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179 Cards in this Set
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what is the CDC Behavioral Risk Factor Surveillance System |
data collection system from 50 states like mental health risk factors, demographics, social and emotional support, days with health problem in order to increase awareness and help get services and remove stigma and health disparities
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what is FMD?
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frequent mental distress= >14 days with poor mental health in a month
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Depression definition
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a persistent or recurrent disorder d/t psychosocial stress or physiological effects of dz
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what is late life depression?
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Late-life depression includes aging patients whose mood disorder presented in earlier life & patients whose mood disorder presents for first time in later life
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whose effected by depression?
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1. Affects 25% patients w/chronic illness
2. 20% >55 y/o experience some type of mental health concern 3. Affects 15 out of every 100 adults over age 65 4. Affects >50% patients in nursing homes |
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Where is depression commonly treated?
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> 80% percent cases treated in primary care setting but many cases remain unrecognized
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is depression normal in older adults?
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no, but many Clinicians assume it's normal age-related changes when depression symptoms are present
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biologicsal risk factors for late life depression
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family hx, depressive episodes or suicidal attempts, current or past substance abuse and Changes in catecholaminergic neurotransmitters d/t aging (epinephrine, norepinephrine, dopamine)
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physical risk factors for late life depression
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Loss of physical abilities or sensory function (vision or hearing); chronic dz, drug interactions
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depression percentage in community elder
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2%
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depression percentage in chronically ill
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9%
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depression percentage in geriatric inpatients/hospitalized/stroke/ca/MI/parkinsons
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over 30% for each catagory
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Psychological risk factors for late life depression
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Cognitive decline
Underlying personality disorder Unresolved conflicts (anger, guilt or perceived sense of unmet needs) Impaired spiritual well-being |
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Social/situational
risk factors for late life depression |
Loss family & friends
Loss of job or status Loss of income/low socioeconomic status Isolation (single, living alone ) Limited social support Loss of independence (drivers' license) |
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Late Life Depression is...
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Not part of normal aging!
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when to assess depression risk factors
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New onset or 2ndary co-morbidity or chronic dz: related to disability, QOL, cognitive changes
Progression of early life psych dz |
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Assess suicide risk
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US: >65 y/o account for 25% of all suicides w/70% older adults suffer from depression
Older men (>85 y/o) have highest suicide rate |
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Suicide risk factors
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Caucasian, male, death or divorce of partner/spouse, isolation
Low paying job or unemployed, retired, poor self-esteem Poor health or terminal illness, persistent pain Substance abuse/ETOH, PMH or FHx psych dz |
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Late Life Depression presentation
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1. Constitutional: fatigue, weak, wt loss, sleep quality
2.Somatic complaints: aches & pains w/out apparent cause 3.Psych: apathy & withdrawal, loss of self esteem, inability to concentrate, sadness, being a burden, suicidal |
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Late Life Depression general symptoms
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Change in appetite (oral health, food access, anosmia, anorexia)
Unintentional weight loss Insomnia or excessive sleeping Loss of energy |
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Late Life Depression cardiac symptoms
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Chest pain, palpitations, dyspnea
Dizziness |
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Late Life Depression GI symptoms
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Abdominal pain
Constipation Diarrhea |
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Late Life Depression Genitourinary symptoms
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Incontinence, frequency, urgency
Reduced sex drive |
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Late Life Depression Musculoskeletal
symptoms |
Weakness
Diffuse or persistent pain (especially back): restless |
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Late Life Depression Neurological
symptoms |
HA, dizziness, memory or concentration disturbance,
paresthesia, agitation , bradykinesia |
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Late Life Depression Psychiatric
symptoms |
Feeling sad or unhappy
Anhedonia Feelings of worthlessness or guilt Frequent thoughts of death, dying or suicide Irritability, frustration, or angry outbursts Crying spells for no apparent reason |
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what is the two question screen for depression?
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Over the past month: have you been bothered by feeling down, depressed or hopeless? Have you been bothered by little interest or pleasure in doing things?
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what to do if have a positive 2 question depression screen?
