• Acquired disease • Exposure during a medical procedure • Instrument infection • Growth hormone • Transplanted human tissue • Eating meat from an infected cow • Mad “cow” disease 30
Memory • Concerned with short ‐ term memory, working memory, long ‐ term memory, declarative/explicit memory, procedural/implicit memory • Long ‐ term memory: memories of distant past • Short ‐ term memory: immediate memories, memories of recent events • Working memory: the memory we use to complete tasks • Doesn’t become short ‐ term unless stored • Can only retain so many items at one time • The number of items retained declines with time 31
Memory • Explicit/declarative memory • Ability to remember facts and experiences • Enables us to explain how to complete the task and to remember learning the task • Episodic memory: ability to remember specific personal experiences • Semantic memory: ability to store factual information • Encoding and retrieving explicit memory requires top down processing and organization • To create an explicit memory you have to do something with it • Talk about, think about it, write it down.\ 32
Memory • Explicit spatial memory: • The ability to remember where something is located • Memory about environment and spatial orientation • Lets you know where you are in space • Situation awareness and awareness of objects around you • Necessary for driving 33
• Implicit/procedural memory • Ability to remember how to do something without actually thinking about doing it • Action movements and skills (toileting, transfers, feeding) • Automatic • Uses past experiences to create memories 34
Hippocampus • Sea horse shaped structure in the inferior temporal horn • Part of the limbic system • Part of the temporal lobe memory system • 1 st area of the brain to be damaged by Alzheimer’s disease • functions to consolidate information from short term memory to long term memory 35
Hippocampus • Other functions: • Formation of new memories • Spatial memory (position in space, location) • Navigation • Response inhibition • Sensitive to conflict and may play a role in conflict avoidance • Important for explicit memory 36
Hippocampus • Loss of explicit memory is associated with the medial temporal lobe • Implicit memory is associated with several areas: basal ganglia, cerebellum, motor cortex • Therefor explicit memory is lost quickly while implicit remains intact until much later in the disease process 37
Hippocampus • Frontal lobe damage is associated with behavioral disturbances (happen later in the disease process because those areas are initially spared) • As is the motor and sensory areas • Therefore early on the ability to ambulate, transfer, toilet, etc. are relatively unaffected 38
Stages of Dementia 39
Staging • There are two ways to stage dementia • General (based on cognitive loss) • Mild cognitive loss • Moderate cognitive loss • Severe cognitive loss • More specific • Stage 1: normal • Stage 2: normal aging • Stage 3: mild cognitive impairment • Stage 4: moderate cognitive decline (late confusion) • Stage 5: moderately severe cognitive decline (early dementia) 40
Staging • Stage 6: severe cognitive decline (middle dementia) • 5 substages • Stage 7: very severe cognitive decline • 6 substages 41
Stage 1: Normal • No complains • No memory deficits • No subjective or objective deficits • Cellular changes have begun in the brain • Amyloid plaques • Neurofibrillary tangles • Lewy body formation • Vascular changes 42
Stage 2: Normal aging • Characteristics • Forgetful: names, where things are, word finding difficulties, trouble concentrating • Not noticeable to external observers • No objective deficits • Can maintain employment, social situations • Able to learn new information with demonstrated directions • Independently perform familiar activities (gait, transfers, toileting) 43
Stage 2 • Treatment suggestions • Limit session to no more than 20 minutes • Can complete 6 ‐ 8 steps of familiar activity • Concrete problem solving only • Memory are effective (lists, calendars, etc. • Can match, sort, sequence, read, use tools 44
Stage 3: mild cognitive impairment • Characteristics: • Get lost traveling to unfamiliar locations • Become disoriented in new places/situations • Difficulty in social situations becomes noticeable (subtle withdrawal) • Decreased ability to concentrate • Language is intact but word finding difficulty begins • Demonstrate verbose, vague speech • Start to become self ‐ centered • Co ‐ workers/friends notice decline in previous activities 45
Stage 3 • Characteristics continued • Become confused with changes in plans and in complex situations • May lose or misplace objects of value • Depression is a common co ‐ morbidity • Begin the decline of episodic and working memories • DENIAL 46
Stage 3 • They can: • Follow sequences to complete tasks • Use watches, calendars, etc. • Complete ADLs with good quality • Change clothes, brush teeth, wash face appropriately • Generally still very mobile 47
