulty walking. •Loss of bladder control. •Mental decline, usually involving an overall slowing in processing and reacting to information. A person's responses are delayed, but they tend to be accurate and appropriate to the situation when they finally come.

Reversible Dementias

•ETOH abuse •Drug toxicity •Depression •Malnutrition •Diseases of the brain •Delirium •Metabolic Conditions •Organ Dysfunction

Purpose of caregiver education

•Educating your patient's family members on your interventions to increase carryover •Important to teach family members how they can reduce their own stress. Family members will benefit from resources and support group information

AOTA: Dementia and the role of OT Occupational therapy interventions

•Health Promotion. promoting maximal performance in preferred activities. •Remediation. interventions to improve the performance of ADLs & functional mobility, & to help restore ROM, strength, and endurance •Maintenance. Practitioners can provide supports for the habits and routines that are working well for the person with dementia, and that can be maintained to prolong independence. Modification.to promote a safe and supportive environment through adaptation and compensation, including verbal cueing, personal assistance, and/or social supports

Special considerations

•If your patient refuses to work with you or appears agitated, assess the environment. •Is there excess stimuli? •Is it late afternoon and they're exhausted?

•Stage 2: Very mild cognitive decline (may be normal age-related changes or earliest signs of Alzheimer's disease)

•Individuals may feel as if they have memory loss and lapses, especially in forgetting familiar words or names or the location of keys, eyeglasses or other everyday objects. But these problems are not evident during a medical examination or apparent to friends, family or co-workers.

Common settings for OT in dementia care

•Inpatient Settings Medical floor •Inpatient rehab •Assisted Living •Nursing Home Client's home

Symptoms of Huntington's

•Involuntary movements such as twitches and muscle spasms. •Problems with balance and coordination. •Personality changes such as irritability, depression and mood swings. •Trouble with memory, concentration, or making decisions. •The age when symptoms develop and the rate of progression varies from person to person.

Alzheimer's disease

•Is the most common form of dementia, a general term for memory loss and other intellectual abilities serious enough to interfere with daily life. Alzheimer's disease accounts for 50 to 80 percent of dementia cases. •Two abnormal structures called plaques and tangles are prime suspects in damaging and killing nerve cells. •Plaques build up between nerve cells. They contain deposits of a protein fragment called beta-amyloid (BAY-tuh AM-uh-loyd). Tangles are twisted fibers of another protein called tau (rhymes with "wow"). •Tangles form inside dying cells. Though most people develop some plaques and tangles as they age, those with Alzheimer's tend to develop far more. The plaques and tangles tend to form in a predictable pattern, beginning in areas important in learning and memory and then spreading to other regions.

Common OT assessment tools

•Large Allen Cognitive Screening Tool •Cognitive Performance Test •Routine Task Inventory •Kohlman Evaluation Of Living Skills

•Stage 5: Moderately severe cognitive decline(Moderate or mid-stage Alzheimer's disease)

•Major gaps in memory and deficits in cognitive function emerge. Some assistance with day-to-day activities becomes essential. At this stage, individuals may: Be unable during a medical interview to recall such important details as their current address, their telephone number or the name of the college or high school from which they graduated Become confused about where they are or about the date, day of the week or season Have trouble with less challenging mental arithmetic; for example, counting backward from 40 by 4s or from 20 by 2s Need help choosing proper clothing for the season or the occasion Usually retain substantial knowledge about themselves and know their own name and the names of their spouse or children Usually require no assistance with eating or using the toilet

Symptoms of Mixed Dementia

•May follow a pattern similar to either Alzheimer's or vascular dementia or a combination of the two. •Some experts recommend suspecting mixed dementia whenever a person has both evidence of cardiovascular disease and dementia symptoms that get worse slowly

•Stage 6: Severe cognitive decline(Moderately severe or mid-stage Alzheimer's disease)

•Memory difficulties continue to worsen, significant personality changes may emerge and affected individuals need extensive help with customary daily activities. At this stage, individuals may: Lose most awareness of recent experiences and events as well as of their surroundings Recollect their personal history imperfectly, although they generally recall their own name Occasionally forget the name of their spouse or primary caregiver but generally can distinguish familiar from unfamiliar faces Need help getting dressed properly; without supervision, may make such errors as putting pajamas over daytime clothes or shoes on wrong feet Experience disruption of their normal sleep/waking cycle Need help with handling details of toileting (flushing toilet, wiping and disposing of tissue properly) Have increasing episodes of urinary or fecal incontinence Experience significant personality changes and behavioral symptoms, including suspiciousness and delusions (for example, believing that their caregiver is an impostor); hallucinations (seeing or hearing things that are not really there); or compulsive, repetitive behaviors such as hand-wringing or tissue shredding Tend to wander and become lost

