PCA Regional Conference on Aging 2014
Recognizing the Signs and Symptoms
of Dementia in Older Adults
Joel E. Streim, M.D.
Professor of Psychiatry
University of Pennsylvania
Philadelphia VA Medical Center
Disclosures
Dr. Streim is on the faculty of the Geriatric
Education Center of Greater Philadelphia,
which is funded by the Bureau of Health
Professions, Health Resources and Services
Administration (HRSA), Dept. of Health and
Human Services (DHHS).
The content of this presentation is solely the
responsibility of the presenters and does not
necessarily represent the official views or
policies of HRSA or the DHHS.
Objectives

Identify at least 3 signs or symptoms of cognitive
impairment in the early, middle and late stages of
dementia;

Identify at lesat 3 cognitive domains other than memory
that may be impaired in older adults with dementia;

Understand the potential effects of impairment in
various cognitive domains on behavior and everyday
function in older adults with dementia;

Appreciate the resources needed to care for older adults
with behavioral changes, disability and activity
limitation.
What cognitive changes do we
see in persons with dementia?
Deficits in one or more cognitive domains:
—learning and memory
(amnesia)
—language
(aphasia)
—perceptual-motor
• visual recognition
(agnosia)
• performing motor activities
(apraxia)
—executive function
(abulia, apathy)
—complex attention
(distractability)
—social cognition
(lack of insight)
Consequences of Cognitive Impairment
Cognitive impairment can interfere with

Communication
— Comprehension
— Ability to report symptoms, express needs

Social awareness, self-monitoring

Ability to follow directions

Self-care (basic ADLs)

Household management (instrumental ADLs)
Impairment in
Activities of Daily Living (ADLs)

Instrumental ADLs
(Household Management)

Basic ADLs
(Personal Care)
— Shopping
— Bathing
— Cooking
— Hygiene
— Cleaning
— Grooming
— Laundering
— Dressing
— Using Telephone
— Feeding
— Paying Bills
— Toileting
Other Consequences
Cognitive impairment can interfere with

Personal safety
— Eating (e.g. risk of choking or aspiration)
— Walking (e.g. risk of getting lost, falling)
— Household tasks (e.g. risk of fires, accidents)

Receipt of medical and nursing care
— Patient participation
— Delivery of care by providers & caregivers
Recognition of Cognitive Impairment
Suspect a neurocognitive disorder when

person has self-care deficits

person has difficulty following instructions

family has “taken over” responsibilities

person doesn’t participate well in medical,
nursing care, or rehabilitative care

behaviors interfere with safety or care delivery
Don’t blame “old age”
What are the signs and symptoms of
cognitive impairment ?

SIGNS are what we observe in these individuals
— Objective

SYMPTOMS are what the individual experiences
— Subjective
Impaired Memory and Learning
(amnesia)

Forgetfulness
— Repetitious statements
— Misplacing things
— Missing appointments
— Leaving bills unpaid
— Inability to recall recent events

Disorientation
— Getting lost
Impaired Language
(aphasia)

Trouble comprehending spoken or written language
— Inability to follow simple directions

Word-finding difficulty
— Hesitant speech
— Paraphasias (word substitutions)
— Anomia (loss of name recall); substitutes general
terms and pronouns
— Circumlocutions (“talking around”)
— Neologisms (non-sense words or sounds)

Perseveration (repetitious speech, echolalia, palilalia)
Impaired Perceptual-Motor Function

Agnosia
— Inability to recognize faces, family members
— Trouble navigating in familiar environs

Apraxia
— Difficulty manipulating objects (e.g., opening
package, unscrewing lid, buttoning, using
zipper)
— Inability to assemble objects, perform spatial
tasks (e.g., sewing, carpentry, dressing)
Impaired Complex Attention

Distracted by multiple stimuli

Can’t scan and focus on relevant stimuli or
objects in environment

Can’t register information just given

Thinking and processing speed is slower

Can’t perform mental calculations
Impaired Executive Function
Loss of frontal lobe function:

Lack of will or initiative (abulia, apathy)

Difficulty with reasoning and decisions

Inability to organize and plan activities

Inability to perform sequential tasks

Poor task completion

Inability to shift between concepts / tasks
Impaired social cognition

Loss of insight
— Lack of awareness of own situation
— Inability to appreciate safety concerns