Stage 3 • Treatment suggestions (same as previous stage) • Limit session to no more than 20 minutes • Can complete 6 ‐ 8 steps of familiar activity • Concrete problem solving only • Memory are effective (lists, calendars, etc. • Can match, sort, sequence, read, use tools 48
Stage 3 Some examples: • Walking and naming objects • Standing and reaching for or stepping on visual targets • Sticky notes on mirror • Drawing on mirror • Performing a specific task when given a specific cue (error free learning) the same way every time 49
Stage 4: Moderate cognitive decline • Characteristics: • Decreased knowledge/recall of recent events • Begin to lose details of personal biography • Trouble handling bills and finances • Ability to plan deteriorates • Word finding difficulty increases, speech content is empty • Can’t follow long conversations • Flat affect, moody, withdrawal • Denial is a defense mechanism 50
Stage 4 • Two major changes • Less aware of environment • Must be within 14” for them to notice you • Become completely self ‐ centered 51
Stage 4 • They can: • Dress with step by step directions (2 step) • Sequence simple tasks such as face washing, brushing teeth • Remember the rules of simple, familiar games • No longer able to use memory aids 52
Stage 4 • Treatment suggestions • Limit session to 5 ‐ 20 minutes • Everything must be directly in front of them • Step by step instructions for all task required (1 ‐ 2 step) • Prefer routine • Need cues to interact with others • Visual demonstration can help • Decline in episodic memory is noticeable 53
Stage 4 • Some examples: • Dusting, card sorting, folding clothes in standing • Matching color patterns in standing (parquetry) • Tossing bean bags in standing • Sit<>stand repetitions 54
Stage 5: Moderately severe cognitive decline (early dementia) • Characteristics: • Need intermittent cues to complete any task • Unable to recall major life events, addresses, phone numbers of many years (can tell you address where they grew up) • Unable to recall names of family members but will still recognize them • Begin to see disorientation to time • Need assist with food choices, paying bills • Anger and suspicion of strangers becomes problematic • Require assist to live in the community • Start needing compensation strategies to manage environment 55
Stage 5 • They can: • Manipulate familiar objects (comb, brush, toothbrush) • Need one step instructions with cues to complete tasks • Will do better with familiar activities • Sock sorting, silverware sorting, cleaning 56
Stage 5 • Some examples • May not be able to stand while completing tasks • Will do best with something they how to do: • Cleaning (dusting) • Ironing • Opening/closing jars • They aren’t going to do well with blocks, cones, etc. unless it’s a very concrete task 57
Stage 6: Severe cognitive decline (middle dementia) 5 substages as the disease progresses • Begin to see motor decline • 6A • Difficulty dressing; clothes on backwards • Need assist for ADLs • Able to remember name, not personal information • Less aware of recent experiences/surroundings • Won’t remember what they did in therapy yesterday 58
Stage 6 • 6B • Difficulty distinguishing familiar from unfamiliar faces • May accuse spouse of being an imposter • Unable to properly bathe unassisted; can’t regulate temperature • Decline in personal hygiene • 6C • Difficulty with the mechanics of toileting • Forgets to flush • unable to dispose of paper 59
Stage 6 • 6D • Urinary incontinence • Trouble with bowel control • Increased suspiciousness/delusions begin • Major changes in personality and behavior • Major changes in sleep pattern • Night wandering or restlessness • Tend to wander and get lost • Often still mobile • w/c or walking 60
Stage 6 • In general their world has narrowed • Only oriented to self • Have lost episodic and working memory • Procedural memory still present • Can still perform functional mobility with assist • Will reflexively respond to input • Causes combativeness 61
Stage 6 • Treatment suggestions: • Ability to attend is absent, need frequent cues • Everything must be 6 ‐ 14” in front of them to be noticed • Task must be directly in front where it can be seen • Limit activities to simple actions performed slowly • More likely to participate if task is related to a prior interest or hobby • Use validation techniques 62
Stage 7: Very severe cognitive decline (late dementia) • Characteristics: • Disoriented X 3 • Automatic reactions/responses • 7A • Ability to speak is limited to 6 words or fewer per day • Will seem completely unaware at times 63
Stage 7 • 7B • Speech is now limited to one word per day • May repeat the word over and over • 7C • Loss of ambulatory/psychomotor skills • Need assistance for mobility • Self feed with assist but will lose interest during the meal 64
Stage 7 • 7D • Unable to sit unsupported • Need arm supports on chairs • Lose ability to respond to environment • 7E • Loses ability to smile (facial expressions) • Don’t respond most of the time (caregivers/family) • Confuse wife with mother, misidentify family members • Confuse spouse with decreased family members 65
