PT 305: Topic 6- Cognition of the
Aging Adult
- Associated symptoms for major depressive
episodes:
Prepared by: Danielle Valerie A. Tabel, PTRP
Main Reference: Geriatic Physical Therapy by Andrew A.
Guccione 4th Edition
Depression in Older Persons
Depression
- Most common psychological mood problem
in the older person.
- It is a Signi cant problem encountered by
health professionals working with older
persons who are ill.
- Often neglected in the older person, possibly
because mental health issues are
overshadowed by physical problems,
especially in older patients who are frail.
- Diagnostic criteria:
1. Major depression- 1 to 4%
2. Sub-major depression- 15 to 30%
3. Clinically signi cant depression- 10 to
43%
- Loss of health- one factor commonly
associated with depression in the older
person.
• Characteristics and Assessment of the Older
Person with Depression
- For depression to be diagnosed as clinical
depression, it should have the following:
1. Cognitive Problems
- Di culty concentrating
- Memory complaints
- Slowed thinking
- Indecisiveness
- Perceived lack of competence
and control
2. D i c u l t i e s w i t h i n t e r p e r s o n a l
interactions
- Withdrawal from family and
friends
- Neglect of previously pleasurable
activities
3. Somatic Symptoms
- Problems with appetite, sleep and
psychomotor function
- Insomnia and early morning wakeningmost common sleep disturbances.
- According to the Diagnostic and Statistical
Manual of Mental Disorders TR, ed. 4
(DSM-IV), the criteria for major depressive
episode are:
1. Depressed mood for at least 2 weeks
2. Loss of pleasure in all activities and
associated symptoms for at least 2
weeks
- Adjustment disorders
- Maladaptive reactions to an identi able
psychosocial stressor that occur within 3
months of the onset of the stressor.
- Te a r f u l n e s s a n d f e e l i n g s o f
hopelessness- predominant symptom
For Example:
• A divorce may cause a person to have a
depressed mood. This response would be
classified as an adjustment disorder with
depressed mood if the person's social
relationships or job were affected.
- The depression response must be
considered excessive to qualify as an
adjustment disorder with depressed
mood.
- Disturbance is considered:
- Acute= less than 6 months
- Chronic= 6 months or more
- Mood Disorder Due to a Medical
Condition
- There must be a prominent and
persistent disturbance in mood that
causes signi cant distress or
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impairment in social, occupational, or
other functioning as well as evidence
that the disturbance is the direct
physiological consequence of a
general medical condition.
For Example:
• A patient classified as having Mood
Disorder due to Hypothyroidism, with
Depressive Features.
-
Dysthymic
(Disthimik) Disorder
- Requires a depressed mood for most
of the day, for more than days than
not, over a period of at least 2 years.
- At least 2 of the associated symptoms
of a major depressive episode must
also be present, for example:
- Poor appetite, insomnia, low energy,
low self-esteem, poor
concentration, or hopelessness
• Assessment of Depression
- Self-report tools
- Frequently used to screen for depression
in the clinical setting.
- A rmative response to the following 2
questions may be as e ective as using
longer screening measures or may
indicate the need for the use of more indepth diagnostic tools:
1. "Over the past two weeks, have
you felt down, depressed, or
hopeless?"
2. "Have you felt little interest or
pleasure in doing things?"
- Depression Scales
- Widely used for the screening of
dementia
- Four (4) most commonly used
depression scales for older adults:
1. Beck Depression Inventory (BDI)
2. Center for Epidemiological Studies
Depression scale (CES-D)
3. Geriatric Depression Scale (GDS)
4. Zung Self-Rating Depression Scale
(SDS)
- Scales that deemphasize somatic signs
of depression such as the GDS and
CES-D are considered more valid for the
older person.
- Higher scores consistently re ect more
severe symptoms.
- Models of Depression
- Indicates an approach to treatment
- Five (5) most frequently cited models for
explaining depression with relevance to
older adults:
1. Cognitive model
- Emphasizes the cognitive
structure underlying depression,
including the negative views of
the self, the environment, and the
future.
- Negative schemata are primary
and the focus of treatment while
the depressed a ect is
secondary.
- Beck Depression Inventorydemonstrates the correlation
betwee negative feelings of self
and depression.
- A strategy to avoid negative
feelings is to develop focused
goals.
It has been found that individuals who
developed focused goals were able to avoid
negative feelings more so than those with
less focus.
2. Learned-helplessness model
- Uncontrollable negative events
can result in passive behaviours.
- People who have an explanatory
schema of pessimism are more
prone to learned helplessness
and depression than those with
an explanatory schema of
optimism.
- Cognitive theory- then used to
help a ect the individual's
explanatory schema.
People with a pessimistic outlook may neglect
healthful behaviours such as good diet,
exercise, and wellness behaviours, which
then places them at risk for poor health.
Subsequent poor health and chronic diseases
may contribute to learned helplessness as
these individuals interpret their poor health
as beyond their control and unexplained.
The result may be excessively passive
behaviour, poor problem solving, weaker
immune system and depression.
3. Interpersonal model
- E m p h a s i z e s o v e rd e p e n d e n t
personality traits that predispose
the individual who has had a loss
or negative life event to
depression.
- Focuses on interpersonal
relationships and personality
rather than external causes for
depression.
