Evidence Based Assessment and Treatment of Dementia Effective - - PowerPoint PPT Presentation

Evidence‐Based Assessment and Treatment

• f

Dementia

Effective Interventions to Improve Quality of Life and Achieve Functional Goals through All Stages of Dementia

1

Objectives

• Identify the stages of dementia and provide two

treatment strategies for each.

• Recognize cognition, declarative memory and

procedural memory and relate to functional levels.

• Outline the neuro‐anatomical changes that occur

with dementia, the different forms of dementia and correlate this information to patient presentation.

• Describe causes of unwanted behavior such as

wandering and provde three alternatives for redirection.

2

Objectives

• Explain the causes of decreased initiation and two

methods of compensation.

• Utilize the role of exercises in treatment and

prevention of decline with dementia.

3

Dementia

4

Confusion is contagious You get it from your patients

5

• Dementia was discovered in 1906 by Dr. Alois

Alzheimer

• Did an autopsy on a woman who had experienced

language problems, unpredictable behavior and memory loss

• Discovered the amyloid plaques and neurofibrillary

tangles Fall risk factor no matter what environment.

• Incidence of falling with dementia is 2‐3 times

greater than without cognitive decline

6

Dementia: a decline in memory and other cognitive abilities

form a previously highest level of functional to an impaired functional state

• Characterized by an inability to make new memories and loss of

existing ones

• Characterized progressive deterioration of memory and other

cognitive domains

• Patients develop behavioral disturbances as the disease

progresses

• There is a strong association with depression
• Quality of life deteriorates with progression of the disease and

the need for assist increases

• 80% will develop neuropsychiatric symptoms
• 45‐80% will suffer from pain at any given time
• The most common form is Alzheimer’s disease with vascular

pathology 7

• Pathological changes:
• Cerebral atrophy
• Memory loss
• Amyloid plaques
• Neurofibrillary tangles
• Location (in order of severity)
• Medial temporal lobes
• Basal temporal lobe
• Frontal lobes

8

• In retrospect the dominant early feature is a subtle

loss of interest or withdrawal from some previous activities and interests.

• Followed by memory loss
• Decline in cognition
• Gait disturbances happen later
• Development of gait disturbances is an indication there

is something else going on

9

Dementia and sleep

• Sleep disturbances are common in the elderly

population

• Disturbed sleep is a major problem with dementia

patients

• A high number will experience it
• Differences in sleep patterns are more varied in

earlier stages

• Become more severe as the disease progresses
• Insomnia is often co‐morbid

10

Dementia and napping

• Nappers have significantly higher medical burdens,

body mass index and higher rates of cognitive impairment

• Longer and more frequent naps are associated with

poor cognition and depression

11

Dementia and depression

• Depression is very common in MCI and the early stages
• f dementia
• The rate of depression is higher in MCI and dementia

patients than that of those with normal cognition

• Evidence suggestion early life depression can be a risk

factor for dementia

• Later life depression is an early indicator for dementia
• Both conditions show similar neurobiological changes
• White matter disease

12

MCI (mild cognitive impairment)

• Occurs between forgetfulness and dementia
• Transitory stage between the cognitive changes of

dementia and normal aging

• Criteria for diagnosis:
• Self reported memory problems with corroboration

from someone else

• Measurable memory impairment on standard testing

(MMSE)

• No impairments in reasoning, general thinking skills or

the ability to perform daily activities

13

MCI

• Tend to overestimate cognitive deficits where

dementia patients will underestimate

• Usually progresses to dementia within 5 years
• Able to live at home and function normally but if

tested will score lower than control groups

• A quarter of these people will remain stable and

never progress to dementia

14

Types of dementia

• Alzheimer’s dementia
• Lewy body/Parkinsonism dementia
• Vascular dementia
• Multi‐infarct dementia
• Binswangers dementia
• Intercranial hemorrhage
• Cerebral amyloid angiopathy
• Frontal lobe dementia
• Crautzfeldt‐Jakob dementia

15

Causes

• Amyloid plaques
• Neurofibrillary tangles
• Lewy bodies
• Vascular changes
• The presentation depends upon the cause
• Multiple causes can co‐exist

16

Alzheimer’s dementia

• Most common form
• Caused by the development of amyloid plaques and

neurofibrillary tangles (loss of brain cells in the hippocampus)