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evaluate to see if they have w/suicidal ideation, plan or attempt
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questions to ask about suicide
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1.How has your life changed over past months? (recent loss/adjustments/new diagnosis/coping/self-medicating)
2. Do you ever feel that you'd be better off dead or your family would be better off w/out you? If there were no ramifications would you kill yourself? |
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PE for late life depression
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PE: evaluate for physical causes that mimic depression
-VS: orthostatic BP, wt pattern, P, RR -GS: grooming, dress & hygiene, affect, speech -C-P: rhythm, ease of breathing -GI: organomegaly, masses, ascites -GU: masses -Vascular: edema, stasis -MSS/CNS/psych: atrophy, gait, balance, strength, MS screening questionnaires, thought process & content |
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diagnosing late life depression can be...
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complicated. Assess risk factors, comorbidities, medications,use validating screening tools, use dsm 5, labs and imaging PRN
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Types of validating screening tools for depression
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-2 question screen
-Geriatric depression scale -PHQ-9 -Cornell scale for depression in dementia (CSDD) -Center/Epidemiologic studies depression scale |
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Geriatric Depression Scale (GDS) (5 questions for it)
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-Are you basically satisfied with your life?
-Do you often get bored? -Do you often feel helpless? -Do you prefer to stay at home rather than going out and doing new things? -Do you feel pretty worthless the way you are now? |
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The two question screen is
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sensative but not very specific
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the GDS is
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is sensative and fairly specific
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late life depression labs based on linical acumen
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CBC w/diff'l, sed rate
Chemistries: electrolytes, renal function, LFTs Serum calcium, vit D, B12, folate, albumin UA w/ C&S TSH, RPR & FTA + 12-lead ECG, CXR, DXA + LP, head CT/MRI Urine/blood toxicology |
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Management goals of late life depression
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Timely & correct diagnosis
Resolve symptoms Maintain independence -Improve function & quality of life Monitor suicide risk |
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management options for late life depression
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1. Disposition
-Outpatient: usual care (PCP, PRN psychiatric referral &/or psychotherapy (learn triggers, coping skills, mood elevating activities) -Outpatient community models: IMPACT, PEARLS -Inpatient (stat, temp hold) w/psych consult 2.Nonpharmaceutical options 3.Pharmaceuticals |
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what is the CDC & Nat'l Association of Chronic Dz Directors (NACDD) Team-based & evidence based collaborative care programs?
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these are programs that are:
1.Patient centered: integrate medical & mental health needs 2.Ongoing assessment w/validated severity instrument to assess Rx response 3.Use proven Rx therapies based on EBM guidelines |
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Impact & PEARLS models are what?
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CDC & Nat'l Association of Chronic Dz Directors (NACDD)
Team-based & evidence based collaborative care programs |
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Impact Model: (Improving Mood-Promoting Access to Collaborative Treatment)
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Doubles effectiveness of depression Rx for older adults in primary care settings
-12 months: 50% reduction in depressive symptoms vs. 19% w/usual care -IMPACT patients > 100 additional depression-free days over 2 yr. period compared to usual care -Benefits persist up to 1 year even when resources not available |
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impact model settings
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HMO, fee-for-service, VA clinics, inner city
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who should be in an impact model
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Suitable for persons with or w/out comorbid medical conditions or anxiety disorders
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impact mpodel costs
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lowers average cost by
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4,000-5,000 =
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impact models rely heavily on
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Collaboration: PCP w/care manager = EBM based treatment plan (meds, brief on-site psychotherapy) & depression care manager: RN, social worker, psychologist
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essential elements of an impact model
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1.Pt education
2.Coach beh'l activation via pleasant events schedule 3. 6-8 sessions problem solving & monitor treatment response 4.Relapse prevention plan for each person that shows improvement 5.Designated psychiatrist consults on pts that do not achieve expected response to treatment 6.Outcome measurement: use validated tool (i.e. PHQ-9) at onset & regular intervals 7.Stepped care: adjust treatment based on clinical outcomes & evidence based algorithms -Expect 50% reduction in symptoms w/in 10-12 weeks -Alter plan if not achieved |
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how soon do you see a 50% in problems with IMPACT model
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10-120 weeks- if not adjust plan
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what is PEARLS program?
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PEARLS Model (Program to Encourage Active Rewarding Lives for Seniors)
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how is PEARLS delivered?