For Example:
• Depression may result in the patient who
may have been in a long-term abusive or
demeaning relationship with a spouse
who is now needed for caregiving.
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4. Neurobiological model
- Somatic symptoms of
depression, such as the
psychomotor retardation
(changes in speech, motility, and
cognition) and temporal variation,
indicate a biological basis for the
illness.
- Causes of depression:
1. Disturbance of catecholamine
transmission.
2. De cient brain serotonergic
transmission
- Many drugs have been developed
on the basis of the
neurobiological model
5. Integrative model
- Describes several individual
predisposing characteristics that
combine with environmental
variables to result in depression.
- Individual characteristics:
1. Low self-reinforcement
2. Negative self-evaluation
3. Pessimism
4. Global attribution
5. Low coping skills
6. P r e o c c u p a t i o n w i t h
negative experiences
7. Interpersonal dependency
8. Withdrawal
9. Low self-esteem
- Environmental issues:
1. L o w s o c i o e c o n o m i c
status
2. Low personal and social
support
3. Stressful life events
- Factors that provide immunity to
depression:
1. Positive coping skills
2. Good social support
• Unique Features of Depression in the Older
Adult
- Suicide occurs more often in the aging
population at a rate of 16% as compared to
14% in the teenage population.
- The over-60 population, born in a time
when mental illness was stigmatized and
emotions were deemphasized ("big boys
don't cry") contribute to the di culty in
recognizing depression.
- Pseudodementia
- Older term used for behaviour such as
depression that appeared similar to
dementia.
- Depression can imitate dementia, and
both depression and dementia can
have depressive symptoms.
- In the early stages of dementia, the
person knows his or her memory is
declining and this loss can lead to
depression.
- Geriatric psychiatrists recommend their
treatment should be rst initiated for
depression because depression can be
reversed.
- Dementia should be a diagnosis of
exclusion that is only given after other
possible diagnoses have been
eliminated.
- Instruments used to measure depression in
persons with high levels of cognitive de cit:
1. Cornell Scale for Depression in
Dementia
2. Dementia Mood Assessment Scale
3. Depressive Signs Scale
• Physical Illness, Function, and Depression
- Physical illness- a factor consistently
associated with depression in older
persons.
- Risk factors for late life depression:
1. Cerebrovascular disease
2. Cancer
3. Thyroid disease
4. Vitamin de ciencies
5. Infections
6. Parkinson's disease
7. Many comorbidities
- Many physical illnesses in old age result in
permanent disabilities which can restrict
mobility. This enforced dependency may
cause:
1. Loss of dignity
2. Sense of being a burden on others
3. Fear of institutionalization
- Mood disorders are often left untreated in
these circumstances, as being "down" is
seen as a normal response to the situation.
Traditional stage theory proposes that
depression is necessary and adaptive part of
rehabilitation.
However, although physicall ill persons have
higher rates of depression, clearly not all
physically ill persons develop clinical
depression.
- Strong association of physical illness to
depression has several factors.
- In a study by Williamson and Schulz,
health status and psychosocial factors
were equally important in explaining
depression.
- Health variables:
1. Physician and self-rated severity
of symptoms
2. Pain medications
3. Activity restrictions
- Psychosocial factors:
1. Worry about transportation
2. Need for future services
3. Satisfaction with social support
4. Worry about becoming a burden
5. Loneliness
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- Several studies have indicated higher levels
of functional incapacity and disability are
associated with higher levels of depression.
- Relationship is not absolute. Many older
adults have high rates of physical
dependency without corresponding high
rates of depression.
- According to Cummings et al, functional
de cits in performing instrumental activities
of daily living (IADLs) was a signi cant
predictor of depression.
- Older adults become at risk for
depression when physical/cognitive
impairment threatens their independent
operation in the community and their
management of typical household tasks.
- According to Baltes and Lindenberger,
those in the 75 years and older age group
may have better perceptions of their own
health than those in the 55 to 64 years age
group.
- Adaptation to the di culties of old is
gradual. Its problems are often most
worrying and least acceptable in the
earlier phases of aging.
• E ect of Depression on Function in the Older
Person
1. Older persons with depression may have
a reduced functional capacity.
2. Depression reduce the aging individual's
capacity to participate in everyday
activities and even perform ADLs.
3. Increased depression is associated with
reduced functional recovery and reduced
response to rehabilitation.
4. Depressed persons had a greater length
of stay than nondepressed persons.
5. Depression predicts increased loss of
function 1 year later.
6. Depression predicted an increase in
limitations in performing ADLs over a 2year period.
7. Depression increases the risk of
developing new illnesses, mortality, and
the use of health care resources.
Because evidence exists for the role of
physical activity in decreasing the symptoms
of depression, exercise interventions for the
functional de cits may mediate the
symptoms of depression and lower health
care costs.
• Pain and Depression
- Pain is linked to higher levels of
depression.
• Depression and Gender
- More women than men become seriously
depressed, but this reverses itself after
menopause.
- After age of 80: men = women
- Causes of depression among older
women:
1. Biological factors: hormonal changes
2. Being unmarried or widowed
3. Lack of supportive social network
4. Social isolation
5. Stresses of maintaining relationships
or caring for an ill loved one and
children.