• Loss of brain cells is a normal part of aging but this is

excessive

• Results in dysfunction of inter and intra cellular processes
• Neuron deaths prevent communication between various

parts of the brain

• The changes can begin as much as 10 years before

behavior and cognitive changes are noted

• Inability to make new memories with a decline in

executive function

17

• Alzheimer’s dementia
• The earliest clinical feature is typically a subtle loss of

interest in or withdrawal from previous activities

• Followed by memory loss of recent events
• Then word finding difficulties, (anomia, aphasia)

resulting in decline in verbal communication

• Then the behaviors:
• Wandering
• Hoarding
• Paranoia and accusatory statements
• Sexually inappropriate
• Agitation and aggression
• Failure to recognize family members
• Unusual activities
• Gait impairment
• Incontinence

18

• Lewy body dementia
• Umbrella term combining Parkinsonism dementia

and Lewy body dementia

• Formation of intraneural inclusions called Lewy

bodies in the substania nigra and widely spaced throughout cortical and subcortical structures

• There is a difference in the timing of onset of

cognitive and physical deficits compared to Alzheimer’s (physical starts much sooner)

• Usually misdiagnosed at first
• Multiple physician visits and consults
• Patients are often younger (55+/‐ 12 years) and

predominantly female

19

Lewy body dementia

• Early symptoms
• Visual hallucinations
• Depression
• Difficulty with problem solving
• Gait difficulties
• Tremors and stiffness
• Sleep disorder
• Psychiatric deficits present early on
• Delusions
• Someone stealing from them
• Fear of being in danger
• Spousal infidelity

20

Lewy body dementia

• Progresses to Parkinsonism with decreased

cognition

• Develop night behaviors

21

Vascular dementia

• Vascular brain injuries proceed and promote the

neurodegenerative changes

• There is an overlap between vascular disease and

Alzheimer’s documented in the literature

• 50% of the elderly population have vascular

pathologies

• Multiple microinfarcts and macroinfarcts
• Cerebral cortex
• Vascular watershed
• Basal ganglia

22

Vascular dementia

• Other vascular contributions
• Anatomic defects
• Dysfunction of the blood brain barrier
• Insufficient cerebral blood flow (MCI)
• Damaged cerebral blood vessels
• The end result is damage to white matter with

cognitive decline

• Other deficits depend on what other areas of the

brain are involved

• Risk factors: HTN, HLD, DM, tobacco, obesity, A‐fib

23

Other forms

Binswangers dementia

• Small vessel dementia associated with chronic HTN

and older age

• Subcortical vascular dementia
• Chronic HTN changes the tension in the smooth

walls of the cerebral blood vessels

• Basal ganglia, thalamus, internal capsule
• Patient’s are younger: 54‐66 years of age
• Characterized by loss of memory, intellectual

decline, mood changes

24

• Usually first diagnosed as mental changes after a

CVA

• Physical symptoms:
• Multiple TIAs
• Ataxia
• Bradykinesia
• Hyperkinetic perseveration of movements
• Decline in mental function but retail episodic and

declarative memories

• Associated with falls, seizures, fainting, urinary

incontinence

25

• Multi‐infarct: several cortical or subcortical infarcts

are present, causes a stepwise deterioration

• Cerebral amyloid angiopathy: multi‐infarcts with

recurrent hemorrhaging

• Frontotemporal dementia: prominent atrophy of

the frontal and anterior lobes

• Behavioral changes and inappropriate disinhibition

behaviors occur early

• Pick’s disease
• Inclusion bodies and protein tangles
• Develop language dysfunction earlier

26

Frontotemporal dementia (cont.):

• Term for a group of neurodegenerative disorders

characterized by progressive deficits in language, executive function and behavior

• Usually <65 y/o at onset
• Mimics psychiatric disorders

27

Crautzfeldt‐Jakob dementia

• Brain disease where preon proteins begin to

deform

• Malformed proteins destroy brain cells
• Characterized by rapid decline
• Rare: one in one million
• Symptoms:
• Decreased thinking and reasoning
• Involuntary muscle movements
• Mood changes

28

Crautzfeld‐Jackob continued

• Gait impairment
• Depression
• Rapidly worsening confusion
• Double vision
• Hallucinations
• Muscle stiffness