Stage 7 • 7F • No longer able to hold up head • No recognition/awareness of the presence of others • Will turn head in response to stimuli • May make facial movements 66
Stage 7 • Treatment suggestions: • Need to be within 8” to be noticed • Can complete 1 ‐ 2 steps of familiar tasks • Sensory cues can be helpful (aroma, music) • Hand over hand cues • Need frequent rests • Max cues need for simple directions 67
Stage 7 • Treatment examples: • Have them reach for the fork or the spoon (offer both) • Have them touch a body part • Give them a familiar object and ask them to use it (comb, toothbrush) • Watch and identify what they respond to and use that 68
Other treatment options • Therapists use explicit verbal instructions, corrective feedback and discovery learning • Dementia patients lose those abilities early in the disease process • Instead use procedural memory (automatic) • Error free learning 69
Error free learning • Repetitive practice of the same activity exactly the same way every time • High repetition, low variability • Remove errors to consolidate memory of correct performance (implicit memory) • Designed to eliminate or minimize inaccurate performance • Creates successful completion of the task throughout session • Eliminates frustration 70
Spaced retrieval • High repetition learning to facilitate recall of facts and strategies • Promote accurate recall of information over longer periods of time • Therapist provides cue, patient provides response • Start with short intervals and gradually increase • For example cuing to remember locking w/c brakes • You ask: “what do you need to do before you stand up” • Patient responds: “lock brakes” then perform task 71
Validation therapy • Based on theory the patient is responding to something from the past in the current time • At all times approach the patient in a validation resourceful way • Accept and validate what ever the patient says as correct • Confirm the patient’s inner world • Ask questions about what is going on • Try to relate therapy tasks to what the patient is experiencing • Helpful with disruptive behaviors 72
Games • Games can be effective treatment strategies • Element of fun so “not therapy” • Need to modify them as the dementia progresses • Prevent frustration • Ensure successful participation • Examples: • Checkers • Connect four • Jenga • Uno 73
Checkers • Targets: visual scanning, attention, planning, cognitive flexibility • Modifications: eliminate kinging rule • Quantifications: • Amount of time to play game • Number of jumps, missed jumps or multiple jumps • Physical: • Hand/eye coordination • Standing tolerance and balance • Trunk control 74
Checkers • Targets: visual scanning, attention, planning, cognitive flexibility • Modifications: eliminate kinging rule • Quantifications: • Amount of time to play game • Number of jumps, missed jumps or multiple jumps • Physical: • Hand/eye coordination • Standing tolerance and balance • Trunk control 75
Connect four • Targets: visual scanning, planning, cognitive flexibility • Modifications: omit diagonal series • Quantifications: • Number of opponent moves blocked • Number of moves before game won/lost • Physical: • Fine motor • Standing balance and tolerance • Trunk control 76
Jenga • Targets: visual discrimination, perceptual motor correlation, categorization, response to tactile feedback, error correction • Modifications: decrease number of levels, verbal prompts • Quantifications: • Number of levels achieved • Time to complete move(s) • Physical: • Fine motor control • Standing balance and tolerance • Trunk control 77
Uno • Targets: attention, divided attention, visual discrimination, low level decision making • Modifications: eliminate “uno” rule, omit wild card, focus only on number or color, verbal prompts • Quantifications: • Won/lost record • Time needed to respond • Number incorrect plays • Physical: • Fine motor • Standing balance and tolerance • Trunk control 78
Weighted blankets • Provide physical touch • Deep pressure used to regulate mood • Proprioceptive input about position in space • Decrease input to the parasympathetic system and fight or flight • Produces feelings of calm • 30# 79
Animal assisted therapy • Provides another input for stimulation • Improves mood and creates a calming effect • Some evidence suggests prevention of the progression of the disease • Positive effect on communication and coping 80
Activates based on severity • Based on mild, moderate and severe • Seven activity types: • Arts and crafts • Physical exercises • Cognitive (card games, puzzles) • Music and entertainment • manipulation/sensory/sorting: silverware sorting, jewelry sorting • Family/social reminiscence: photo albums, memories • Domestic/home making: folding laundry, making snacks 81
• Mild dementia: arts and crafts, cognitive • Moderate dementia: music and entertainment, domestic/home making • Severe dementia: physical exercises, manipulation/sensory/sorting • Severe dementia activities are not goal driven. 82