6. Responsibilities of caregiving
7. Chronic physical illness
• Depression and Institutionalization
- Depression occurs among residents of
nursing homes at a rate of 15% to 25%
higher than the 15% among communitydwelling older adults.
- Factors linked to depression among
nursing home residents include:
1. Pain
2. Poor health
3. Cognitive decline
- Although depression responds to
antipsychotic drugs, too often of these
drugs are linked to falls.
• Suicide
- Suicide completion rate of older adults is
50% higher than the population as a
whole.
- Most common methods of suicide used
by persons aged 65 years or older:
1. Firearms (71%)
2. Overdose by liquids, pills or gas
(11%)
3. Su ocation (11%)
Management of Depression in the Older
Person
2 most common treatment approaches for
depression are:
1. Pharmacotherapy
- Most common approach in
managing older adults with
depression
2. Psychotherapy
• Pharmacotherapy
- Primary therapy for major depressive
episodes in the older person.
- Medications used to treat major
depression:
1. S e l e c t i v e s e r o t o n i n r e u p t a k e
inhibitors (SSRIs)
- Mainstay of pharmaceutical
treatment for depression in the
older person.
- Adverse side e ects:
anticholinergic and hypotensive
e ects characteristic of the TCA
- Anticholinergic side e ects of the
TCAs:
1. Dizziness **
2. Tachycardia
3. Constipation
4. Blurred vision
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5. Urinary retention
6. Postural hypotension **
7. Mild tremor
- **- particular concern to PTs
2. T r i c y c l i c o r t e t r a c y c l i c
antidepressants (TCAs)
- Side e ects:
1. Poorer balance (from moving
from supine to sitting or
sitting to standing)
- More pronounced in the
period immediately after
the medication is taken.
3. Heterocyclic antidepressants
4. Serotonin/norepinephrine reuptake
inhibitors
- Have potential side e ects that
are intermediate between SSRIs
and TCAs.
5. Monoamine oxidase inhibitors
- Also have major side e ects
similar to the tricyclics but are
less commonly used in the older
person.
- The choice of an antidepressant for a
particular person is dependent on the
following factors:
1. Prior response
2. Concurrent medical illnesses
3. Other medications used by the
patient
- The use of SSRIs and heterocyclic
antidepressants are preferred in the older
person.
- Medication is needed for at least 6
months to 2 years.
• Psychotherapy
- Include:
1. Cognitive behavioural therapy (CBT)
- Combines elements of behavioral
and cognitive approaches
- Challenges pessimistic or selfcritical thoughts and emphasizes
rewarding activities and
decreasing behaviours that
reinforce depression.
- Clients learn to recognize their
faulty thoughts and behaviours
and then modify them.
2. Problem-solving therapy
- Teaches clients to address
problems by identifying the
s m a l l e r e l e m e n t s o f l a rg e r
problems and speci c steps
toward solutions.
3. Interpersonal therapy
- A combination of psychodynamic
therapy and cognitive therapies
to address interpersonal
di culties and role transitions.
4. Brief psychodynamic therapy
- Focus on the personality
characteristics common in
depression.
• Exercise/Physical Activity
- In uence of Exercise/Activity on Depression
in older persons:
1. Increases self-mastery and selfe cacy beliefs.
2. Provides distraction from negative
thoughts.
3. I n c r e a s e s e n d o r p h i n e a n d
monoamine transmitters in the brain
reducing depression.
- Barriers to participation in exercise
programs by older persons with
depression:
1. Transportation
2. Medication problems
- A program of aerobic exercise caused a
reduction of depression symptoms in
patients aged 50 to 77 years old.
- Progressive resistance training has also
been shown to decrease depression and
pain as well as increase quality of life and
social functioning in older persons with
depression.
- A high dose and frequency consistent with
physical activity recommendations of 150
to 300 minutes of moderately intense
exercise per week is recommended.
- Recommendations for exercise/activity
programs for older persons with depression
include:
1. S c r e e n f o r p o s s i b l e m e d i c a l
conditions that might limit exercise
participation.
2. Provide multiple choices for exercise/
activity so that the individual can pick
enjoyable activities for himself or
herself.
3. Recognize possible barriers such as
medication and transportation
problems and provide appropriate
support.
• Working with the Depressed Older Patient
- The course of therapy would be expected
to be longer, because the apathy and extra
energy required necessitates more time to
accomplish goals.
- Experts agree that a matter-of-fact
approach that emphasizes the patient's
feelings of mastery is a more e ective
approach.
- Encouragement and acknowledgment of
the great degree of e ort required by the
person with depression to accomplish even
everyday tasks should be frequent.
- Goals should be discussed in small, easily
achievable steps since people with
depression may have di culty visualizing
goals far into the future.
- Persons with depression may need
assistance and training to improve their
interactive skills in order to maximize the
e ectiveness of their support networks.
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- Over cheerfulness may only emphasize the
separateness and depression of the patient
and increase negative feelings.
- Projecting a genuine regard for the
person that comes from respect and
valuing will be more e ective than an
insincere attitude or demeanor.
Cognitive Decline and Dementia
Alzheimer's Disease (AD)- most common type of
dementia
• Continuum of Cognitive Change
- Mild cognitive impairment (MCI) and
Dementia- considered pathologic
changes
• Normal Cognitive Aging
- There is no clear line between a
completely healthy brain and a diseased
brain.