29

• 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
• 1st 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

Predisposing factors

• Brain disorder (CVA, PD, dementia)
• Advanced age
• Sensory impairment (hearing, vision)
• ETOH intoxication
• Drug use (3+)
• Poor nutrition (low sodium)
• Unfamiliar environment

101

Predisposing factors continued

• Anemia
• Multiple room changes in short period of time
• Excessive noise
• Bad lighting
• Recent exposure to anesthesia
• Especially if also exposed to prolonged use of anti‐

cholingerics

• Post‐op use of opioids for pain control

102

Pathophysiology

• Reversible impairment of cerebral oxidative

metabolism

• Multiple neurotransmitter disorders
• Stress that deregulates symphathetic tone resulting

in downward regulation of parasympathetic tone

• Impairment of cholingeric function

103

Presentation

• Difficulty maintain attention
• May have hallucinations, delusions, paranoia
• Confusion about day today events, worse at night
• Either:
• Irritable, agitated, hyperactive and hyper alert
• Quite, withdrawn, lethargic

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Types of delirium

Hyperactive

• Hallucinations
• Pacing and restlessness
• Agitation
• Mood swings

Hypoactive

• Appear to be dozing
• Unusual drowsiness
• Sluggishness
• Lack of movement

Mixed

• Components of both that switch back and forth

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Comparison of dementia and delirium

• Reversibility
• Dementia: no, progressive disease
• Delirium: usually, treat the underlying cause
• Duration
• Dementia: gradually becomes permanent
• Delirium: days to months with sudden onset
• Cause:
• Dementia: varies, but generally a brain disorder
• Delirium: many (dehydration, medications, infections)

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• Onset
• Dementia: gradually with minor symptoms that progress
• Delirium: within days/hours; severe at onset
• Orientation to place/time
• Dementia: eventually disappears
• Delirium: maybe
• Ability to attend and focus:
• Dementia: able until later stages
• Delirium: severely impaired

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• Night symptoms:
• Dementia: yes
• Delirium: yes
• Need for immediate medical attention:
• Dementia: rarely
• Delirium: yes
• Symptom fluctuation:
• Dementia: moderate fluctuations
• Delirium: frequently fluctuates

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Medication management

• low dose haloperidol (Haldol) for agitation or

psychotic

• Second generation antipsychotics
• Resperidorz (resperdal)
• Olanzapin (Zyprexa)
• Quietapine (seoquel)
• Benzodiaziprins
• Lorazeprin (Ativan)

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Problematic Behaviors

110

Behavior

• Behavioral abnormalities begin around stage 5
• Unless frontal lobe dementia, then begin early on
• Also called neuropsychiatric symptoms,

neurobehavioral symptoms, behavioral and psychological syndrome

• Care givers cite this as the most distressing aspect
• f care
• Responsible for greater health care costs and long

term placement

• 50% of dementia patients will demonstrate

aggression and disinhibition

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Behavior

• 50‐90% will demonstrate apathy and depression

(often overlooked because not dramatically evident)

• 90% of all dementia patients will demonstrate

some level of behavioral disturbance

• Multiple causes:
• Loneliness
• Boredom
• Need for meaningful activity
• Unmet needs (inability to communicate needs)
• Discomfort/pain
• Inability to respond to environment

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Behavior

Behaviors include:

• Wandering
• Wandering without clothes
• Paranoia and/or accusatory
• Sexually inappropriate
• Agitation and aggression
• Hoarding
• Overaction
• Restless, night‐time restlessness
• Sundowning

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Behavior

• More specific causes:
• Biology:
• serotine deficiency, decreased dopamine metabolism
• Psychosocial/environmental:
• Unintentional continuous confrontation
• Constantly confronted with limitations caused by the

dementia

• Lacks the cognition to deal with the situation
• Altered sense of environment
• Disorientation
• Word finding difficulty
• Impaired facial recognition

