DEMENTIA
Ashley Frazier M.S. CCC-SLP
The University of North Carolina Greensboro
Learner Objectives






Define dementia and its hallmark characteristics
Describe ways in which dementias are categorized
Identify characteristics of language of dementia
Use basic scales and bedside exams commonly used in
dementia care
Describe SLP role in treatment of patients with
dementia
Contrast compensatory therapy with rehabilitation
Which most accurately defines and describes
dementia?
O Progressive disease associated with old age that is characterized by
impairment of speech, language, and swallowing
O Disease with various symptoms associated with Central Nervous
System deterioration whose major impairments are in the areas of
Cognition, Memory and Communication
O Degenerative disease associated with lesions to the brain which most
often results in language, memory, and motor disturbance
O Devastating and heartbreaking
What is dementia?
Mixed bag of
signs and
symptoms of
CNS
degeneration,
complicated by
variability,
progressive and
persistent
deterioration of
intellectual
function
Memory
• Forgetfulness
• Profound Impairment
Cognition
• Problem Solving/Judgement
• Orientation
• ADL
Communication
• Semantics most affected
• More automatic structures spared
Various types of Dementia are often categorized into
which of these?
O Cortical/Subcortical Types
O Reversible/Irreversible Types
O Both of these
Categorizing Dementia
Reversible vs. Irreversible
Cortical vs. Subcortical
Cortical vs Subcortical Dementia

Examples of Each
DAT
http://www.youtube.com/watch?v=7wbYEK7O14E&feature=related
Huntington’s
http://www.youtube.com/watch?v=JzAPh2v-SCQ
What differences do you notice between them?
Which Category?
O Cortical
O Subcortical
O Reversible
Alzheimer’s Disease
Alzheimer’s Characteristics







Cortical Dementia
Disorientation
Communication affected
Short term memory impaired
Long term memory impaired
Impaired judgement and abstraction
Personality Changes
Mini Mental State Exam
CLINICAL STAGING OF DAT:
NYU/Silberstein Scale p427-428 in textbook
Stage 1 (No Cognitive Impairment)
Normal mental and motor function.
Stage 2 (Very mild decline)
Stage 3 (mild cognitive decline)
Early Stage Alzheimer’s can be diagnosed in some but
not all individuals with these symptoms
Stage 4 (moderate cognitive decline)
Mild or early-stage DAT
Stage 5 (Moderately severe cognitive decline)
Moderate or mid-stage DAT
Stage 6 (severe cognitive decline)
Mid Stage DAT
Stage 7 (Very severe cognitive decline)
Late Stage DAT
“HIV is now becoming one of the leading
causes of dementia worldwide…”
Sacktor, N. (2002). The Epidemiology of Human Immunodeficiency Virus-Associated Neurological Disease in the Era of Highly Active
Antiretroviral Therapy. Journal of Neurovirology, 8(2), 115-121. doi:10.1080/13550280290101094
“Confusion, forgetfulness, cognitive symptoms”
HIVD: Acute vs. Chronic

Early on, dementia was acute and severe
 Entire
course was often matter of weeks
“Mental Disorders can develop into full-blown dementia in just a few
days from the appearance of the first symptom, or take as long as
two months.” (Lezak, 2004, p275)

Since mid-90’s, more often chronic cognitive
involvement that spans life of disease
 May
last for years
HIV-D Characteristics






Subcortical dementia *
Psychomotor slowing
Memory deficits
Impaired executive function
Impaired visuospatial function
Impaired recall/retrieval
*With cortical features – memory is one of the primary deficits
Cognitive Profile