Symptoms of Alzheimer's:

•Memory loss that disrupts daily life •Challenges in planning or solving problems •Difficulty completing familiar tasks at home, at work or at leisure •Confusion with time or place •Trouble understanding visual images and spatial relationships •New problems with words in speaking or writing •Misplacing things and losing the ability to retrace steps •Decreased or poor judgment •Withdrawal from work or social activities •Changes in mood and personality

Symptoms of vascular dementia

•Memory problems may or may not be a prominent symptom, depending on whether brain regions important in memory are affected. •Confusion, which may get worse at night. •Difficulty concentrating, planning, communicating and following instructions. •Reduced ability to carry out daily activities. •Physical symptoms associated with strokes, such as sudden weakness, difficulty speaking or confusion. •Magnetic resonance imaging (MRI) of the brain may show characteristic abnormalities associated with vascular damage.

Symptoms of dementia with Lewy bodies

•Memory problems, poor judgment, confusion and other cognitive symptoms that overlap with Alzheimer's disease. •Excessive daytime drowsiness. •Visual hallucinations. These are detailed. •Cognitive symptoms and level of alertness may get better or worse (fluctuate) during the day or from one day to another. •Movement symptoms, including stiffness, shuffling walk, shakiness, lack of facial expression, and problems with balance and falls. ( Soft signs of Parkinson's disease.) •Exquisite sensitivity to neuroleptics, ie, Modest dose leads to profound Parkinson's

Examples of OT interventions

•Person forgets what season it is when selecting clothing: Help the care provider set up limited clothing selections to fit the season, which helps avoid conflict while supporting client choice and self-efficacy. •Person gets disoriented and wanders: Set up the environment to enhance daily activity, including mobility within safe confines, and use technology to ensure safety. Sometimes a fenced courtyard with stop signs at the gates could be all that is needed to keep the person oriented to his or her own yard; for others, alarms can be installed to go off when the person opens a gate or a door. •Person has trouble communicating, along with uncharacteristic, frequent outbursts: Help caregivers identify nonverbal cues. Teach the concepts of caring, non-defensive responding techniques, and work on determining the underlying emotion that may have precipitated the client's behavioral outbursts. Avoid correcting factual errors. •Person paces or shows other repetitive non-productive behavior: Provide opportunities for engaging in occupational tasks that fulfill the person's need to be productive and help support relationships with others. For example, if the person once enjoyed crossword puzzles, perhaps simplified puzzles or word searches would still be enjoyable. Simple, repetitive tasks like folding laundry can lead to feelings of accomplishment.

Reisberg Global Deterioration Scale: 4 &5: Moderate/Moderately Severe Stages

•Stage 4: Moderate cognitive decline(Mild or early-stage Alzheimer's disease) •Stage 5: Moderately severe cognitive decline(Moderate or mid-stage Alzheimer's disease)

Reisberg Global Deterioration Scale: 6 & 7: Severe & Late Stages

•Stage 6: Severe cognitive decline(Moderately severe or mid-stage Alzheimer's disease) •Stage 7: Very severe cognitive decline(Severe or late-stage Alzheimer's disease)

Symptoms of Creutzfeldt-Jakob disease

•The first symptoms may involve impairment in memory, thinking and reasoning or changes in personality and behavior. •Depression or agitation also tend to be early symptoms. •Problems with movement may be present from the beginning or appear shortly after the other symptoms. •Symptoms progress rapidly and death typically occurs within a year. •There may be characteristic changes on an electroencephalogram (EEG, or "brain wave" test). •There may also be a characteristic substance called "14-3-3 protein" in the spinal fluid

•Stage 7: Very severe cognitive decline(Severe or late-stage Alzheimer's disease)

•This is the final stage of the disease when individuals lose the ability to respond to their environment, the ability to speak and, ultimately, the ability to control movement. •Frequently individuals lose their capacity for recognizable speech, although words or phrases may occasionally be uttered •Individuals need help with eating and toileting and there is general incontinence of urine •Individuals lose the ability to walk without assistance, then the ability to sit without support, the ability to smile, and the ability to hold their head up. Reflexes become abnormal and muscles grow rigid. Swallowing is impaired.

Early Stage •In the early stages of dementia, your patients will generally still be able to function in daily life pretty well. They may start noticing that they forget simple things like appointments, where they placed their keys, or if they've taken their medication.

