Dementia diagnosis
- impaired short-term memory
- impaired long-term memory
- at least one of those: impaired abstract thinking, personality change, impaired judgement, impaired constructional abilities, impaired language, impaired praxis, or impaired visual recognition
Dementia substypes
- subcortical
- cortical
- mixed
- other
- pseudodementia
General symptoms of Dementia
- memory failure
- disorientation
- lapses in judgement
- difficulty performing activities of daily life
- difficulty performing mentally challenging tasks
- misplacing things
- apathy and loss of initiative
- changes in mood
Cortical dementia
- alzheimer’s
- Pick’s disease
- Primary progressive aphasia
Subcortical dementia
- parkinson’s
- huntington’s
- progressive supranuculear palsy
- HIV encephalopathy
mixed dementia
- vascular dementia
- lewy body dementia
other dementia
- normal pressure hydrocephalus
- Creutzfeldt-Jakob disease
Parkinson’s Disease
A degenerative disease affecting nuclei in the midbrain and brain stem.
Primary symptoms: disturbances of movement
Neuropathology: deterioration not dopaminergic neurons in the basal ganglia and brainstem (called substantial nigra)
PD symptoms
- resting tremor (“pill rolling” tremor of the hands often in the first sign of tremor to appear)
- muscle rigidity (the person may complain of unusual stiffness and difficulty moving)
- slowness of movement and difficulty initiating movement (bradykinesia)
- postural instability (impaired balance)
PD communication deficits - early
Weak voice, increased speech rate and imprecise articulation, stutter-like syllable repetitions; micrographia (small writing)
PD communication deficits - middle
Drooling and swallowing impairments
PD communication deficits - late
Comprehension and attention
Huntington’s Disease symptoms
- chorea (involuntary writhing movements)
- cognitive decline
- neurobehavioral symptoms (personality changes, depression, agitation, paranoia, delusions)
Huntington’s cognitive and communication deficits
Dysarthria due to chorea is the most common language symptom; cognitive impairments include sustained attention, memory, and judgement
Progressive supranuclear palsy - symptoms
- Similar to PD - rigidity and slowness of movement, but without tremors
- rigidity is primarily in neck and trunk, rather than in limbs
Progressive supranuclear palsy - cognitive and communication deficits
- dysarthria appears early and can be severe at that stage
- progressive dementia appears in mid to late stages
HIV - later symptoms
- later symptoms (impaired perception, memory, intellect and language) more cortical
HIV - early symptoms
- early symptoms (weakness, slowness, rigidity, dyskinesia) are characteristic of extrapyramidal pathology
HIV cognitive and communication deficits - early
Subtle word retrieval effects, speech & reading comprehension impairments
HIV cognitive and communication deficits - mid
Motor speech impairments, comprehension impairment worsen
HIV cognitive and communication deficits - late
Speech output and comprehension limited to highly familiar materials
AD symptoms
- progressive deterioration of intellect
- first disturbances are in memory, reasoning, judgement, orientation, mood; increasing agitation, wandering off, incontinence as disease progresses
- eventually, almost cognitive function is grossly impaired
- usually pass away within 5-10 years from diagnosis
AD communication symptoms - early
- sounds: used correctly
- words: may omit a meaningful word, usually a noun, when talking in sentences; may report trouble thinking of the right word; vocabulary is shrinking
- grammar: generally correct
- content: may drift from the topic; reduced ability to generate series of meaningful sentences; difficulty comprehending new information; vague
- use: knows when to talk, although may talk too long on a subject; may be apathetic, failing to initiate a conversation when it would be appropriate to do so; may have difficulty understanding humor, verbal analogies, sarcasm, and indirect and nonliteral statement
AD communication symptoms - middle
- sounds: used correctly
- words: difficulty thinking of words in a category; anomia in conversation; difficulty naming objects; reliance on automatisms; vocabulary noticeably diminished
- grammar: sentence fragments and deviations common; may have difficulty understanding grammatically complex sentences
- content: frequently repeats ideas, forgets topic, talks about events of past or trivia; fewer ideas
- use: knows when to talk; recognizes questions; may fail to greet; loss of sensitivity to conversational partners; rarely corrects mistakes
AD communication symptoms - late
- sounds: generally used correctly, but errors are not uncommon
- words: marked anomia, poor vocabulary, lack of word comprehension; may make up words and produce jargon
- grammar: some grammar is preserved, but sentence fragments and deviations common; lack of comprehension of many grammatical forms
- content: generally unable to produce sequence of related ideas; content may be meaningless and bizarre; subject of most meaningful utterances is the retelling of a past event; marked repetition words and phrases
- use: generally unaware of surroundings and context; insensitive to others; little meaningful use of language; some patients are mute; some are echolalic
Pick’s disease - symptoms
- alternations in personality and emotion are first to appear (apathy toward former interests, difficulty with goal-directed behaviors, social inappropriateness)
- judgement and insight are impaired next, obsessive behaviors
Pick’s: differences from AD
- onset before age 65
- earlier personality change
- earlier roaming/wandering off
- impulsivity, lack of social inhibition
- hyper-oral behavior - overeating, putting items in mouth
- less early memory impairment than Alzheimer’s