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Delivered via existing service provision programs in community or in the home
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PEARLS is a ....
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Team based (medical providers, supervising psychiatrists, PEARLS counselors) model
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PEARLS is suitable for
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Suitable for persons w/chronic dz & depression
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PEARLS goals
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improve QOL & reduce depression symptoms
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PEARLS teaches skills to enable
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action & make lasting changes via Problem Solving Treatment (PST) and take on Problems daily life that cause &/or maintain depression symptoms
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Problem Solving Treatment (PST) systematically addressees
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problems. to make problems less severe & have fewer depressive symptoms
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PST gives clearly defined
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problems & set concrete/realistic goals which gives a person sense of control over life & empowerment to make lasting changes
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PST overview
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1. Common sense approach
2. Uses six to eight 45-60 minute sessions/6 months 3.Focuses on present (here & now) 4. Addresses social, financial, health related issues |
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PST steps
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1.Clarify & define problem
2.Set realistic goals 3.Generate multiple solutions then 4.evaluate & compare solutions 5.Select & implement feasible solution 6.Evaluate the outcome |
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nonpharm ways to treat depression
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-Exercise body: aerobic, tai-chi, qigong
-Keep brain/mind active -Social activities (volunteer, support groups, learn a new skill or new hobby) -Sleep hygiene -Healthy diet -Pet therapy -Humor/laughter |
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SSRIs (selective serotonin reuptake inhibitors)
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-Common side effects: dry mouth, nausea, weight gain, agitation, anxiety, sleepiness/sedation
-ADR: risk hyponatremia, serotonin syndrome, suicidal ideation -Discontinuation syndrome: N, HA, dizzy, lethargy, flu-like symptoms |
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SNRIs (Serotonin-norepinephrine reuptake inhibitors)
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May require BP monitoring
Some associated w/significant drug interactions |
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Newer antidepressants for depression
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-May be useful in pts who would benefit from weight gain (appetite stimulant)
-Useful if need stimulant effect -May be useful for insomnia -Be mindful of significant drug interactions |
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Monoamine Oxidase Inhibitors (MAOIs)
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Not recommended as 1st line treatment d/t dietary restriction, drug-drug interactions
Side effects: HA, dry mouth, N/V, diarrhea or constipation, drowsiness, insomnia, dizziness |
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Tricyclic antidepressants (TCAs)
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Not recommended for 1st line treatment d/t anticholinergic side effects (dry mouth, constipation, dec'd urination/retention, sedation, postural hypotension)
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In elderly depressed use...
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Monotherapy: when possible to minimize side effects
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in Elderly patients: full antidepressant response may not occur unti
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8 to 12 or even 16 weeks of therapy
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after each vist, check...
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drug discuss tolerance, adjust dose as indicated, monitor for side effects
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Factors associated w/maintenance cognitive health
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Prevent/control high BP, elevated cholesterol & blood sugar; prevent/eliminate smoking, obesity: promote physical activity & healthy weight
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Healthy Aging Research Network works to ID
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knowledge gaps:Public perception about cognitive health
Examine care givers & PCP perceptions |
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Factors that increase dementia risk
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BP
Blood sugar belly size inflammation cortisol stress genetics sedentary lifestyle |
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Healthy Brain Initiative =
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national Public Health "road map" to maintain cognitive health
-Translate science to Public Health practice -NIH: research cardiovascular risk factors vs. exercise, lifestyle & medication interventions to ID risk factor mechanisms & protective factors that work |
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Components Healthy Cognitive Functioning
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Speech & language, thoughts & perceptions, memory, attention & executive functions
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Spontaneous speech includes
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Quantity, rate, articulation (word formation) & pronunciation
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what is fluency
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verbalization of thoughts & ideas via...semantics=(word selection)
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what is syntax
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formulating appropriate phrases or sentences
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How to test for aphasia?
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1.word comprehension (ask staged commands)
2.Repetition-phrase-"no ifs and or buts" 3. naming-name parts of watch 4. reading-paragraph 5. writing-ask pt to write a sentance |
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what is aphasia?