•Training in use of memory aids like calendars, journals, medication reminders, and daily routine schedules to help maintain independence w/ higher level ADLs. •Your patients or family members might also notice the individual beginning to need reminders to bathe or eat. Focus your interventions on these less complex tasks if patient is having trouble even though they might appear completely intact cognitively

•Stage 1: No impairment (normal function)

•Unimpaired individuals experience no memory problems and none are evident to a health care professional during a medical interview.

Mild Cognitive Impairment (MCI) & Alzheimer's

•an individual's report of his or her own memory problems, preferably confirmed by another person • measurable, greater-than-normal memory impairment detected with standard memory assessment tests • normal general thinking and reasoning skills • ability to perform normal daily activities

Parkinson's disease and dementia

•begins by affecting movement, resulting in tremors and shakiness, stiffness, difficulty with walking and muscle control, lack of facial expression and impaired speech. Parkinson's is another disease in which Lewy bodies are found in the brain. Many individuals with Parkinson's develop dementia in later stages of the disease.

Late stage • will likely not be oriented to person, place, or time, and are often dependent in all or most self care, including feeding. They will have a severe loss of motor control, and will likely be wheelchair-bound because of this.

•focus to educating caregivers on safe transfers, contracture management through home exercise programs, proper positioning to avoid skin breakdown and increase comfort, and providing enjoyable sensory stimulation. •Caregivers may be experiencing increased stress, depression, and exhaustion with this stage. ØSupport groups (either online or in-person) can really help to have others that are going through the same life stresses.

Mixed Dementia

•is a condition in which Alzheimer's disease and vascular dementia occur at the same time. Many experts believe mixed dementia occurs more often than was previously realized and that it becomes increasingly common in advanced age. •This belief is based on brain autopsies showing up to 45 percent of people with dementia have signs of both Alzheimer's and vascular disease.

Huntington's disease

•is a fatal brain disorder caused by inherited changes in a single gene. These changes lead to destruction of nerve cells in certain brain regions. Scientists identified the gene in 1993. Anyone with a parent with Huntington's has a 50 percent chance of inheriting the gene, and everyone who inherits it will eventually develop the disorder. In about 1 to 3 percent of cases, no history of the disease can be found in other family members

Frontotemporal Dementia

•is a rare disorder that affects the front (frontal lobes) and the sides (temporal lobes) of the brain. Because these regions often, but not always, shrink, brain imaging can be useful in diagnosis. •There is no specific abnormality associated with all cases of frontotemporal dementia. In one type called Pick's disease, there are abnormal microscopic deposits called Pick bodies, but these are not always present.

Wernicke-Korsakoff syndrome

•is a two-stage brain disorder caused by a deficiency of thiamine (vitamin B-1). Thiamine helps brain cells produce energy from sugar. When levels of the vitamin are too low, cells are unable to generate enough energy to function properly. •Wernicke encephalopathy is the first, acute phase and Korsakoff psychosis is the long-lasting, chronic stage. •The most common cause is alcoholism, but the syndrome can also be associated with AIDS, cancers that have spread through the body, very high levels of thyroid hormone, and certain other conditions.

Normal pressure hydrocephalus (NPH)

•is another rare disorder in which fluid surrounding the brain and spinal cord is unable to drain normally. The fluid builds up, enlarging the ventricles (fluid-filled chambers) inside the brain. As the chambers expand, they can compress and damage nearby tissue. •The "normal pressure" refers to the fact that the spinal fluid pressure often, although not always, falls within the normal range on a spinal tap.

Dementia with Lewy Bodies

•is characterized by abnormal deposits of a protein called alpha-synuclein that form inside the brain's nerve cells. •These deposits are called "Lewy bodies" after the scientist who first described them. Lewy bodies have been found in several brain disorders, including dementia with Lewy bodies, Parkinson's disease and some cases of Alzheimer

Younger-onset Dementia

•refers to Alzheimer's that occurs in a person under age 65. •Younger-onset individuals may be employed or have children still living at home. •Issues facing families include ensuring financial security, obtaining benefits and helping children cope with the disease. •People who have younger-onset dementia may be in any stage of dementia - early, middle or late. •Experts estimate that some 500,000 people in their 30s, 40s and 50s have Alzheimer's disease or a related dementia.

Vascular dementia

•second most common type of dementia. It develops when impaired blood flow to parts of the brain deprives cells of food and oxygen. •The diagnosis may be clearest when symptoms appear soon after a single major stroke blocks a large blood vessel and disrupts the blood supply to a significant portion of the brain. This situation is sometimes called "post-stroke dementia." •There is also a form in which a series of very small strokes, or infarcts, block small blood vessels. Individually, these strokes do not cause major symptoms, but over time their combined effect becomes noticeable. This type is referred to as vascular cognitive impairment (VCI) or multi-infarct dementia.