Aging and Dementias

DEMENTIAS: Definition & APA diagnostic criteria:
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DEMENTIAS: Definition & APA diagnostic criteria:
I) Definition: "Dementia is a condition of chronic progressive deterioration of intellect, memory, and communicative function resulting from organic brain disease" (Bayles, K.A. 1984).
II) American Psychiatric Association Diagnostic criteria for dementia:
1) evidence of impairment of STM & LTM and
2) at least one of the following: a) impairment of abstract thinking, b) impairment of judgment & c) disturbances of higher cortical functions: aphasia, apraxia or agnosia
3) disturbances in 1 & significantly interferes with work or social activities or relationship with others.
4) Not occurring exclusively during the course of delirium
5) organic brain syndrome related to the disturbance or evidence of absence of nonorganic factor
III) Implications of APA criteria for early detection of dementias
Distribution by probable cause:
-Alzheimer's Disease: 55.6%
-Stoke: 14.5%
-Multiple causes: 12.2%
-Parkinson's Disease: 7.7%
-Brain Injury: 4.4%
-Other causes: 5.5%
Signs of Alzheimer's disease in brain tissue:
-senile plaques and neurofibrillary tangles
-plaques and tangles appear in the brains of healthy aged adults, but usually to a much lesser extent and in restricted regions
CAUSAL FACTORS ASSOCIATED WITH THE DEMENTIAS:
1) Alzheimer's disease
2) Pick's disease
3) Movement disorders: PD, HD, PSNP, & WD
4) Vascular disorders: MID
5) Toxins: drug over dose
6) Brain tumors
7) Trauma: open & CHI
8) Infections: brain abscess, bacterial meningitis, encephalitis, neurosyphilis, Creutzfeldt-Jakob disease
9) Multiple sclerosis
DEMENTIA TYPES & RELATED DISORDERS:
1) Reversible & Irreversible dementias
2) Cortical Dementias: DAT & dementia in Pick's disease
3) Subcortical dementias: Parkinson's dementia, dementia in Huntington's disease, Supra nuclear palsy, & wilson's disease
4) Mixed dementias:
Multi infarct dementia
Creutzfeldt-Jakob disease
Korsakoff's syndrome
5) Related disorders: Aphasia & slowly progressve aphasia
pseudo dementia
right hemisphere damage
Reversible dementias resulting from:
-drug toxicity, metabolic imbalances, infections, tumors, normal measure hydrocephalus, alcohol abuse, neurosyphilis, epilepsy & pseudo dementia
Irreversible dementias:
-DAT, MID, Pick's disease, Huntington's disease, Wilson's disease, SNP, C-J disease & Korsakoff's syndrome
CORTICAL DEMENTIAS: Dementia of Alzheimer's Type (DAT) & Pick's Disease
I. Onset
II. Etiology
III. Course
IV. Language & speech
V. Memory
VI. Performance characteristics
VII. Physical characteristics
SUBCORTICAL DEMENTIAS: PD & HD
Onset
Etiology
Course
Language & speech
Memory
Performance Characteristics
Physical characteristics
SUBCORTICAL DEMENTIAS: SNP & WD
Onset
Etiology
Course
Language & Speech
Memory
Performance characteristics
Physical characteristics
MIXED DEMENTIAS: Korsakoff's, C-J Disease & MIDOnset Etiology Course Language & Speech Memory Performance characteristics Physical characteristicsRELATED DISORDERS: APHASIA, SLOWLY PROGRESSIVE APHASIA & PSEUDODEMENTIAOnset Etiology Course Language & Speech Memory Performance characteristics Physical characteristicsLINGUISTIC CHARACTERISTICS OF ALZHEIMER'S DISEASEStages: Early or mild stage, Middle or moderate stage, & Late or severe stage. Naming Verbal expression Comprehension Repetition Automatic Speech Writing ReadingDEMENTIA: DIAGNOSIS AND ASSESSMENTI. Conceptual Model: Dementia is a symptom complex that includes physical, social, cognitive, and communicative features. Multiple perspectives are required: professionals from medicine, nursing, social work, psychology, SLP & audiology will be involved. Communication assessment will be broadly based. II. Diagnosis & Initial Evaluation: Areas of evaluation (a) case history interview, (b) neurological & Medical eval, © behavioral assessment & (d) language & communication assessment III. Case History: Use an informant (family, friend or care giver). History to include areas of health, psychological & cognitive status, Social and communication status. Alzheimer Dementia Risk Questionnire.Dementias: Diagnosis & Assessment (continued)-Neurological and Medical evaluation: Includes a series of lab tests. Results can rule out a variety of systemic diseases. -Behavioral Assessment: includes three areas, (a) performance on neuropsychological tests, (b) observation of behavior in naturalistic contexts, and © reports from family members. -Neuropsychological Tests: a) Mental status, b) Behavior rating scale, Intelligence, & Memory -Language & Communication Assessment: Use an assessment battery.Language and Communication Assessment Measures for use with Dementia PatientsLanguage Comprehension Pragmatics and Discourse