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disorder of proding and understanding language - usually caused by lesions in left heisphere
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if pts speach lacks meaning or fluency, assess for
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aphasia
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Wernickes aphasia
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fluent but sentances lack meaning/incomprehensable
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brocas aphasia
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non fluent with few words but good comprehension
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what are you assessing in thoughts
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logic, relevance, organization & coherence of thought in words & speech
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problems of thought process
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1. confabulation
2. neologisms 3. blocking 4. perseveration 5. echolalia 5. clanging 6. circumstantiality 7. derailment |
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what is confabulation
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fabrication of facts or events in in response to questions to fill in gaps of memory
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what is neologisms
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invented or distorted words or words whith highly idiosyncratic meanings
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what is blocking
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sudden interruption of speech in midsentance or before completion of an idea. The person attributes this to losing thought. normal people have blocking too.
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what is perseveration
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persistant repitition of words or ideas
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what is echolalia
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repitition or the words or phrases of others
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what is clanging
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speech in which a person chooses a word on the basis of sound rather than meaning as in ryming and punning speach.
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what is circumstantiality
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speech caharacterized by indirection and delay in reaching the point because of unessasay detail, although componants of the desctription have meaningful connection. can be common in normal people too.
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what is derailment
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spech in which a person shifts from one subject to antother that are unrelated and not realizxing the subjects dont go weith each other
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what is compulsion
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an irresistible urge to behave in a certain way, especially against one's conscious wishes.
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what is obsessions
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intrusive thoughts that produce uneasiness, apprehension, fear or worry
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what is delusions
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false, fixed, personal beliefs that are not shared by other members of ones cultures
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problems of Thought content
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1.compulsions
2.obsessions 3.phobias/anxiety 4.feelings of unreality 5.delusions |
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what is circumlocution
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he use of many words where fewer would do
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what are paraphasias
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type of language output error commonly associated with aphasia, and characterized by the production of unintended syllables, words, or phrases during the effort to speak.
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what are Illusions
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misinterpretations of real external stimuli
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what are Hallucinations
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subjective sensory perceptions in absence of relevant external stimuli (auditory, visual, olfactory, gustatory, tactile)
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what is Insight
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awareness that current symptoms & behaviors are abnormal
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what is Judgment
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compare & evaluate course of action based on given situation
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how to assess Attention
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serial 7s, 3s, count backwards from 100 or spelling a 5 letter word backwards
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how to assess memory
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recent (new learning ability/3 word repetition) & remote (verifiable information)
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how to assess Executive functions (IADLs)
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1. Calculation ability - single/double digit addition/ multiplication or make change for a dollar
2. Abstract thinking: similarities 3. Construction ability-draw clock |
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with normal aging, it may take longer to
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process & respond, Reaction time may be slower, and may take longer time to complete executive functions
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signs of Age related decline
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sporadic difficulty w/names, mild forgetfulness or reduced concentration, impact function
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signs of mild cognitive impairment
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memory issue but no interference w/daily functioning, noticeable to person & close friends/relatives
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signs of Depression
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depressed mood or decreased interest or pleasure in all or most activities most of day, nearly every day in same 2 week period
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signs of Dementia
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progressive global deterioration in multiple domains
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signs of Delirium
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rapid functional change in MS that fluctuates w/in minutes/hours
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delirium
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Transient & usually reversible disturbance of consciousness : ↓ ability to focus, sustain or shift attention; develops over short period of time (hours to days) & tends to fluctuate during course of the day
