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51 Cards in this Set
- Front
- Back
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What is the new term used in DSM-5 in place of dementia? |
Major neurocognitive disorder (NCD) |
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What are the criteria for a mild NCD (per the DSM-5)? |
* Typically just 1-2 SD below the mean on standardized cognitive measures, which may be confounded by really high or low education level * Modest decrease in one or more cognitive domain, causing concern and with modest documented impairment * Does NOT interfere with independence in complex activities of daily living (ADLs) * Not better explained by another cause * Should specify cause and whether with/without behavioral disturbance |
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What are the criteria for a major NCD (per the DSM-5)? |
* Typically 2-3 SD below the mean on standardized cognitive measures (below 3rd %ile) * Significant decrease in one or more cognitive domain, causing concern and with substantial documented impairment * Interferes with ADLs--at a minimum, assistance needed in complex ADLs * Not better explained by another cause * Should specify cause, whether with/without behavioral disturbance, and current severity |
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What are some reversible causes of dementia? |
pseudodementia (associated with severe depression) and adverse drug reaction = most common (but still rare)
Also metabolic imbalances (severe hypothyroidism), normal pressure hydrocephalus (triad of symptoms = onset of cognitive decline, ataxic gait, incontinence), or infections (e.g., syphilis) |
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What is the current and projected incidence of dementia? |
In 2010 = 5.1 million Americans
Projection for 2050 = 11 to 16 million Americans over the age of 65 |
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What are the four most common classes (etiologies) of irreversible dementia? |
1) NCD due to Alzheimer's 2) Vascular NCD 3) NCD with Lewy bodies 4) Frontotemporal NCD |
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What are the diagnostic criteria for dementia due to Alzheimer's disease (DAT) |
* Meets criteria for NCD * Has insidious onset and gradual progression * Major = at least 2 domains including decreased memory/learning + one or more others + Minor = at least 1 domain (decreased memory/learning) |
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What are 3 diagnostic markers of Alzheimer's disease? |
1) amyloid neuritic plaques - extracellular deposits clogging spaces between neurons 2) neurofibrillary tangles - intracellular deposits of tau protein that interfere with transport of nutrients/molecules w/in brain cells 3) cortical atrophy |
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What are 2 neurotransmitter changes that accompany the pathologic changes in Alzheimer's disease? |
1) Pronounced decrease in production of acetylcholine (important for learning and memory) - so has led to drugs that inhibit AchE (e.g., Donepezil, Rivastigmine, Galantamine)
2) Excessive release of glutamate - so has led to drugs to regulate glutamate levels (e.g., Memantine) |
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What is the strongest risk factor for Alzheimer's disease? |
Age!
(Another one we're learning more about is diabetes, esp. Type 2) |
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Compare early, middle, and late stages of Alzheimer's. |
Early = Impaired episodic memory as well as difficulties with working memory; but other memory forms (including semantic memory) still intact
Middle = Worsening early stage symptoms + impairment of semantic memory beginning to show up (esp. on pure recall tasks; still may be ok in recognition and cued recall); nondeclarative memory still intact
Late = All declarative memory impaired as well as some aspects of nondeclarative (i.e., procedural) memory, but very ingrained habits may still be intact |
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What are 3 concomitant aspects of cognition (along with memory) that are often impaired in Alzheimer's? |
1) Attention - may be seen even in early stages, particularly selective and divided attention
2) Visuospatial processing - e.g., misinterpreting a stimulus, like may think a rug is a hole in the floor
3) Executive functioning - judgment, problem solving, etc. |
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Describe the cognitive-linguistic profile of early stage DAT. |
* Difficulty with word finding - but circumlocution often leads to the right word * Problems comprehending abstract language/following complex conversation * Often aware of lapses in concentration or attention * Intact phonological, syntactic, and pragmatic skills * Reading and writing generally intact |
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Describe the cognitive-linguistic profile of moderate stage DAT. |
* Gradual worsening of semantic abilities * Creative, novel generation of language more difficult * Output becomes increasingly irrelevant and tangential (or using more vague/general terms because of anomia) * Phonology and syntax remain intact, as well as oral reading and simple writing * Can contribute meaningfully to conversations with support * May provide on topic responses to questions and can respond best to concrete questions |
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Describe the cognitive-linguistic profile of severe stages of DAT. |
* Exacerbation of word finding difficulties (with decreased awareness by patient) * Severely reduced vocabulary * Conversations filled with vague, generic words * Minimal comprehension of simple, familiar phrases *Reading/writing of simple words & phrases may be intact |
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Describe the cognitive-linguistic profile of late stages of DAT. |
* Language becomes severely impaired in expression and comprehension * Ambiguous, echolalic, perseverative utterances deteriorate to incoherent mumbling and eventual mutism |
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What are some associated behaviors of DAT? |
Depression, apathy, irritability, insomnia, incontinence, delusions, agitation, combativeness, wandering, dysphagia |
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What is the GDS and what do the scores mean? |
GDS is Global Deterioration Scale (1-7)
1-3 = pre-dementia stages 4 = mild dementia 5 = moderate dementia (patient can no longer survive without assistance) 7 = severe dementia |