Executive Function
 Effect
on social skills, communication
 Work/Activities

Memory
 Effect
on HAART adherence
 Recall & retrieval impact on function
 Co-morbidity factors
HIV Dementia Scale
Power, et al. (1995) HIV Dementia Scale: a rapid screening test.
J Acquir Immune Defic Syndr Hum Retrovirol. 1995;8(3):273–278
CLINICAL STAGING OF ADC:
Memorial Sloan Kettering Scale
Stage 0 (normal)
Normal mental and motor function.
Stage 2 (moderate)
Cannot work or maintain the more demanding aspects
of daily life, but able to perform basic activities of
self-care.
Ambulatory, but may require a single prop.
Stage 0.5 (equivocal/subclinical)
Either minimal or equivocal symptoms of cognitive or
motor dysfunction characteristic
of ADC, or mild signs (snout response, slowed extremity
movements), but without impairment
Stage 3 (severe)
of work or capacity to perform activities of daily living Major intellectual incapacity (cannot follow news or
(ADL). Gait and strength are normal.
personal events, cannot sustain complex conversation,
considerable slowing of all output) or motor disability
Stage 1 (mild)
(cannot walk unassisted, requiring walker or personal
Unequivocal evidence (symptoms, signs,
support, usually with slowing and clumsiness of arms as
neuropsychological test performance) of
well).
Functional intellectual or motor impairment
characteristic ADC, but able to perform all
Stage 4 (end stage)
but the more demanding aspects of work or
Nearly vegetative. Intellectual and social
ADL. Can walk without assistance.
comprehension and output are at a rudimentary level.
Nearly or absolutely mute. Paraparetic or paraplegic
with double (urinary and bowel) incontinence.
Assessment



Full Neuropsych Evaluation likely
SLP may be “front line” in early stages
Differential dx from similar looking diseases
 ABCD
(AZ Battery Comm Dementia)
 Global Deterioration Scale
 “Bedside Eval” – quick tests
“Clock Drawing” & Visuospatial Tests
Practice: MMSE
3 objects:
Apple
Table
Penny
Close Your Eyes
Practice: MMSE Scoring
Normal score: 24 or higher
There are published norms based on age, education, gender. There are norms
for native Spanish speakers, and the “very old” population
Example:
Eighth Grade Education
Ages 18 to 69: Median MMSE Score 26-27
Ages 70 to 79: Median MMSE Score 25
Age over 79: Median MMSE Score 23-25
High School Education
Ages 18 to 69: Median MMSE Score 28-29
Ages 70 to 79: Median MMSE Score 27
Age over 79: Median MMSE Score 25-26
College Education
Ages 18 to 69: Median MMSE Score 29
Ages 70 to 79: Median MMSE Score 28
Age over 79: Median MMSE Score 27
Comfort with MMSE?
O Very Comfortable
O Sort of Comfortable
O Not very comfortable
O Can’t figure it out
Impact of Dementia
"For me, disabled is not being able to keep up,
not being able to fully function, and feeling the
guilt, and feeling the sadness and the
emptiness, the loss. That's disability – just
feeling exhausted and worn out"
(study participant, O'Brien, Bayoumi, Strike, Young, & Davis, 2008)
Impact of Dementia







Disruption in self-care abilities
Slowed information processing
Impaired problem solving
Changes in affect
Reduced social functioning
Failure to adhere to medication regimen
Very difficult for caregivers
Which describes the role of the SLP in the treatment of
clients with dementia?
O Build memory skills so that patient can function more effectively
at work and home
O Help patient become more focused and clear in conversations
with friends and family members to reduce frustration
O Develop compensatory strategies for deteriorating skills to
support participation in daily activities and connection to loved
ones
Role of SLP



Develop strategies to compensate for cognitive
changes
Critical to maintain medical compliance
Support for family/caregiver
 Increased
responsibilities as disease progresses
 Society not very supportive
 Enabling meaningful connection with patient vital
Role of SLP (ASHA)



Increase reliance on spared systems and decrease
dependence on impaired ones
Strengthening of knowledge and processes that
have the potential to improve
Design interventions that will evoke a positive
emotion in the client
http://www.asha.org/docs/html/TR2005-00157.html
Role of SLP (ASHA)



Must consider the cultural background of their
clients
Direct intervention: work directly with individuals
who have dementia
Indirect intervention: environmental modifications,
development of therapeutic routines and
activities, and caregiver training
http://www.asha.org/docs/html/TR2005-00157.html
Role of SLP - Strategies

Restorative


Promote recovery and restore function
Compensatory

Internal
Enhanced Learning
 Mnemonics


External
Environmental Modifications
 External Aids

Parsons & Robertson http://www.medscape.com/viewarticle/513278
Singing For The Brain
http://www.youtube.com/watch?v=J4S_FX9bieg&feature=BF&playnext=1&list=QL&index=3
The “Other” Role of SLP
ASHA has a
progressive
nondiscrimination
statement which
includes “sexual
orientation” as a
protected status and
strongly urges the
membership to
develop cultural
competence as a
matter of ethical
service delivery.
Counseling
Education
Advocacy
http://www.asha.org/docs/html/PS2005-00118.html