Sensory deprivation • As the disease progresses patients tend to withdraw and isolate themselves • Creates an atmosphere lacking stimulation • Increasing sensory input improves anxiety and increases engagement • Sensory deprivation • Results in poor communication and decreased motor coordination with disorientation • Use familiar/meaningful sounds, smells, textures, tactile input 83
Sensory deprivation • Examples • Music: • Simulates brain activity differently than speech • Tactile: • Objects that represent parts of previous lives and used to maintain identity • Telephone, hair brush, kitchen utensil, musical instrument, sports equipment • Aroma: • Lavender and lemon • Coffee, cinnamon, sawdust, floral 84
What About Exercise? 85
Exercise • In older adults exercise promotes strength and endurance • Increase strength and balance to decrease fall risk • Other goals: • Decrease the burden of care, decrease the amount of assist, promote mobility for as long as possible • Normal aging is associated with declines in gait, balance and endurance resulting in a higher fall risk • With dementia patients the decline is more progressive 86
Exercise • Research supports the use of exercise to improve cognition in older population and suggests there may be neuroprotective benefits • There is general agreement in the literature the exercise programs should be a combination of resistive training, walking and endurance • Programs need to be at least 4 ‐ 6 months to show improvement • The literature reports socialization during the exercise as beneficial • Can facilitate cognitive function • Combats depression (20 ‐ 86% are depressed) 87
Exercise What do the studies say? Guido, Hess, Polaha, etal (2016) • 4 month program combining moderate exercise (walking program) with social interaction resulted in: • Increased cognitive function and MMSE scores and slowed the rate of decline • Related socialization to higher cognitive function • Recommended resistance training and walking 88
Exercise Dawson, Judge, Gerhart (2019) • Moderate intensity exercise can positively effect several domains • Has been found to have neuroprotective benefits and resistance to neurodegeneration • Recommended a combination of resistive and aerobic exercises 89
Exercise Forbes, Forbes, Blake, et al (2015) • Cochran review • Promising evidence that exercise programs may improve the ability to perform ADLs in people with dementia • No benefit for cognition, neuropsychiatric symptoms and depression 90
Exercise Laufensch, Cor, Cyata (2012) • Clear evidence exercise contributes to healthy aging • Recommended a combination of endurance training, strengthening and balance training • Suggested exercise possibly increases blood flow to the hippocampus 91
Exercise Ohman, Souikko, Strandberg, Pike (2019) • Systematic review • Insufficient evidence exercise effects cognition • Found a positive effect on executive function and attention in patients with MCI • Some improvement with memory in patients with MCI • No effect on any of those in patients with Alzheimer’s disease 92
Exercise Toots, Leitbrand, Undelof, et all (2016) • Looked at exercise and individuals living in residential care facilities • Recommended task specific exercises due to decreased ability to generalize motor skills • Exercise appears to achieve gains in balance and decrease dependency upon others who are mobile 93
Exercise So …….what does this really tell us? • Yes, exercise helps with dementia but only in the early stages • Patients with MCI showed the greatest improvement • All of the studies used able to interact • Dementia patients begin having difficulty interacting with others early in the disease process • Patient’s in the later stages won’t be able to participate • Can’t follow the commands • Need concrete activities • Would require significant cuing for simple exercises (probably not familiar activities) 94
Exercise • These studies also tell us keeping these patient moving is beneficial • Decreased fall risk • Decrease need for assist • Gives them a purpose • Helps prevent boredom • Enables them to maintain independence longer • Motor function doesn’t deteriorate until later stages 95
Delirium • Acute confusional state, also called metabolic encephalopathy • Follows an acute disease or drug toxicity • Usually reversible • Can occur at any age but most common in the older population • Diagnosis often missed because it is believed to be dementia • 50% patients are misdiagnosed • Approximately 22% of dementia patients will develop delirium • 81% dementia patients who are hospitalized will experience delirium 96
Delirium • 10% of all older patients admitted to the hospital will become delirious • 50% of these patients will develop delirium • Delirium in combination with dementia more than doubles the risk for mortality 97
Dementia affects memory Delirium affects attention The most obvious sign of delirium is confusion 98
Common causes of delirium • Drugs (anti ‐ cholinergics, pyschoactivies, opioids) • Dehydration • Infection • UTI • Thiamin deficiency • Pain • Lack of sleep, poor sleep 99
Cases continued • Sensory deprivation • Stress • Presence of a urinary catheter 100
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