diffuse impairment of memory, intellect, and cognition.  It usually appears later in life and generally gets worse over time.  Behavioral and personality changes, and physical impairments are also common

"insidious onset" - no defining point - it happens over time

• impaired short term & long term memory
• impairments in at least 1 :
• abstract thinking, personality, judgment, constructional ability, language, praxis, visual recognition

• gradual/insidious onset
• not accounted for by delirium, schizophrenia, or depression
• it is acquired (not congenital)
• persistent
• exhibit across sever mental functions - diffuse
• severe enough to interfere with work, social activities and relationships (daily life)

• memory failure
• disorientation
• lapse in judgment - give away lots of money
• difficulty performing daily life activities
• difficulty with mentally challenging tasks - balancing a checkbook
• misplacing things - put in odd suits
• apathy & loss of initiation
• mood changes - radical

1. reversable - malnutrition - utlizing drugs - infection - metabolic disturbances
2. irreversable

1. subcortical dementias- pathological changes in the basal ganglia, thalamus, and brain stem -
• motor function changes first, then cognitive later - Parkinson's Disease (decreased loudness - nasal, rate of speech = early on)
2. Mixed dementia - vascular types - cause by pathologic changes in both cortical & subcortical structures
3. Cortical dementia - caused by pathological changes in the cortical structures; high level(memory) - top down to memory
• DAT - dies of aspiration of pneumonia - motor system
• Pick's Disease & Fronto-Temporal

• motor impairments then cognitive deficits
• Parkinson's Disease
• Hunington's Disease
• Progressive supranuclear plasy
• HIV
• Identifying Subcortical
• less ambiguous because we know which diseases typically progress into dementia
• expected manifestation of diseases in mid-->late stages

Subcortical Dementias:

Parkinson's disease

• degenerative affects nuclei in midbrain & brainstem
• depletion of dopamine in substantia nigra
• muscle rigidity, tremor, slowness, reduced mvmt
• 55-65years of age
• slow deterioriation of mental & motor function
• usually die 15-20 years after onset
• cause: unknown
• more men than women

Subcortical Dementias:

Hunington's Disease

• inherited degeneragitve
• diagnostic markers :
• chorea, cognitive decline, and neurobehavioral symptoms
• due to neuronal loss in putamen & caudate
• 40-60 years (sometimes as early as 20)
• dies 15-20 years after onset

Subcortical Dementias:

Progressive supranuclear plasy (PSP)

• rare
• resembles PD - rigidity & slowness of movement
• differs - absence of tremor & in presence of rigidity affecting muscles of the neck and trunk
• degeneration of brainstem & neurons in B.G.
• severe motor disturbances especially muscles by CN

Subcortical Dementias:

HIV

• transmitted by body fluids; there is no cure
• immune deficencies
• younger than 35 years of age
• 70% with AIDS / HIV developing dementia
• results in death in 90%
• subcortical (B.G.) to cortex

• vascular disease is an important cause of dementia in adults
• umbrella term caused by vascular disease "multi-infarct dementia"
• produces reduced cerebral involvement
• slow accumluation of neurologic events eventually producediffuse cerebral involvement and dementia
• repeated infacrts in different locations --> diffused damage
• personality & intelect preserved, until later stages
• produces reduced cerebral involvment
• increases with age with prevelance

1. Lacuna State - repeated infarcts in Brainstem, Basal Ganglia, and Thalamus
2. Multiple cortical infarcts - small strokes - most common
3. Binswanger's  - white matter (subcortical pathways) severe hypertensions

1. DAT
2. Pick's
3. other causes of demention
• normal-pressure hydrocephalus
• creutzfeldt--jakob disease
• occasional causes of dementia - brain tumors, bacterial or viral infections of the brain, hematoma

Cortical Dementia:

DAT - frontal & occipital lobes are sparred --> posterior dementia

• most common cause & most prevelant
• Caused by:
• neurogibrillary tangles - affect transmission of signals - filaments/fibers on axons become tangled - affects conduction
• neuritic placque -small area of nerve cell degeneration - reminents of neuronal process left
• granuovacular degeneration - pockets/fluid filled cavities that develop - usually in hippocampus
• progressive deteoration of intellect
• die of aspiration pneumonia 
• early stages = language less affected than conginition, memory, or intellect
• changes in temporal-parietal-occipital junction

Cortical Dementia:

Pick's Disease

• frontal lobe damage -
• difficulty initiation; hyper oral; poor daily activity carrying out; OCD
• language breakdown occurs early in progression and cognitio and memory breakdowns occur later
• Pick bodies in frontal lobe - TAU protein - abnormal amount
• no known cause
• personality/emotional changes - 1st symptoms
• disinhibited, impulsive & inappropriate in behavior
• occurs before 65 years of age! (54 years is the average)

• rarely have motor problems (early)
• forgetfulness, mental slowing, apathy (indifferent - does not matter what happens), depression, fatigue, and simial non-specific impairments
• **look at memory & nonverbal**
• dementia does poorly regardless verbal vs nonverbal
• DAT depeds upon mental effort needed
• DAT - social syntax affected later on - disorientation (place, time, person), but they know their name

1. Blessed Dementia Scale - uses information obtained from family members, caregivers, and patient's medical record to estimate the patient's ability to get along in daily living activites
2. Global Deterioration Scale - assigns patients to one of seven levels representing increasing severity of  intellectual imapirments, completed after interviewing the patient, family members, and caregivers **used most frequently**

depressive symptoms (loos of appetite, loss of cognition, ADLs change, withdraw socially)

mimics dementia

family can say when it started - they can identify onset

course/development = rapid

short answers - little effort - not concerned about performance

Assessment:

Language & communication

Comprehension & Retention

• Language & communication
• Arizona Battery for Comm. Disorders of Dementia - ABCD
• Boston
• Western
• Comprehension & retention of spoken language
• PPVT
• Delayed story retelling
• spoken sentence comp. test
• discourse compt test
• anything shows up as indicator - must be addressed in Tx

Assessment:

Speech Production

• generative naming
• controntational naming test - boston
• sample of connected speech
• cookie theft picture
• information about the ability to produce cohesive and topically relevant narrative

**mild- pretty well on delated story retell, PPVT, mini mental or gestural pantomine**

• clinical objectives of intervention:
• minimize effects on everyone -
• ensure patient's safety
• to keep the patient healthy - swallowing
• to provide support & direction for the patient, family, & caregivers
• The patient & the family - experiencing dementia:
• magnitude & nature stresses increases as the patient's intellectual and behavioral dysfunction progress
• symptoms - at first - may be subtled and overlooked/ignored

Management Issues:

Early Stages

What do you focus on (8)?

1. memory
2. language and communication
3. anxiety/depression
4. behavioral changes
5. denial
6. excess disability
7. health

Management Issues:

Early Stages

memory & language/communication

• memory- most troublesome
  
• declaractive - from the past
• prospective - do things at specific time - remember to remember
• procedural is spared - motoric activities/keep busy
• language and communication
• sufficient ADLs; subtle problems early on
• typically have sufficent langauge comp. and speech to manage routine daily-life situations
• subtle attn & memory problems compromise patient's retention of spoken or printed material - affect retention of spoken & written

Management Issues:

Early Stages

anxiety/depression ; behavioral changes

• anxiety/depression
• will be present - loss of control and independence
• behavioral changes
• apathy
• hyperactive - always do something - inability to sit still
• irritable
• mood swings
  

Management Issues:

Early Stages

Denial & Excess Disability

• Denial
• patient often denies or minimize impairments
• Excess Disability
• may be caused by co-existing illness, emotional, psychological state, medications or environmental influences
• sometiems caregivers unintentionally contribute to excess disability by rewarding dependant behavior and ignoring or discouraging independent behavior
• **important to determine; want the patient to answer questions/provide information**
  

Management Issues:

Early Stages

sleep disturbances / health

• sleep disturbances
• medications for sleep
• abnormal sleep/wake ccles
• health
• nutrition & fluid intake
• dehydration can lead to confusion & physical problems
  

• memory and attn impairments increase in severity and affect more dimensions of patient's daily life
• patient's awareness of severity and extent of the impairments diminishes as the impairments become more pronounced
• Trouble shooting behaviors
• memory disturbances
• catastrophic reactions - low frustration levels
• demanding & critical behaviors - cticizing caregivers or others - demand their way
• night walking - restlessness; wonder around
• hiding things - hoarding - paranoid for no reason

1. memory & attention
2. behabioral problems
3. insight, judgment, orientation
4. physical dependence
5. communication

1. physical violence
2. memory disturbance
3. catastrophic reactions
4. incontinence
5. delusions

Insight, judgment, and orientation

middle stage intervention/management

• decreases - more troublesome to keep at home
• or behaviors are hard to manage (violent & delusions)
• restrictors --> irritate patient 
• as the disease progresses, patient needs continual supervision
• need to aply restrictions, which often irritate