- However, the way we think changes
gradually, becoming more noticeable
after the age of 50 years.
- Changes in cognition are usually mild
and a ects:
1. Visual and verbal memory
2. Visuospatial abilities
3. Immediate memory
4. Ability to name objects
- Changes in cognitive performance re ect
an aging brain and nervous system.
• Aging Brain
- 1400 g- weight of an average adult male
human brain.
- Contains 20 billion neurons with synaptic
connections.
- Although neurons cannot divide after
birth, their ability to remodel synaptic
connections occurs throughout life -- the
anatomic basis for memory and learning.
- Pathologic loss of these synaptic
connections- basis of dementia.
- Synaptic connections permit the ow of
information from one neuron to another
or to the end organ via neurotransmitters
(acetylcholine).
- Suppression or enhancement of
neurotransmission is the
pharmacologic basis of most
neuroactive compounds.
- Neurotrophins- Important signaling
molecules that regulate the synapse that
leads to learning and memory.
- Brain-derived neurotrophic factor
(BDNF)- linked to Alzheimer's disease
and other neurological disorders.
- The inhibition of BDNF and another
neurotrophic factor, neural growth
factor (NGF), stimulates the
molecular events typical of the AD
process.
- Amyloid beta- the protein that
accumulates and aggregates into the
plaque lesions of AD, is increased in a
deprived BDNF and NGF neural
environment.
- Interruption of the BDNF and NGF
signaling sets up the toxic
mechanisms that induce the death of
neurons --> brain tissue atrophy.
- Plaques and tangles- present in both
healthy and diseased brains, are the
waste products that ll up the spaces
between neurons (plaques) and form
inside the neuron (tangles).
- Both senile neuritic plaques
neuro brillary tangles may be seen in
cognitively intact aged individuals but
are generally less extensive than seen
in individuals with dementia of the
same age.
- Senile neuritic plaques are considered
to have no pathologic signi cance
until the plaque matures and is lled
with neuro brillary tangles and other
abnormal proteins.
- Neuro brillary tangle frequency and
distribution does predict cognitive
status.
• Normal Cognition
- Cognitive abilities include:
1. Memory
2. Language
3. Perception
4. Reasoning
5. Perceptual speed
6. Spatial manipulation
7. Executive skills
- 2 types of Intelligence:
1. Crystallized Intelligence
- Continues to increase gradually
throughout adulthood, even
until the ninth decade
2. Fluid Intelligence
- Tends to reach its peak during
adolescence and decline
rapidly during adulthood -a ected by neurologic insult,
genetics, and biological aging
processes.
- Intelligence is measured by IQ tests.
- Typically, IQ scores should remain
steady throughout adulthood, with
some decrease in later years.
- Wisdom is most frequently associated
with age.
• Executive Functioning
- Involves complex behaviour that
combines memory, intellectual capacity,
and cognitive planning.
- Activities of executive functioning
include:
1. Planning
2. Active problem solving
3. Working memory
4. A n t i c i p a t i n g p o s s i b l e
consequences of an intended
course of action
5. Initiating an activity
6. Inhibiting irrelevant behaviour
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7. B e i n g a b l e t o m o n i t o r t h e
e ectiveness of one's behaviour
Working memory- center of executive
functioning and incorporates complex
attention, strategy formation and
interference control.
There is evidence of a mild decline of
executive functioning with normal aging.
- Decline is greater when a neurologic
disorder, such as CVA or dementia, is
present.
Executive functioning is an important
factor for self-reported and observed
performance of complex, independent
ADLs, such as managing money and
medications.
Intact executive functioning serves as a
fall prevention measure by minimizing
behaviour that jeopardizes safety despite
motor or sensory impairment.
-
-
-
• Memory
- Memory loss- most comon cognitive
component associated with aging.
- 4 Types of Memory:
1. Working memory
- Memory that allows us to "hold
on" to bits of information such
as a phone number before we
dial it.
2. Episodic memory
- Memory of an event or episode
such as remembering where
the car was parked.
Encoding is an e ortful process that includes
memorization. Memorizing is enhanced
through repetitions and practice. Working
memory must be encoded into episodic
memory. Once information is encoded,
information must be retrieved, again an
e ortful process.
Hippocampus is critical for encoding, and
because it is so often involved in AD,
episodic memory, especially retrieval, is
frequently a ected.
3. Semantic memory
- Strongly language-based and
describes memory for facts
and words.
4. Remote memory
- Memory for remote or past
events.
Semantic memory and remote memory ca
become independent of the hippocampus
and thus may not always be impaired in
pathologic cognitive dysfunction.
- Health issues that can a ect memory:
1. Medication side e ects
2. Vitamin B12 de ciency
3.
4.
5.
6.
7.
8.
Chronic alcoholism
Brain tumors
Infections
Blood clots
Thyroid, kidney or liver disorders
Emotional problems: stress,
anxiety, depression
• Personality
- Personality types remain fairly stable
throughout life.
- Activity level also follows this model: with
age, people who were active stay active.
- Traits that have been predominant will
continue to be in uential as a person
ages.