↓environmental awareness, altered MS w/memory deficits, disorientation, language or perceptual disturbance |
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evidence of delirium
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from H&P & labs supports physiological consequence d/t a medical condition
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With delierium, rule out
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change in cognition or perceptual disturbance is not d/t a preexisting, established or evolving dementia
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delerium can be a
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Medical emergency
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delierium is a
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Syndrome not a disease
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delerium hallmarks
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dec'd attention span & a waxing & waning confusion
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delerium precipitating factors
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Age, preexisting sensory impairment, sleep deprivation
Immobilization Sudden change in environment Emergent hospitalization |
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delerium is a common complication in
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hospitilized pts that increases in mortaity and occurence with number of days stayed; seen in up to half ICU pts
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delerium underlying pathology
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CNS: CVA, postictal state, trauma, meningitis
Cardiac: MI, HF, arrhythmia, hypotension, shock/blood loss Medications; intoxication/withdrawal; metabolic derangement; sepsis, UTI, dehydration Psychiatric decompensation |
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what to ask for in Hx for delierium
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Hx of behavioral change:
timing & duration Level of consciousness Orientation Attention Thought process & content Perception: illusions, hallucinations Speech |
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PE for delierium
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VS: T, P, RR, BP, glucose
GS: level of consciousness, facial expression, posture, distress Skin: jaundice, track marks, temp, T&M Head: trauma Eyes: pupils, nystagmus, fundi Lungs: dyspnea, adventitious sounds Cardiac: murmurs, rhythm Abdomen: ascites, hepatomegaly, masses Vascular: carotid bruits, edema, pulses, capillary refill MSS/CNS/Psych MMSE, CNs, muscle strength, RAM, PTP, DTR, gait, stance |
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Diagnostics for delierium
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1.Clinical acumen w/ labs & imaging as adjuncts
2. DSM 5 criteria 3. Assessment tools: -confusion -assessment method (CAM) -delirium symptom interview (DSI) |
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Treatment/Management of delirium
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1.Hospitalize - ID & correct cause = symptom reversal
2.Stabilize pt w/supportive measures 3.Minimize stimulation (quiet room) 4.Orient pt -Good lighting; ID health care team members -Sensory aids (calendar, clock, pictures/family, glasses, hearing aid, cane, etc) -Avoid physical & chemical restraints 5.Avoid iatrogenic situations 6.Continually reassess cognitive function |
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progressive cognitive impairments and dementia
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alzheimers
dementia with lewy bodies fronto-temporal dementia vascular dementia parkinsons |
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non-progressive cognitive impairments and dementia
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TBI
Anoxia (example-sleep apnea) Vacular (ex-stroke) |
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reversible cognitive impairments and dementia
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depression
anxiety metabolic conditions medical condtitions infections normal pressure hydrocephalus |
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Commonness of different dementias
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alzheimers 55%
lewy body 20%??? stroke/mixed 15% ??? TBI 4% others 6% |
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what is Dementia w/Lewy body (DLB)
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Decline in thinking, reasoning and independent function d/t abnormal microscopic deposits that damage brain cells
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3rd mosst common cause of dementia after multi-infarct & AD
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Dementia w/Lewy body (DLB)
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Hallmark brain abnormality of DLB
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alpha-synuclein protein
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DLB symptoms overlap with
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AD & Parkinson's
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DLB may be linked to
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underlying abnormalities in how the brain processes the protein alpha-synuclein
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Parkinson's patients develop problems w/thinking & reasoning with overlap of
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DLB
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Many w/DLB experience hunched posture, rigid muscles, a shuffling walk & trouble initiating movement
caused by |
parrkinsons
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Many w/DLB & Parkinson's dementia also have plaques & tangles =
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hallmark brain changes linked to Alzheimer's disease
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Multi-infarct dementia (aka vascular dementia/VaD)
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is found in peeps >55-60 and more men than women. RF: HTN, DM, TIA, CVA & pt at risk CVA (PAD, a. fib, hyperlipidemia, smoking)
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Pathology of Multi-infarct dementia (aka vascular dementia/VaD)
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Multi infarct of cerebral artery territories OR Single infarct of critical brain tissue OR Multiple small infarcts (lacunar state)/subcortex & white matter
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Multi-infarct dementia Symptoms depend on
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location of ischemic insult
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Multi-infarct dementia Symptoms
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-Confusion, problems w/ recent memory
-Wandering or getting lost in familiar places -Incontinence, emotional (laugh or cry inappropriately) -Difficulty following instructions, problems handling money |
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Multi-infarct dementia can be considered a
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Stepwise ischemic insult w/asymmetric CNS deficits
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Multi-infarct dementia Hx
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Hx: timing/course symptoms of ischemia (TIA & CVA, , PMH (at risk comorbidities), meds