Physical Dependence and Language & Communication

middle stages intervention/management

• Physical Dependence
• will not be able to carry out personal care without assistance
• Communication & Language
• 1 sided conversations
• don't initiate conversation
• reponses = tangential - no communicaitonal value - automatic phrases
• happy to sit by themselves - pragmatics start becoming an issue

• no longer able to collaborate in treatment
• help with diets
• routines are important
• non-oral feedings
• dependent on everyone else for ADLs
• **manage behaviors**
• Tx = teaching caregivers to manage behiors, ensure patient's health & security, and maintain patient participation in daily life activities as the patient's condition permits

Intervention: Early Stages

Memory impairments

**pts are aware of thier impairments and willing to participate in programs to teach them compensatory skills**

• has problems remember that
• no effective procedures for direcly improving memory - must compenstate
• mental imagery, memory aids, checklists, memory wallets
• Modify the Patient's daily life environment
• schedule - have calendar helps anticipate for the day - review the schedule for the day
• want a constant day to day
  
• alarm sound when time to perform given activity
• checklists - simple marking off or to go thru complex activity to know it is accomplished
• items used for a given activity are placed together - grooming items

Intervention for Early-mid Stages:

Confusion (more the mid stages)

• large calendar posted in visible area; patient to circle the day on the calendar
• wear watch to indicate time of day & am/pm
• label drawers & cabinet doors with contents
• patient's personal possessions kept in consistent location - no moving around, very stable/consistent
• maps & printed instructions depicting familiar routes are prepared & given to the patient before the patient sets out
• patient to carry card printed with constructive responses to disorientation

1. adaptive strategies - used by patient to regain control when communication breakdown occurs
2. facilitative strategies - used by the patient to prevept or repair comm. failure
3. script strategies - help maintain topic and cohesion with spoken discourse  (follow a script)
4. life-experience strategies - help pt who have difficulty expressing abstract ideas - illistrate abstract ; ideas with life experiences

• common component - patient and caregivers
• Goals include:
• stimulate self expression
• stimulate cognitive processes
• promote social interaction
• enhance feelings of self-worth
• may provide environment to practice strategies

• pt less able to monitor behviors
• intervention now requires collaboration between the clinician and the caregiver
• Managing troublesome behaviors (6)
1. restrict - if doing something undesirable, stop it
2. reassess - or assess
3. reconsider - imagine from person's perspective
4. rechannel - behavior in safe - allow person to own their drawer & rummage through
5. reassure - everything is okay
6. review - go over and see what could be better

• pt less able to compensate for deficitst
• automatic responses & stereotypic responses are more frequent
• how to accept what is going on:
• accepts the patient's contributions at face value
• adapts his/her contributions to the patient's comprehension impairments
• modify input - simplify commands - what is said - 1 command at a time - SLP train to break down
• encourage pt participation
• set aside daily tiem for structured conversation - talk about news or family members
• ensures incidental communicative changes

• still want to stimulate
• provide activities to stimulate - target some skills
• maintaining orientation
• stimulating cognitive processes
• attention, reasoning, memory, etc.
• maintaining communicative abilities
• reinforcing appropriate interpersonal behaviors

• a structured approach to at-home care is important
• focus: environmental control and management of behavioral contingencies
• objective: maintain pt's ability to carry out familiar and well learned daily routines & help pt participate in life experiences
• **ENVIRONMENTAL CUES to elicit routines**
• help caregivers
• motor disability - need a lot of physical assistance
• picture books - don't use - cannot associate meaning

1. environmental manipulation
• reality orientation
• mileu therapy
2. Behavioral Modifications

Intervention: Late Stages:Intervention & Management for Insitutionalized Patients (2)

environmental manipulation

reality orientation

milieu therapy

• environmental manipulation - manipulate the characteristics of patient's living environments to maintain/enhance their cognitive status, communicative competence, and social participation - "auditory bombardment"
• reality orientation - watch when to use in nursing home - get them involved - where they are and what day; oldest and most common approach to management
• milieu therapy - ehances the patients' alertness & increase appropriate social behavior by making the patient's environment more interesting and more conducive to social interactions -

Intervention: Late Stages:Intervention & Management for Insitutionalized Patients 

Behavior Modifications

• Behavior Modifications - manipulates antecedent stimuli and response consequences to influence the frequency and form of specific patient behaviors
• positive reinforcement, negative reniforcement, & punishment  --- like TBI

reality + mileu = behavioral modification (good approach)