Semantics Syntax Phonology Memory and LanguageArizona Battery for Communication Disorders of (ABCD) DementiaI. Sensory reception II. Receptive language III. Expressive Language IV. Receptive & Expressive V. Orientation & MemoryCommunication/Environment Assessment and Planning Guide-General Visual Environment -Personal Visual Environment Needs -General Auditory Environment -Personal Auditory Environment Needs -General Tactile & Olfactory Environment -Personal Tactile/Olfactory Needs -General Spatial Environment -Personal Spatial Environment -General Psychosocial Environment -Personal Psychosocial Environment NeedsBehavior Assessment Measures for Use with Dementia Patients-Weschler Adult Intelligence Scale -Wescler Memory Scale ® -Fuld Object Memory Test -California Verbal Learning Test -Benton Visual Retention Test -Stanford-Binet (Picture Absurdities) -Mini Mental -State Examination -Brief Cognitive Rating Scale -Global Deterioration ScaleCognition and Communication In Dementias: Approaches to Treatment Part I-Nun study: implications for prevention of DAT -Treatment for cognitive deficits -Direct Vs Indirect treatment approaches to communicationNun Study': Epidemiological investigation of DAT- David Snowdon, University of Kentucky scientist, has been studying 678 school sisters since 1986. -What kinds of people are most seriously ravaged by DAT ? Which people tend to escape relatively unscathed ? -Snowdon & colleagues have teased out a series of intriguing links between lifestyle & DAT - Genetic predisposition, stroke, & TBI - College education & active intellectual life may protective factors -a surprising result of the study: the way we express ourselves in language, even at an early age, can foretell our vulnerability to DAT. - Snowdon's analyses of short autobiographies of nearly 200 nuns revealed: 1) Sisters who had expressed the most positive emotions in their writing as girls ended up living longest, & 2) those on the road to DAT expressed fewer and fewer positive emotions.'Nun Study': Epidemiological Investigation of DAT: Snowdon, Mortimer, & Kemper analyzed the autobiographies of sisters written in their 20s and discovered: the number of ideas packed into their sentences was a powerful predictor of who would develop DAT 60 years later.-low idea density, high risk -high idea density, low risk -those who had taught for most of their lives showed more moderate declines than those who had spent most of their lives in service related tasks. -Strokes and other brain trauma might contribute to the dementia of DAT. -Diet may play a role in DAT: low concentration of floate (folic acid) in blood. Sisters with high level of floate showed little evidence of DAT in their brain (examined at post-mortem)Nun Study: Implications for prevention of DAT:-Head for cover - Stay in school - Mind games - Eat smart - Stay connected -Know your genesCOMMUNICATION AND ENVIRONMENTThree premises: 1) The ability to communicate is the single most important skill for the elderly to maintain 2) The physical and social environment where communication occurs influences the availability of partners, topics, and activities that generate conversation. 3) The environment of those with dementia is a crucial determinant of their well being.Definition of the environment:Environment is an "open system which is seen as a total, active and continuous process involving the participation of all aspects" (Ittelson, 1973, p 1). It encompasses factors such as physical environment, the individual, space, privacy, territoriality, and social environment.Communication-Impaired environment: Lubinski (1991):A communication-impaired environment is one where there are few opportunities for successful, meaningful communication. 1) lack of sensitivity 2) restrictive rules 3) few or no partners of choice are present 4) few reasons to talk 5) individuals perceive themselves as having little meaningful contribution to their environment through communication 6) a lack of private places 7) limited accessibility 8) the environment is sensory-confusing and depriving 9) communication-impaired environment is socially stagnant 10) the environment does not support particular needs of the caregiver.ASSESSMENT OF THE ENVIRONMENT IDENTIFICATION STRATEGIES-Goal: Assessing the physical and psychosocial dimensions of the environment in which the demented individual lives. -Professionals involved in assessment: Nurses, physicians, social workers, SLPs & audiologists and professionals who were trained in human engineering and environmental psychology. -Identification Tools: 1)Environmental checklists and 2) Communication Environmental Assessment and Planning Guide (Lubinski, 1991)SUGGESTIONS FOR IMPROVING THE GENERAL PHYSICAL ENVIRONMENT: The physical environment should be designed to maximize