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Behavior

• Causes continued
• Somatic:
• Pain
• UTI
• Co‐committent somatic/mental disease
• Left hemispheric ischemia results in organic affective

disorder which causes liability, agitation and delusions

• Unmet needs:
• Patient is attempting to communicate physical or

psychological distress

• Being cold
• Boredom
• Needing to be changed

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Behavior

Causes continued

• Verbal and vocal behaviors are associated with pain,

discomfort, being alone, wanting attention

• Physically aggressive behaviors result when they’re not

engaged in an activity and/or unable to cope with situation

• Night‐time wandering can result from disturbance of the

sleep/wake cycle

• Hoarding is caused by a need to control
• The more they lose, the more they want something to

hang on to

• Having things makes them feel safe

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Behaviors

Causes continued

• Blamers/accusers are blaming others because they

fail to accept what is happening to them

• Behaviors associated with restlessness include:
• Wandering, agitation, aggression, anxiety
• Verbal/physical aggression
• Attempts to leave home/facility
• Physical signs of anxiety
• Visual and auditory impairments crease delusions

and hallucinations

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Behavior

Causes continued

• Wandering and pacing can be goal driven
• They are trying to get somewhere

Wandering

• Refers to seemingly aimless or disoriented ambulation
• Common factors: cognitive impairment and moving

through space

• In SNFs peak occurrence times are between 5:00‐

7:00pm

• Behavior is considered wandering if walking or using w/c

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Behavior (wandering)

• Occurs in individuals who score 13 or less on the MMSE
• Alzheimer’s patients are more likely to wander than those

with vascular dementia

• If asked will say they are looking for something (spouse,

place, etc.)

• Positive emotional expression is associated with wandering
• Negative emotional expression and higher cognitive

function is not

• Wanders will have moderate to severe depression
• Pre‐morbid extroversion is a negative predictor
• Best management to maintain them in a safe walking area

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Sundowning

• Symptom of Alzheimer’s dementia characterized by

worsening of confusion and agitation in the late afternoon and evening

• May be related to increased activity of shift change
• Behaviors:
• Confusion
• Anxiety
• Aggression
• Ignoring instructions
• Pacing/wandering

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• Aggravating factors:
• Fatigue
• Low lighting
• Increased presence of shadows
• Disruption of sleep/wake cycle
• Difficulty separating reality from dreams
• Unmet needs
• Depression
• Pain
• boredom

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• Prevention
• Some studies suggest a low dose of melatonin at

bedtime

• Limit the amount of activity during the day to prevent

fatigue

• Maintain a predictable routine/schedule of meals and

bedtime

• Limit caffeine and sugar to the morning
• Night lights
• Familiar items when in a new or different environment
• Play relaxing music or nature sounds
• Schedule any significant activity (MD appt) in the

morning

• Decrease evening stimulation
• Noise, activity, visitors

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• Non‐verbal behavior of others can be transferred to

the Alzheimer’s patient

• Creates stress and confusion
• Allow the person to pace but maintain safety
• Medications:
• Block acetylcholine
• Toltidine (urinary incontinence)
• Anti‐depressants
• Anti‐psychotics
• Anti‐spasmatics
• Anti‐vertigo
• Parkinson’s medications

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Some examples

• Not taking food or water
• May have gastritis or other stomach issue
• Associate food intake with pain so refuse to prevent pain
• Not wanting to bathe
• Possible reasons:
• Invasion of privacy
• Fear of water (cold water)
• Don’t want water splashing into face
• Discomfort in the BR setting
• Easily become chilled
• Depth perception issues
• Memory loss
• Don’t want to bathe because they believe they just

bathed 124

Anosognosia

• Unawareness of deficits
• They don’t think they have a problem
• Creates poor awareness of their ability to perform

ADLs and mobility

• Will overestimate
• The frequency of occurrence increases as the

dementia progress

• More patients will demonstrate it
• More severe in those already demonstrating it
• It is a characteristic symptom of early dementia

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Anosognosia

• Unknown if they are aware of their behavior
• Literature suggests the behaviors worsen as the

anosognosia worsens

• Examples:
• Getting out of bed to go the BR and falling repeatedly
• Driving
• Trying to get out of a chair to go somewhere and falling
• Insisting they can do something by themselves when

they can’t

126

Management

• The first defense is prevention
• Create an environment that is user friendly
• Keep them busy
• Maintain routines
• Avoid unintentional confrontations
• Maintain the familiar

127

Management

Any change to the routine can be a trigger

• Change in meal time
• Change in food choice
• Getting up later or earlier
• Construction in the facility
• Change in bath day/time
• New person in enviornment

128

Management

• Validation therapy
• Accept what the person is saying no matter what
• Allow them to expression emotions
• Ask specific questions:
• About the behavior
• What is happening in their world
• How do they feel