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What are the diagnostic criteria for vascular dementia (per the DSM-5)? |
* Meets criteria for NCD * Cerebrovascular disease present * Clinical features are consistent with vascular etiology: onset temporally related to vascular event (e.g., CVA) OR decline prominent in complex attention, processing speed, and executive functions |
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Describe common symptoms you might expect to see in vascular dementia. |
Symptoms will depend on distribution and type of lesions: * Language changes may be focal in nature and co-exist with hemiparesis, facial weakness, visuospatial deficits, etc. * Memory impairment common, as well as: executive function problem, attentional problems, personality/mood change/lability * Stepwise deterioration pattern more typical (than gradual progression seen in DAT) |
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What are 4 main differences between DAT and vascular dementia? |
1) VaD = stepwise progression after abrupt onset; DAT = gradual progression after insidious onset
2) VaD = focal neurological signs present; DAT = focal neurological signs usually absent
3) VaD = better performance on immediate/delayed memory measures (than DAT); DAT = cardinal, early-appearing, severe deficit in delayed verbal memory measure
4) VaD = attention tends to be worse than in DAT; DAT = attention better than in VaD |
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What are the diagnostic criteria for Lewy body dementia (LBD)? |
* Meets criteria for NCD * Slow onset and gradual progression * Core diagnostic features: fluctuating cognition w/ pronounced variations in attention/alertness; recurrent & detailed visual hallucinations; spontaneous features of parkinsonism * Suggestive diagnostic features: REM sleep behavior disorder, severe neuroleptic sensitivity
Probable = 2 core features, or 1 core + 1+ suggestive feature Possible = 1 core feature, or 1+ suggestive features |
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What are Lewy bodies? |
* They commonly coexist with the plaques of Alzheimer's disease * They are pathological markers of Parkinson's disease (PD), where they are abundant subcortically in the basal ganglia * In LBD, they are far more distributed in a widespread manner, throughout frontotemporal cortex, brainstem, and subcortical areas |
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What are some expected symptoms/signs of LBD you might expect to see? |
* Progressive, often rapid (1-5 year) course * Periods of normal cognition alternating with abnormal cognition in early stages --> leads to a wide fluctuation of cognitive skills in assessment * Associated confusion, memory difficulties (in later stages), and attentional deficits will disrupt communication in ways similar to DAT
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What are the diagnostic criteria for frontotemporal dementia (FTD)? |
* Meets criteria for NCD * Slow onset and gradual progression * Relative sparing of learning/memory and perceptual motor function * Behavioral variant: 3 or more behavioral symptoms (disinhibition, apathy, loss of sympathy/empathy, perseverative/compulsive/ritualistic behavior, hyperorality & dietary changes) AND prominent decline in social cognition and/or executive abilities * Language variant: prominent decline in language ability (same as Primary Progressive Aphasia) |
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What is MCI and how does it fit in with the new DSM-5? |
MCI = mild cognitive impairment
This is now what is considered mild NCD - the person is experiencing a decline that can be documented but is not yet interfering with their complex ADLs (e.g., paying bills)
A risk factor for dementia, but not everyone with MCI goes on to develop full dementia (i.e., major NCD)
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What are 3 factors that determine whether an evidence-based practice gets implemented in clinical practice? |
1) perceptions of evidence 2) organizational culture and climate 3) facilitation |
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What are some things to be sure to rule out when doing an assessment where dementia is suspected? |
Side effect of drugs - check medical records & consult with pharmacist about side effects
Depression
Vision impairment
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What are two things you should do before beginning an assessment of dementia? |
1) Screen for vision, hearing, literacy (by reading just a few sentences)
2) Make sure environment is conducive (quiet, well lit without shadows, etc.) |
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What are two tests that can be used to screen general mental status (orientation, general knowledge)? |
1) ABCD (Arizona Battery of for Communication Disorders of Dementia) - Mental Status subtest (13 items, < 5 min)
2) Mini-Mental State Exam - but a lot of research suggests this is not a very good screening tool because it can miss many people--there are better general tools for quick overall screening (RBANS, MOCA) |
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What are three tests/methods for screening episodic memory? When would you especially want to do this? |
Would want to do it if you suspected DAT (most typical presentation of dementia)
1) Story retell (immediate and delayed) - subtest from ABCD is great, very sensitive and specific, as well as quick
2) Word learning - again, subtest of ABCD is great
3) Mini-Cog - takes 2-4 min to give (recall 3 words, distractor task [draw clock], recall 3 words again)
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What is a good screening measure of language during a dementia assessment? |
Verbal fluency (letter or semantic category) - a great, quick one is the generative naming subtest of the ABCD - good sensitivity and specificity |
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What are 2 comprehensive screenings for dementia that can be used? |
1) RBANS - good at distinguishing mild impairment from cognitively intact peers, but there are questions about its sensitivity
2) MOCA - 90% sensitivity to detecting mild cognitive impairment in one study (way better than Mini-Mental); but age- and education-based norms suggested |
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What are 3 reasons to do a comprehensive assessment with someone who comes already having a diagnosis of dementia? |
1) Establish what needs to happen in treatment - a profile of their impairment
2) Determine what supports they respond to best (using dynamic assessment!)