the individual's current abilities while accommodating the progressive nature of the disorder.I) Personalization of the environment: Encourage the demented indidual to make choices in room design, color, furniture & decorative elements. Increase the caregivers' understanding that personalization is important. II) Privacy: personalization can enhance privacy III) Accessibility: To facilitate communicative interaction, patients need to have reliable and frequent access to partners and activities of their choice. IV) Design consideration: " The environment of the demented people must be as homelike as possible" V) Physical props: a) encourage use of focal areas, b) use of sociopetal seating arrangements during meal-time and activities, c) Visual access to activities occurring outside the setting, d) access to bathroom or call system & e) access to rest areas on the way to activities.SUGGESTIONS FOR ENHANCING SENSORY ENVIRONMENT: Demented individuals are likely to incur some degree of change in their sensory abilities associated with aging itself.I) Visual environment 1) Referral for complete optometric & opthalmologic evaluations 2) Ensuring that glasses & visual assistive devices are readily accessible to demented individuals 3) Improving visual contrasts within the environment 4) Using color to enhance orientation 5) Eliminating shiny, slick surfaces that reflect glare to the demented patient's visual field. 6) Having communication partners come face-to-face with the demented patient when communicating. 7) Placement of important visual information and decorative items at eye level. 8) Making the environment as visually interesting as possible without provoking sensory overload. 9) Providing opportunity for lumination control of the visual environment.SUGGESTIONS FOR IMPROVING AUDITORY ENVIRONMENT1) Provide a complete otologic & audiologic evaluation 2) Encourage patients to wear hearing aids if prescribed. 3) Encourage the use of assistive hearing devices. 4) Reduce interior noise sources especially in an area where communication is likely to take place. 5) Reduce interior noise through carpeting, sound-absorbent ceilings. 6) Reduce extraneous sounds (TV, radio etc) 7) Encourage caregivers to monitor background noises when communicating with the demented individual. 8) Speak within hand-shake distance of the patient, slightly loudly, and articulate clearly while facing the patient. 9) Avoid creating rooms that are "sound;dead" 10) Avoid using public address system for transmitting crucial information. -Also consider enhancing the olfactory, and tactile/kinesthetic environment.SUGGESTIONS FOR COGNITIVELY STIMULATING ENVIRONMENT1) Both sensory and social environments are integral aspects of cognitive environment. 2) A stimulating cognitive environment considers the person's past history, interests and abilities while matching current and changing abilities to allow for maximum competence. 3) Provide the individual with maximum multisensory cueing regarding time and place. 4) Introduce changes in the physical environment slowly, orienting the demented individuals to theses changes. 5) Adapt to the demented individual's time and place: allow ample time during conversational exchange 6) Provide a menu of activities that reflects the demented individual's interests rather than that of the caregivers. 7) Provide opportunities for the demented individual to contribute to the functioning of the environment. (e.g; to assist with food preparation, clean up etc)SUGGESTIONS FOR IMPROVING THE SOCIAL ENVIRONMENT1) Increase caregiver's understanding that they are crucial in creating positive social and communicative environment. 2) Provide appropriate reading materials to families & caregivers (e.g., The thirty-six hour day and Alzheimer's: A caregiver's guide and Sourcebook). 3) Provide every opportunity for the dignity of the individual to be preserved. 4) Encourage other individuals (old friends, volunteers, other patients, ..) to play an active role in communicating with the demented patient 5) Create opportunities for the demented individuals to interact frequently with those in their environment. 6) Encourage dementia patients to observe activities even if they are reluctant participate. 7) Encourage dementia patients to help others in some way. 8) Provide ample social events that have as their primary goal communicative interchange 9) Develop cross-generational access between children & dementia patients 10) Encourage communication partners to appreciate the cultural and historic background of the demented individual. 11) Promote participation in activities outside the home and institutional setting. 12) Encourage family members of the institutionalized dementia patients to visit and participate in activities whenever possible.