129

Management

• Assess for signs of pain/discomfort
• Being cold
• Being hungry
• Needing to be changed
• Nightmares
• Feeling threatened

130

Management

• Assess the environment
• Move them away from possible causes
• Did something change
• Did something happen
• Something we perceive as normal can be perceived

as abnormal, threatening or challenging

131

Management

Redirection

• Despite our best efforts behaviors occur
• Something as simple as being bumped in the dining room or

getting food late can cause them

• Need to redirect as soon as possible to prevent

escalation

• Increased risk of injury to patient, caregiver, staff
• Assess situation and move them away from stimulus
• Over stimulation (noisy dining room)
• Noise
• Lots of movement
• Already feel insecure in environment

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• Be calm (validation therapy)
• Use what they say to redirect
• Try to relate current behavior to something more

appropriate

• If going somewhere offer to take them
• If they need something take them to go get it
• Will respond better to someone familiar

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Dementia, depression and alcoholism

• In the early stages dementia can resemble

depression and alcoholism

• Symptoms of dementia and depression can occur in

those with alcoholism

• Alcohol damage causes mild to moderate memory

impairment, slow cognition and decline in executive function similarly to dementia

134

Comparisons

• Behavior
• ETOH: fluctuates
• Dementia: gradually decreases
• Depression: results from an event
• Memory
• ETOH: confusion/loss
• Dementia: decreased short term
• Depression: recognizes difficulties

135

• Language
• ETOH: slow, maybe slurred
• Dementia: deteriorates over time
• Depression: slow but normal
• Response to deficits:
• ETOH: may not pay attention to
• Dementia: changes early on
• Depression: notices and worries

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• Motor skills
• ETOH: frequent falls
• Dementia: decreases with progression of disease
• Depression: none specific
• Sleep
• ETOH: drunken sleep
• Dementia: gradually disrupted
• Depression: too much or not enough

137

• Agitation
• ETOH: anxiety
• Dementia: gradual increase, worse with disease

progression

• Depression: restless

138

Caregivers And Dementia

139

• The presence of dementia effects the entire family,

not just the patient

• Physical, financial, emotional challenges
• Family dynamics and roles change
• Financial
• In 2015 Medicare payed $57,407 annually per patient

for dementia

• Doesn’t include out of pocket expenses which can run

into thousands of dollars

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• Paid care givers
• The average cost of a paid caregiver is $21.25/hr
• 8 hours: $170
• 40 hours: $850
• One month: $5,100
• One year: $61,200
• On average a SNF costs $245/day
• One month: $7350

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Statistics

• 83% of all caregivers are family members
• Usually an elderly spouse
• 1 in 3 are 65 or great years of age
• 2/3 are women
• About ¼ of them will be concurrently be caring for a

parent and child under 18

• 42% provide an average of 9 hours of care per day
• 53 % say it is more challenging to care for a dementia

patient than raise a child

• Few caregivers are given formal training or made aware
• f resources

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Caregiver characteristics

• Have elevated rates of depression
• Tend to ignore their own health needs
• Have increased vulnerability for disease due to

chronic stress

• Diminishes their ability to provide optimum care
• Have a higher level of morbidity
• Have to deal with higher levels of grief and

bereavement while providing care

• Demented individuals often die in LTCs

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• Believe those around them (family members) don’t

understand the burden

• Feel a lack of support
• <40% will utilize adult day care, respite care or

attend support groups

• Report feeling isolated and loss of social life
• Have increased stress and frustration when

behavioral symptoms begin

• Face regular uncertainty about what to do next

144

Home modifications

• Remove throw rugs and create a clutter free

environment

• Increase lighting throughout the home
• Install locks and latches, deactivate automatic locks
• Store foods, sharp objects, tools, cleansers and

firearms in locked cabinets, bins, etc.