Insensitivity to other persons’ mental state
— Inability to recognize social cues or read facial
expressions

Disinhibition

Impaired judgment
Common Presentations:
Early and Middle Stages of Dementia

Visual complaints

Trouble following directions

Difficulty performing familiar tasks

Family members take over usual roles

Loss of initiative
— Disengagement from usual activities
— Self-neglect
— Weight loss

Diminished social spontaneity
— Less conversation
Common Psychological Changes:
Early and Middle Stages of Dementia

Depression
— Apathy, withdrawal
— Sad or flat affect

Anxiety
— Fear of being alone

Paranoia
— Delusions about “imposters”
— Accusations of infidelity, theft

Personality changes
Loss of Cognition and Function
in Late-Stage Dementia

Aphasia: single words, echolalia, palilalia,
mutism

Apraxia:
—Manual: inability to hold or manipulate objects
—Oral: difficulty chewing & swallowing
—Gait: instability, loss of ambulatory ability

Incontinent of bladder and bowel

Terminal stages: inability to sit up, smile,
hold up head; bedbound

Total dependence in basic ADLs
How does memory impairment lead
to inability to perform basic ADLs?
Example
Patient is able to dress himself, but can’t
remember where his clothes are kept
Walks outside naked
How does apraxia lead to difficulty with
basic ADLs?
Example
Patient is continent of bladder, but cannot
unzip or unbutton to pull down her pants
Wets her clothing
How does language impairment (aphasia)
interfere with care?
Example
Patient who can’t verbally communicate
that pills are hard to swallow
Spits medication at caregiver
How does visual agnosia lead to changes
in behavior and function?
Example
Patient can maneuver to pull down his
pants, but can’t recognize that a toilet is a
receptacle for urination
Urinates on living room floor
Common Caregiver Misattributions

Laziness

Dependency

Belligerence

Depression
Misattributions can lead to caregiver
distress (frustration, anger, anxiety,
depression) and increased risk of
elder abuse
Initial approach to assessment,
management, and prevention

Recognize
areas of impaired cognitive function
and
areas of preserved cognitive function

Help compensate for impairment

Support residual abilities
What other factors interact with
cognitive deficits, contributing to
behavioral changes and functional
decline in patients with dementia?
Factors that Affect Function and
Behavior in the Cognitively Impaired
Cognitive deficits reduce a person’s ability to
deal with:
Unmet needs (e.g., physical or psychological)

Environmental or social irritants

Acute or chronic illness (medical, psychiatric)

Distressing symptoms (e.g., pain, anxiety)

Adverse effects of medications

Many of these aggravating factors are
modifiable or treatable
Unmet needs that can lead to
functional and behavioral changes

Physical needs
— Nutrition, hydration, toileting, exercise, rest

Psychological needs
—Security, autonomy, affection, self-worth
Environmental irritants that can lead
to functional and behavioral changes

Physical
— Noise
— Confusing visual stimuli
— Uncomfortable temperature
— Unfamiliar surroundings

Social
— Changes in routines
— Provocative social interactions
Adverse drug effects that can cause
functional and behavioral changes

Nuisance symptoms

Anticholinergic effects

Antihistaminic effects

Paradoxical excitation / disinhibition

Intoxication or withdrawal states

Akathisia
Medical conditions and somatic discomfort
can alter function and behavior
Medical condition
Somatic discomfort
— Arthritis
— Pain
— Dehydration
— Constipation
— Prostatic hypertrophy
— Urinary urgency
— COPD
— Shortness of breath
— Cerebrovascular disease — Dizziness
— CHF
— Fatigue
Psychiatric conditions can cause
functional and behavioral problems

Depression

Delirium

Psychosis
— delusions
— hallucinations

Anxiety

Sleep disturbance
What do we need to learn as caregivers?

Understand how the cognitively impaired person
experiences situations (the environment, social
interactions)

Recognize specific factors that cause or contribute to
behavioral changes and functional deficits
Once understood, interventions and
management strategies become apparent
Person-centered Care: WHAT?