- Clinically, this means patients who
display a negative outlook about
therapy have probably always had a
negative attitude about a variety of
situations.
- Plasticity- ability of the brain to change
and keep itself vital.
Scientists are discovering that when the mind
is challenged, the brain responds positively,
in physical and chemical ways, regardless of
age. Increasingly, aging adults who expand
their experiences and environment develop
new intellectual pursuits, oftentimes
accomplishing extraordinary things.
• Cognitive Reserve
- According to the cognitive reserve
perspective, cognitive impairments
become apparent only when cognitive or
neurologic resources become depleted
beyond a certain threshold.
- The disuse perspective "use it or lose it"
emphasizes that sedentary activity
(passive) patterns result in atrophy of
cognitive skills and processes.
- Lindstrom et al found that each hour
increase in television viewing in middle
adulthood corresponded to a 1.3 times
risk of developing AD.
- They also found that increased daily
social and intellectual activity hours,
higher income, higher levels of
education, and being female were all
associated with decreased risk of
developing AD.
• Preservation of Normal Cognition and
Prevention of Cognitive Disease
- The more engaged and mentally stimulated
an individual, the less likely cognitive
decline and disease will result.
- Cognitively inactive lifestyles are an
important risk factor for MCI and AD.
- Lifestyles that combine cognitively
stimulating activities with physical activities
and rich social networks may provide the
best odds of preserving cognitive function
in old age.
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is questionable and may cause
unnecessary anxiety.
Mild Cognitive Impairment
• Mild Cognitive Impairment (MCI)
- Condition that lies between normal aging
and dementia.
- Individuals with MCI have heightened risk
for developing dementia.
- The best single predictors of likelihood to
progress were measures of:
1. Recent verbal/visuospatial learning
and memory, especially from tests of
delayed recall.
2. Assessments of language function
and motor/psychomotor integration.
- The usefulness in motor tests is
that motor tests do not seem to
be corrected with education, as
are cognitive tests.
- MCI was originally characterized by 4
criteria:
1. Memory complaints
2. Normal ADLs
3. Normal general cognitive functioning
4. Abnormal cognitive measures using
age- and education-adjusted norms
- The diagnosis of MCI begins with
subjective complaint of memory
impairment. Current criteria include:
1. Subjective, gradual cognitive decline
for at least 6 months
2. Objective criteria as measured by
performance at 1 standard deviation
below age and education norms by
neuropsychological testing.
Delirium
- Hallmark of Delirium: sudden, and
sometimes rapid change in mental function
and should not be confused with dementia.
- One of the most common complications of
medical illness or recovery from surgery
among older adults.
- Most common complication of hospital
admission for older people.
- Develops in up to a half of older adults
postoperatively, especially following
1. Hip fracture
2. Vascular surgery
- Adverse consequences of Delirium:
1. Average increase of 8 days in the
hospital
2. Wo r s e p h y s i c a l a n d c o g n i t i v e
recovery at 6 and 12 months
3. Increased time in institutional care.
- Causes of morbidity in hospital patients
diagnosed with delirium:
1. High risk of dehydration
2. Malnutrition
3. Falls
4. Continence problems
5. Pressure sores
- Agitated Delirium
- Most often associated with adverse
e ects of anticholinergic drugs, drug
intoxication, and withdrawal states.
- Older adults may exhibit disruptive
behaviours such as shouting or
resisting, may refuse to cooperate, be
combative or harmful to themselves.
- Hypoactive or quiet delirium
- May appear apathetic, sluggish, and
lethargic or low in mood and confused
- Pathophysiology of dementia:
1. Neurotransmitters disturbances
(Acetylcholine de ciency and
dopamine excess)
2. Illness-related stress with overactivity
of the hypothalamic-pituitary-adrenal
axis
3. E ects of increased cytokinetic
production on cerebral function
• Treatment of MCI
- A trial of donepezil suggested a therapeutic
e ect for the rst 12 months in subjects
with MCI, but the results were not
replicated in a 48-week trial with donepezil
alone, thus no treatments have been
approved for MCI.
- Because pharmacological treatment is
unsuccessful in preventing the decline into
dementia, the usefulness of this medication
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Dementia
- AKA Senility, Organic Brain Syndrome
- Organic brain syndrome- general term
that refers to physical disorders (not
psychiatric in origin) that impair mental
functions.
- Not a disease but rather a group of
disorders that a ect the brain and present
as symptoms that most commonly a ect
memory and language.
- Essential feature of dementia- development
of multiple cognitive de cits that include
memory impairment and at least one of the
following cognitive disturbances:
1. Aphasia
2. Apraxia
3. Agnosia
4. Disturbance of executive functioning
- A systematic approach to the assessment
of any suspected dementia should be
undertaken with an emphasis on both
medical problems as sources of the
cognitive symptoms and how the patient's
cognition, mood and home situation are
a ecting the patient and the caregiver.
- Two key parts of dementia are:
1. Acquired- impairment represents a
change from previous functional
abilities to dysfunctional ones.
2. Persistent- di erentiates dementia
from delirium, which produces a
uctuating state of dysfunction
- Cortical Dementia- tends to cause
problems with memory, language, thinking,
and social behavior and primarily a ects
the cortex.