3) To be able to give detailed instructions/suggestions for communicating with client when making suggestions to caregivers |
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What are 5 areas that should be assessed in a person with suspected mild NCD? |
1) Memory - especially declarative (because so common in DAT); possibly other aspects depending on complaint; California Verbal Learning Test or Wechsler Memory Scale subtests 2) Executive function - Wisconsin card-sorting task, trail-making test, but functional observation of person performing a task is always going to be the best method 3) Language - expressive and receptive; could use Boston Naming Test, discourse sample, some subtests of WAB, verbal fluency tasks 4) Visuospatial functioning - use figure copying task 5) Attentional control - use a divided attention task |
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What are comprehensive dementia batteries appropriate for 1) mild, 2) moderate, and 3) severe stages of dementia? |
1) ABCD
2) Functional Linguistic Communication Inventory - can compare to others with Alzheimer's, subcategorized by severity
3) Severe Impairment Battery - composed of very simple 1-step commands accompanied by gestural cues |
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Aside from case history/interview and overall/specific domain testing (formal and informal), what is another important component of assessment for dementia? |
Caregiver quality of life!! - use a scale/rating form/schedule - there are several available |
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What are 3 general treatment principles for dementia treatment? |
1) Capitalize on spared cognitive abilities while reducing demands on impaired abilities
2) Include individualized stimuli that evoke positive emotion, action, and memories
3) Maintain quality of life through engagement in tasks that are personally relevant and likely to be used daily |
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What are two direct interventions in dementia treatment that we discussed? |
1) Reminiscence therapy
2) Spaced retrieval training (with errorless learning) |
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What is reminiscence therapy? |
Often conducted in groups; recall is stimulated through presentation of pictures, newspaper articles, video clips, props associated with a theme (e.g., world events, holidays, weddings)
Rationale is that there is greater preservation of remote memory in early-mod stages of dementia, and capitalizing on this strength can enhance communicative interactions and pysch well-being |
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What is spaced retrieval training? |
The rationale is that conceptual associations are strengthened through repeated activation of stimulus-response pairing
Patient told a piece of info and asked to recall the info repeatedly and systematically over time, with intervals between recall lengthened to facilitate production of a high number of correct responses over longer periods of delay (ERRORLESS LEARNING)
Note: this does NOT restore memory processes/improve general memory function; rather, it is meant to target/alleviate specific problems in activities/participation |
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What is the profile of a good candidate for spaced retrieval training? |
Declarative memory impairment with cognition mildly to severely impaired and ability to engage in structured training tasks |
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What is errorless learning and why is it used? |
What = providing sufficient cueing and scaffolding to minimize errors with gradual fading of cues as target is learned
Why = explicit recall of learning episode impaired, and repeated activation of error response strengthens the error, so we don't want to do that! |
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What are some steps for implementing errorless learning? |
1) Break the targeted task into small/discrete steps or units 2) Provide sufficient models before the client is asked to perform the target task 3) Encourage the client to avoid guessing (and just say "I don't know" if they aren't sure) 4) Immediately correct errors 5) Carefully fade prompts |
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What is the definition of indirect interventions in dementia treatment? |
Per Hopper, improve communicative function through caregiver training, mods to physical environment, and development of therapeutic routines and activities |
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What are 4 examples of indirect interventions that can be used in dementia treatment? |
1) memory books 2) memory aids 3) caregiver training (including communication strategies specific to stage/severity of dementia) 4) modifications to physical environment (including ensuring safety) |
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What are some examples of memory aids that can be useful for clients with dementia? |
Step-by-step instruction cards, calendars and planners, written supports to help person remember names of friends, hobbies, etc., other picture/writing aids and cues (e.g., pain scale, visual pics of body parts to show where pain is, etc.) |
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What is the most important theme to be taught in caregiver training in communication strategies? |
Use validation and not confrontation! (Okay to reinforce the client's own frame of reference) |
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What are 4 main techniques for validating/not confronting in caregiver communication? |
1) Repeating/reformulating their utterances 2) Attempting to understand feelings being expressed 3) Use calm/soothing communication & body language 4) Gentle redirection |
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What are 2 undesirable behaviors in people with dementia that caregivers can be trained in some strategies for coping with/reducing? |
1) Disruptive vocalizations - encourage caregiver to identify triggers as well as best ways to calm the patient
2) Repetitive question asking - recommend that caregiver not continue to answer but instead comment on and maintain topic of conversation; then, if appropriate, can train use of written instructions/reminders to have patient redirect himself (e.g., a simple daily schedule) |
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What are 4 modifications to the environment that empirical evidence supports making for clients with dementia? |
1) Increased natural light 2) Reduce/eliminate strong contrasts and patterning in flooring, but provide strong contrasts for dish vs. table, floor vs. toilet, etc. 3) Reduce clutter 4) Minimize or remove mirrors
*Also: adding visual cues may be helpful! |