Focus on the elderly person’s experience
— Try to imagine being in their world
— Consider how things look from their
perspective

Accept their reality
— Their subjective experience is real to them
— Doesn’t mean you actually adopt their point of
view for yourself
Person-centered Care: HOW?

Look for meaning in verbal and non-verbal
communication
— Ask, “what do you want? “how can I help?”
— When language comprehension and
communication are severely impaired,
LOOK AND LISTEN for non-verbal clues to
sources of distress or unmet needs


Avoid saying “no”, arguing or disagreeing
Offer to help in ways that reduce distress or
meet needs, without compromising safety
QUESTIONS
CLINICAL VIGNETTES
SIGNS OF IMPAIRMENT
IN VARIOUS COGNITIVE DOMAINS
Vignette #1
A woman has a doctor’s appointment
tomorrow. Her husband tells her it’s on Wed
at 9am. 10 minutes later, she asks when
she’s going to the doctor’s office. Husband
repeats the information. 2 minutes later, she
asks the same question. This is repeated
more than 15 times in the course of the
afternoon.
Vignette #2
A man tells his son that his neighbors stole
his socks. When his son opens his dresser
drawer and shows him the socks, he seems
surprised, and states that the neighbors
must have come in the middle of the night to
return them.
Vignette #3
A woman who used to be very social and
talkative now speaks only when someone
asks her a question, and she usually
responds with a single word answer.
Sometimes she only nods her head. The
caregiver thinks she may be depressed.
Vignette #4
A man refers to his belt as “my strap.”
When pointing to his watch, he calls it “that
thig-a-ma-jig.”
Vignette #5
A man has urinary incontinence.
His adult daughter, who is his caregiver,
notes that prior to episode of incontinence,
rather than asking to go to the bathroom, he
becomes increasingly agitated, begins
pacing, and seems upset.
Vignette #6
A man asks his wife of more than 50 years
who sent her to his house. When she says
she’s his wife, he insists that she doesn’t
look anything like his wife. However, when
she begins to sing their favorite song, he
begins to cry, and asks her how she knows
that.
Vignette #7
A man who has been very active and always
enjoyed hikes in the woods, has been
spending more time sitting in a chair over
that past 3 months, and now seldom gets up.
When he stands, he doesn’t fully extend his
knees, and needs coaxing to take a step. He
appears fearful, even when his caregiver
offers support under his arm.
Vignette #8
A woman who was always fastidious and
well-mannered at the dinner table has
stopped using and knife and fork to cut her
food.
Vignette #9
A man who loves to eat keeps chewing and
chewing without swallowing, and pieces of
food sometimes fall from his mouth.
Vignette #10
A woman who is continent of urine most of
the time, today is wearing pants that button
on the side, gets to the bathroom and wets
herself before she can pull down her pants.
Vignette #11
A man tries to use a butcher knife to open a
cardboard milk container.
Vignette #12
A woman always baked Christmas cookies
every year to bring to her grandchildren.
This year she doesn’t. Her daughter
observed that on one occasion she added
whole egg yolks to a batter without beating
them, after first assembling all the other
ingredients.
Vignette #13
A man used to be very social, and the person
at home who always initiated dinner
conversations. Now he spends most of the
day sitting on the couch. Family is concerned
that he is depressed or lacking motivation.
Vignette #14
A man writes a check for his electric bill with
the correct payee and amount, signs and
dates the check, places it in the envelope,
and seals the envelope without including the
payment stub with the address showing
through the envelope window. He then
deposits it in a mailbox.
Vignette #15
A usually well-mannered elderly man is
walking down the sidewalk accompanied by
his wife of 60 years. The couple passes a
young girl walking the other way, and the
man asks her if she wants to have sex with
him. His wife is horrified and embarrassed.
Vignette #16
A woman sends her husband to buy a quart
of milk and a box of tea bags at the local
grocery store, 3 blocks away from their
house. He returns two hours later without
any groceries.
Vignette #17
A woman has been living independently for 8
years since her husband died. A daughter
from California, who hasn’t seen her in the
past six months, is now in town for a visit
and notices that her mother has lost so much
weight that her clothes are sagging on her.
The refrigerator is full of spoiled dairy
products and moldy fruit.
DISCUSSION:
SHARE YOUR CASES
THANK YOU !