- Subcortical Dementia- a ects parts of the
brain below the cortex and tends to cause
changes in emotions and movement in
addition to problems with memory.
- Dementia increases with age.
- Most common in African Americans due to:
1. Overrepresentation in the lower
socioeconomic
2. Disadvantages classes
3. Increased incidence of vascular
disease
4. Hypertension
5. Hyperlipidemia
6. Generally lower education level
- Although dementia is common in very old
individuals, dementia is not a normal part of
the aging process.
- The most common cause of dementia is
Alzheimer's disease.
- Other frequent forms of Dementia:
1. Vascular Dementia
2. Dementia resulting from other
neurodegenerative processes such
as Lewy body dementia (including
dementia due to Parkinson's disease)
3. Frontotemporal dementia (including
Pick's disease)
• Alzheimer's Disease
- Most common type of dementia accounting
for 60% to 80% of those with dementia.
- On average, patients with AD live for 8 to
10 years after they are diagnosed.
However, some people can live as long as
20 years.
- Patients with AD often die of aspiration
pneumonia, because they lose the ability
to swallow late in the course of the
disease.
- Characterized by 3 pathologic changes in
the brain:
1. Amyloid plaques- protein fragments
known as beta-amyloid peptides
mixed with additional proteins,
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• Prevention and Treatment of Delirium
- The management of hypoxia, hydration,
and nutrition, minimizing the time spent
lying in bed, and walking are also important
steps to preventing and treating delirium.
- Physical restraints should be avoided
because they increase agitation and may
cause injury.
- Most common drugs associated with
delirium:
1. Psychoactive agent: Benzodiazepine
2. Narcotic analgesis: Morphine
3. Drugs with anticholinergic e ects
- Ketamine- an intravenous anesthetic agent
a s s o c i a t e d w i t h e x c i t a b i l i t y, v i v i d
unpleasant dreams and delirium.
- Postoperative delirium has been associated
with inhalational anesthetics.
- Low-dose haloperidol- best studied agent
with the least side e ects for short-term
use.
- E ective strategies for preventing delirium
include:
1. Orienting communication
2. Therapeutic activities
3. Early mobilization and walking
4. Nonpharmacologic approaches to
sleep and anxiety
5. Maintaining nutrition and hydration
6. Adaptive equipment for vision and
hearing impairment
7. Pain management
8. Stimulation such as familiar objects,
a f a m i l y m e m b e r ' s p re s e n c e ,
patient's favorite pillow or blanket,
and familiar music and sounds
9. Early discharge to home-based
medical management
remnants of neurons, and bits and
pieces of other nerve cells.
2. Formation of neuro brillary tangles
that are found inside neurons
- Neuro brillary tangles- abnormal
collections of a protein called tau.
Although tau is required for
healthy neurons, in AD, tau
clumps together, causing neurons
to fail and die.
3. L o s s o f c o n n e c t i o n s b e t w e e n
neurons that are responsible for
memory and learning.
- Types of AD:
1. Early-onset
- Rare (5%)
- Develops in people between ages
of 30 to 60
- Familial AD
- Caused by gene mutations on
chromosomes 21, 14 and 1.
- Even if only one of these
mutated genes is inherited
from a parent, the person will
almost always develop earlyonset AD.
2. Late-onset
- Most common
- Related to the apolipoprotein E
(APOE) gene found on
chromosome 19.
- APOE comes in 3 forms:
1. APOE ε2
2. APOE ε3
3. APOE ε4
- Risk factors for AD.
1. Advancing age (most important)
2. Positive family history
- In families with early onset (ages
40 to 60 years), AD is generally
inherited in an autosomal
dominant manner.
- African Americans and Hispanics
are at a higher risk for developing
AD possibly due to prevalent
health conditions such as
hypertension and diabetes.
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• Clinical Presentation
1. Awareness of cognitive decline is often
accompanied by depression.
2. A s A D p ro g re s s e s , m e m o r y a n d
language problems worsen and patients
begin to have di culty performing
independent ADLs.
3. Visual-spatial problems such as getting
lost on formerly familiar routes
4. Patients may become disoriented to time
and place, may su er delusions.
5. During the late stages of the disease,
patients begin to lose the ability to
control motor functions.
6. Eventually, patients fail to recognize
family members and to speak.
7. As AD progresses, the disease a ects
emotions, behaviour, and personality.
• Vascular Dementia
- 2nd most common type of dementia (20%)
but has a higher mortality than AD.
- A ects more men than women.
- Classi ed as an organic mental disorder,
with the essential feature being
cerebrovascular disease.
- Risk factors:
1. Hypertension
2. Smoking
3. Hypercholesterolemia
4. Diabetes mellitus
5. Cardiovascular disease
6. Cerebrovascular disease
- Multi-infarct dementia- type of vascular
dementia resulting of the additive e ects of
small and large infarcts that produce a loss
of brain tissue.
- 3 forms of vascular dementia:
1. Large vessel disease
2. Stroke
3. Multiple microcerebral infarcts
•Clinical Presentation
1. P ro b l e m s w i t h m e m o r y, a b s t r a c t
thinking, judgment, impulse control, and
personality.