• Modify the BR: grab bars, DME
• Paint with contrasting colors to separate items from

back ground

• Brightly paint grab bars and hand rails for easy

identification

145

• Outlet covers
• Remove dials from the stove
• Memory aides
• Label household items
• Put pictures on cabinets and drawers of what is in them

146

Dementia gait

• Gait characteristics can be used to identify

dementia patients in earlier stages

• Dementia gait characterized by:
• Decreased stride length
• Decreased gait speed
• Increased double stance duration
• Other deviations:
• Difficulty with direction changes
• Difficulty with obstacle avoidance
• Irregular steps

147

• Gait disorders are more prevalent in dementia

patient than in normal aging

• Slower gait is associated with shrinking of the

hippocampus

• There is an element of cortical control in older

adult ambulation

• Motor control: basal ganglia, cerebellum, primary

motor area

• In older adults there is cortical involvement in

processing information

• Cognition involved to maintain attention to task

148

Cognitive control of gait

• ADT: adaptic control of thought
• Identifies 3 phases of though in motor activity
• Declarative: selection of relevant information for

the task

• Relies on intellectual abilities and attention
• Knowledge compilation phase: transformation of

knowledge into procedure

• Elaboration of the motor program
• Procedural phase:
• Adjustment and automation of task

149

• Procedural phase enables automatic, unconscious

triggering of underlying motor programs in healthy adults

• Limited attention demand in younger population
• Attention: multidimensional cognitive function
• Combines executive functions and processing

information

• Limited resource that may be overloaded by

multiple completing task

• Results in decline in all tasks

150

• Two types of interference for task completion
• Capacity: control overload due to involvement of

different processes (cognition and motor) that require attention

• Structural: peripheral overload to inability to

physically perform multiple tasks simultaneously

151

• Test dual task to identify dementia
• Dual task:
• Testing 2 domains at the same time (gait and

cognition)

• Creates divided attention
• Measure gait speed while counting backwards
• Dementia patients will have declines with both
• Stride to stride variability more specific identifier
• Can also test rhythmic tasks (toe tapping, finger

tapping)

• Will be performed slower
• Inability to repeat alternate movements of LEs is

associated with high risk for cognitive decline

• Stride to stride variability more specific identifier

152

Medications

• There is no medication that cures dementia
• Used for management of the symptoms
• Limited by side effects, short duration and need for

monitoring to prevent toxicity

• Improvement lasts 6‐12 months
• 2 groups
• Acetylcholinesterase inhibitors
• NMDA blockers

153

Other reasons for medications

• Anti‐depressants
• Anti‐psychotics
• Acute psychosis
• Increase risk for CVA
• Anti‐anxiety
• Increase daytime sleepiness
• Can worsen memory
• Associated with increased risk of dementia progression
• Mood stabilizers
• Sleep aids

154

Acetylcholinesterase inhibitor

• Cognex, Aricept, Reminyl, Exelon (for confusion)
• All work similarly
• Delay the breakdown of acetylcholine
• Allows the cells to continue to communicate with each
• ther
• Contraindicated by liver disease
• Side effects: nausea and vomiting
• Once started must continue indefinitely
• Causes abrupt possibly severe cognitive and behavioral

declines that can’t be reversed by resuming the medications

155

NMDA blockers

• N‐methyl‐D‐assartale blockers
• Prevent over‐excitement of NMDA receptors by

glutamate

• Excessive levels of glutamate is thought to be

responsible for decreased neuron function and death

• Memantine

156

Other medications

• Also used to manage behavioral symptoms
• Antipsychotic drugs:
• Haldol, Risperdal, Seroquel, Zypreha
• Manage psychosis and agitation
• Anti‐depressants
• Anti‐anxiety
• Valium, Buspor

157

Predictors

• You can’t prevent dementia
• You can predict who might become demented
• Medical imaging can identify vascular problems
• Contributing factors:
• Age (>65)
• Down’s syndrome
• Genetics
• Exposure to heavy metals
• Obesity
• Tobacco use
• Depression
• Alcoholism
• Severe or repeated head trauma

158

Predictors

• Activity level may be an indirect indicator
• Exercise is effective in improving memory in non‐

demented people:

• Other contributors:
• HLD: some research indicates statins decrease risk
• Poor diet
• Poor sleeping patterns
• Multiple CVAs

159

Prevention

• Activities that can decrease the risk of dementia
• Regular, moderate exercise
• Regular participation in challenging mental activities

and/or learning new things

• Healthy diet
• Treatment of HTN or other co‐morbidities
• Alzheimer's patients almost always have another

chronic condition (HTN, CAD, DM, osteoporosis)

• Treatment of depression
• Strong social support

160

Case Studies

161

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