- greater impairment in activities of daily living
- earlier language impairment
Pick’s language impairment
- word retrieval, confrontation naming, circumlocution, overuse of generic words, echolalia, verbal stereotypies
- speech and reading comprehension impairment shows up in mid-stages
- late-stage patients are essentially mute
Mixed dementia: vascular dementia
- 2nd most common cause of dementia (15-20 of all cases)
- often co-morbid with AD (~75%)
- criteria: memory impairment, cognitive deficits in social or occupational functioning, focal neurological signs
- dementia symptoms due to vascular dysfunction, in the form of stroke/TIA
Mixed Dementia: Lewy body dementia
- 3rd most common cause of dementia (10-15% of cases)
- combination of parkinson’s and AD damage types
Lewy body symptoms
- parkinson’s motor symptoms
- memory, attention, and visuospatial deficits
Other: Normal Pressure hydrocephalus symptoms
- dementia
- gait disturbance
- incontinence
Other: Normal Pressure hydrocephalus cognitive and communicative deficits
- slowed mental function
- attentional and memory impairment
- emotional dullness
Other: Creutzfeldt-Jacob disease symptoms
- dementia & neuromuscular impairment, with rapid deterioration
- patients are eventually completely unresponsive to stimulation
Pseudodementia symptoms
symptoms of depression can mimic those of dementia
- identifiable onset, and rapid symptom development
- low effort on cognitive tests
- high variability on test performance from test to test and day to day
Assessment for screening depression in dementia
- geriatric depression scale
- cornell scale for depression in dementia
Primary progressive aphasia
- slowly progressing language impairment
- can be co-morbid with AD
3 subtypes of PPA
- PPA-G (Agrammatic/non-fluent): problem with word order and word production
- PPA-L (Logopenic): problem with word finding
- PPA-S (Semantic/Semantic dementia): problem with word understanding
Assessment - comprehensive batteries
- Arizona Battery for Communication Disorders of Dementia (ABCD - most common measure)
- Boston Diagnostic Aphasia Examination (BDAE)
- Western Aphasia Battery (WAB)
-Communicative Activities in Daily Living-Second Edition (CADL-2)
Assessment - Comprehension and retention of spoken language
- Peabody Picture Vocabulary Test
- Discourse Comprehension Test
Assessment - Speech production
- Boston Naming Test (BNT)
- BDAE cookie theft
Management - early stages
- memory impairments: affects declarative memory and prospective memory
- impaired language and communication: sufficient to manage routine daily life interaction
- anxiety and depression
- behavior change: apathetic, loss of interests in activities previously important to them
- denial: minimize or deny their impairment
- excess disability
- sleep disturbances
- health
Management - middle stages
- troublesome behaviors: memory disturbance, catastrophic reaction, demanding and critical behavior, night waking, hiding things, physical violence, delusions
- insight, judgement and orientation: become salient, supervisions and restrictions required
- physical dependence
- language and communication: become one-sided, no initiation, response limited to trivialities and automatisms
Management - late stage
working with caregivers
Intervention - early stage
- memory
- confusion
- impaired communication
- group activities
Intervention - early stage - memory
spaced retrieval, external memory aids
Spaced retrieval
- choose one or more functional targets or goals
- ask a question to elicit the target response. pick another target if the person answers correctly; tell or show them the right answer and have them repeat it back if the person does not get it right
- ask again 15 seconds later. if they can’t recall, give the answer and have them repeat it back. try again in 15 seconds, if it’s still not correct, spaced retrieval may not be appropriate
- when the answer is given correctly, double the time interval and ask the question again. repeat this step each time the answer is correctly given
- if the answer is incorrect, give the right answer immediately and ask the question again at the last correct time interval
- in between asking questions, fill the intervals with other therapy activities or conversation - though it’s best to choose activities or topics that have little to do with the memory target
external memory aids
- alarms
- timers
- notebooks
- calendars
- journals
- computers
Internal aids
- repetition
- making association
- chunking
- first-letter cues
- visualization
Memory book
uses photos and descriptions of names, people, places etc. that a person with dementia often forgets
Intervention - early stage - confusion
lots of external labels and directors
- ex.) large calendars, labels on drawers, items kept in consistent locations
Intervention - early stage - impaired communication
- compensatory treatment: focusing on teaching the individual specific methods and skills to compensate for or overcome deficits
- restorative treatment: direct therapy aimed at improving or restoring impaired functions
Intervention - early stage - group activities
stimulate self expression, stimulate cognition, promote social interaction, enhance feelings of self-worth
Intervention - middle stages
- troublesome behaviors
- communication
- reminiscence
Intervention - middle stages - troublesome behaviors
six R’s
- restrict
- reassess
- reconsider
- rechannel
- reassure
- review
Intervention - middle stages - communication
focus caregiver interactions on adapting to level of patient function and reinforcing/practicing successful communicative strategies
Intervention - middle stages - reminiscence
using intact episodic memories to promote conversation and social interaction
Intervention - late stages
assisting caregivers, through strategies for environmental control and behavioral management