2. Speci c signs and symptoms:
- Abrupt onset
- Step-by-step deterioration
- Fluctuating course
- Emotional lability
3. Focal neurologic signs:
- Exaggeration of deep tendon
re exes
- Extensory plantar response
- Laboratory evidence of vascular
disease
4. Treatment for vascular dementia focuses
on the cause of the damage such as:
- Hypertension
- Hyperlipidemia
- Uncontrolled blood glucose levels
5. May or may not improve with time,
depending on the degree of control of
the causative factors and further strokes.
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• Lewy Body Dementia (LBD)
- One of the most common progressive
types of dementia.
- The central feature of LBD is progressive
cognitive decline, combined with 3
additional de ning features:
1. P r o n o u n c e d " u c t u a t i o n s " i n
alertness and attention, such as
frequent drowsiness, lethargy,
lengthy periods of time spent staring
into space, or disorganized speech
2. Recurrent visual hallucinations
3. Parkinsonian motor symptoms, such
as rigidity and the loss of
spontaneous movement
- Symptoms of LBD are caused by the
buildup of Lewy bodies- accumulated bits
of a-synuclein protein- inside the nuclei of
neurons in areas of the brain that control
particular aspects of memory and motor
control.
- a-synuclein accumulation is also linked
to:
1. Parkinson's disease
2. Multiple system atrophy
3. Other synucleinopathies
- LBD usually occurs sporadically, in people
with no known family history of the disease.
• Clinical Presentation
1. Gait and balance disorders
2. Visual hallucinations
3. Delusions
4. Extrapyramidal symptoms
5. Visual-spatial dysfunction
6. Poor executive functioning
7. Increased sensitivity to antipsychotics
8. Fluctuation in alertness
9. Clinical depression
10. There is no cure for LBD and treatments
are aimed at controlling the parkinsonian
and psychiatric symptoms
language impairment, extrapyramidal
signs (rigidity, tremor, bradykinesia)
5. Gross assessment of functional
status
6. Evaluation of mental status
- Neuroimaging:
- Computed tomography (CT) or magnetic
resonance imaging (MRI) - reveals
cerebral atrophy, focal brain lesions,
hydrocephalus, periventricular ischemic
brain injury.
- Functional imaging:
- Positron emission tomography (PET) or
single-photon emission computed
tomography (SPECT)- not routinely used
in the evaluation of dementia but may
provide useful di erential diagnostic
information such as parietal lobe
changes in AD or frontal lobe alterations
in frontal lobe degenerations.
- Useful screening tests for Dementia:
1. Mini-Cog
2. Number of animals named in 1
minute
3. Mini Mental Screening Exam (Folstein
Mini Mental Exam)
4. Geriatric Depression Scale
5. Patient Health Questionnaire-9
• Management
• Assessment
- Dementia is only diagnosed if 2 or more
brain functions- such as memory and
language skills- are signi cantly impaired
without loss of consciousness.
- A diagnosis of dementia is applicable only
when there is demonstrable evidence of
memory impairment and other features to
the degree there is interference with social
or occupational function.
- The diagnosis of dementia is primarily
made on clinical grounds:
1. Medical history to determine the
precise features of cognitive loss
2. Questions about past medical history
such as falls, head trauma,
hypertension, heart disease,
diabetes, vitamin de ciences or
thyroid disorder, alcohol use and
substance exposure
3. Medications and alcohol use
4. C o m p r e h e n s i v e p h y s i c a l a n d
neurologic examination to check for
focal weakness, gait impairment,
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• Pharmacologic Management
- Medications for behavioral control
include:
1. Antidepressants (SSRIs)
2. Antipsychotics (Risperidone or
Olanzapine)
3. Mood stabilizers
4. Anxiolytics
5. Mood stabilizers (Carbamazepine
and
(Dehpukkaat),
Temazepam)
6. Cholinesterase inhibitors and
neuropeptide modifying agent
receptor antagonists
- Used to reduce the
progression of dementia
- Cholinesterase inhibitors
(Donepezil, Galantamine,
Rivastigmine)- slows the
breakdown of acetylcholine
to make it more available for
cellular use and are
prescribed in mild to
moderate AD.
Depakote
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7. Neuropeptide-modifying agents
(Muhmanteen)- regulate
glutamate availability but have
not been shown to be particularly
e ective in improving functional
abilities.
- Only available drugs for
severe AD but have not been
shown to be e ective in
slowing the progression of
dementia.
8. Antidepressants
9. Atypical antipsychotics- used to
manage behavioral disturbances
but has side e ects, thus are
discouraged for long-term use.
• Behavioral and Environmental Management
- These interventions are designed to
manage undesired behaviours through
progressively lowering the stress
threshold management.
- One way to approach challenging
behaviours is using Antecedent-
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Behavioral-Consequences (ABC)
strategies.
- The ABC method is based on social
cognitive theory.
- The theoretical premise advocates that
changing what happens directly before
or after a problem behavior can be
u s e d t o a l t e r o r d e c re a s e t h e
frequency of problem behavior.
Recognition that consequences can “reinforce”
behavior, both positively and negatively, forms
a basis for management. Behavior that is
desired should be rewarded or encouraged and
behavior that is undesirable should be
negatively reinforced.
The first step is to collect as much information
about challenging behaviors to detect patterns
about why the challenging behaviors occur or
what function they might serve for the person
with dementia. After the behavior has been
observed for a week or so, the triggers or
antecedents usually become obvious.
Behavior is also managed through consistency
and providing a secure and safe environment.
Often, the individual with dementia is looking
for some measure of control and may react to
overchallenging tasks or too much stimulation,
similar to what can occur in a physical therapy
gym. These behaviors are referred to as
provoked behaviors and are most often
triggered by event-related factors such as the
physical environment, physiologic needs, or the
social environment.
Once the provoked or antecedent behavior is
understood, the triggers can be changed to
decrease the challenging behavior.
• Depression and Dementia
- Depression has an e ect on functional
status beyond the e ects of cognitive
impairment.
- If depression is an overlying condition,
functional status may improve with
successful treatment of the depressive
episode.
- If the mood improves as the depression
is resolved, cognitive function will return
to predepressive level. Should the
individual continue to display
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characteristics of decline in mental
ability, investigating for dementia would
be initiated.
- Patient Health Questionnaire-9- useful in
di erentiating dementia and depression.
• Exercise
- Positive e ects of exercise on persons
with dementia:
1. Increased strength and endurance
2. Increased ADL function
3. Improved sleep
4. Increased balance and decreased
falls
5. Improved mood
6. Decreased anxiety
7. Decreased use of medications
- Seattle protocol
- Evidence-based program of exercise
designed for older adults with
dementia.
- Activities included in the Seattle
protocol:
1. Dancing with simple steps
2. Tandem walking on an imaginary
tight rope
3. Walking
4. Stationary bicycle
5. Tai Chi (sticky-hands technique)
- Results of Seattle Protocol:
1. Decreased depression
2. Fewer restricted-activity days
3. Increased physical functioning
4. Decreased institutionalization due
to behavioral disturbances
5. Less awake time at night
- Given a proper cueing, a supportive
environment and appropriate exercises,
individuals with dementia can participate
and bene t from many di erent kinds
and forms of exercise.
• Physical Therapy Management
- Role of the physical therapist in the
presence of dementia:
1. The PT needs to assist the
patient, family, and caregiver with
activities that will maximize the
individual's functional abilities
and slow down physical declines.
2. The PT can assist in changing
and simplifying the environment
to maintain function.
3. T h e P T s h o u l d a s s i s t t h e
caregiver(s) in providing
functional, meaningful, pleasant,
and safe activities.
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- The features of dementia that most
in uence the rehabilitation process are
memory decline and that di culty or
inability to learn new material.
PTs should modify treatment methods
and goals to accommodate the
limitations of the patient's cognitive
disability. Therapy should not be denied
on the basis of cognitive dysfunction.
Assessment tools:
1. For mobility:
- Timed Up and Go
- Gait Speed
- Sit to stand
2. To evaluate ADLS:
- Barthel Index
- The Structured Assessment of
Independent Living Skills (SAILS)
- Erlangen test of ADLs
Traditional PT interventions need to
focus on task-speci c and relevant
activities.
Emphasis is on positive reinforcement
while avoiding criticism.
Strategies to maximize success in
physical therapy sessions:
1. U s e o f c o n s i s t e n t , s i m p l e
commands
2. Providing sensory cues
3. Demonstration
4. Providing rest periods
5. Avoidance of environments with
overwhelming stimuli
Adults learn better when the information
is relevant to their activities, and this may
even be more relevant for older adults
with cognitive de cits.
-
-
-
-
help create a more trusting and less
stressful therapy session.
- Environmental adaptations for the
home include the :
1. Use of visual pictures for key
rooms such as the kitchen and
the bathroom
2. Storage of medications and
harmful materials out of reach of
the person
3. Provision of adequate lighting,
especially if the individual
wanders
4. Installation of a shut-o switch on
the stove
5. Limitation of clutter and mirrors
6. Lower water temperature to avoid
burns
Caregiver Issues
- Education and training for the caregiver are
essential because management of the
patient is heavily dependent on the family
support and coping resources.
- Psychological health of the caregiver is a
concern to the therapists and is often
related to the function of the patient.
- Keys to decreasing caregiving stress:
1. Extensive education regarding
strategies to deal wih behavioral
problems, including role-playing.
2. Enhance ADL abilities with strategies
to reinforce
3. Reinforcement with practice, home
visits, and phone calls
4. Encourage self-care with pleasurable
activiies and health-promoting
behaviors.
For Example:
• Sit to stand could be a more appropriate
functional measure of strength and balance.
In addition, strengthening activities may be
best accomplished using functional activities
such as sit to stand activities and weighted
ADL activities (weighted clothes or hair
brush).
• Hip Fracture
- Individuals with AD sustain hip
fractures more often than individuals
with normal cognition.
- The PT should be aware of the
adverse consequences of prolonged
immobility and promote and advocate
for mobility within the imposed
constraints.
- Working with persons with dementia
requires a careful balance of simple
instructions and repetition without
treating the person as a child.
- Avoid debate or con ict with the
person; rather, change the subject or
task if it is too stressful.
- Finding a connection with the
person, perhaps through their
hobbies or past employment, can
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This document was prepared by DANIELLE VALERIE A. TABEL, PTRP for the BSPT students enrolled in
CDU. Using this document for other purposes, please email me at cdu.daniellevalerietabel@gmail.com