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Multi-infarct dementia PE
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focused CNS/HEENT, C-P/vascular
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Multi-infarct dementia diagnostics
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CT/MRI confirmation, carotid doppler
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Multi-infarct dementia TX
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Prevention: risk factor evaluation
Active interventions for established conditions or habits at risk for CVA/TIA |
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Alzheimer's dementia (AD) is the
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Most common form of dementia
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AD occours
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older than 60
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AD pathophys
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Deposits of protein fragments (beta amyloid plaques) & twisted protein strands (Tau tangles)
Neuron damage & death Brain atrophy in later stages |
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Changes in brain from AD effects
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language and memory
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Alzheimer's dementia =
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gradual onset multiple cognitive deficits that cause significant impairment in social or occupational functioning
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AD course characterized by
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progressive global deterioration in multiple domains: short term memory, language, executive function, sequential tasks, intellectual function & cognitive skills w/ADL & IADL skill performance decline
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Problems associated with AD (5 A's)
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Anomia
Apraxia Aphasia Agnosia Amnesia |
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what is Anomia
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(inability to name persons/objects)
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what is apraxia
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(speech and/or learned, purposeful movements)
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what is Agnosia
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Agnosia is the inability to process sensory information. Often there is a loss of ability to recognize objects, persons, sounds, shapes, or smells
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stages of alzheimers progression: one
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Impaired recent memory, loss of formerly mastered complex activities (IADLs/driving), can't follow directions, stop taking initiative, trouble w/words, seem hostile or agitated
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stages of alzheimers progression:2
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Unable to learn new information, ADLs impacted, can't use social or environmental clues (lost in home, wander) risk accidents d/t judgment errors & confusion (driving, falls), physically aggressive or sexually inappropriate, don't recognize self
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stages of alzheimers progression:3
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Dependent on others all ADLs, ambulation severely limited or bed bound, memory lost, incontinent, lack proper swallow response (aspiration, dehydration, under nutrition), risk pressure ulcers
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stages of alzheimers progression:4
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End stage: mute, coma, death
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Taking a history for AD
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Duration, pattern & order of occurrence of each behavioral change; functional activities questionnaire; recent change environment or head trauma
Co-morbid conditions; med'n review Caregiver/family perspectives FHx Risk gene = APOE-e4 gene/clinical trials; deterministic genes/rare familial - autosomal dominant form |
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Gene associated with AD
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APOE-e4; autosomal dominant
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PE for AD
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VS; GS (physical appearance, habitus, glasses, hearing aids, grooming/dress)
CNS/MSS MS: how aware of symptoms, orientation, short term recall & follow instructions (mini-cog), simple calculations; speech/language; mood/affect DTRs, coordination/gait/balance, muscle tone/resistance/ease of movements |
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diagnostics for AD
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TSH, B12, folate, CBC, LFTs, RFTs, 'lytes, RPR/FTA, HIV, drug screens PRN
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CT or MRI, PET for AD
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Clinical studies: validation process for beta-amyloid biomarker on imaging studies
Structural changes, functional activity patterns Molecular imaging w/ radiotracers |
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Alzheimer's dementia Treatment/management goals
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1.Serial monitor cognitive status: scored MS tools
-Maintain QOL & daily functioning -Incorporate patient & family preferences 2.Monitor behavioral changes: serial behavioral assessment tools & manage disruptive changes 3.Stabilize co-morbidities |
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Cohen-Mansfield Agitation Inventory (CMAI):
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assesses agitation in AD PT
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Ryden Aggression Scale (RAS):
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assesses agression in AD PT
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Beh'l pathology in AD (BEHAVE-AD):
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evaluates psychotic symptoms but not disruptive behaviors in AD PT
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Revised Memory & Behavior Problem Checklist (RMBPC): caregiver report tool
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given to caregiverrs of AD PT to assess modifiable beh'l issues
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Neuropsych Inventory Questionnaire (NPI-Q)
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used to assess caregiver strress
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Palliative & End Of Life care for AD PT
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designate a Decision making capacity or surrogate decision maker
-Shift to discomfort relief or hospice -Avoid futile treatments - merely prolong dying process |
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Primary caregiver/support system education of AD PT
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1.Home safety measures & environmental modifications
2.Stick to schedule, try not to move or change environment; maintain toileting schedule 3.Daily log: precipitating events & duration of behaviors, ways to redirect attention/avoid confrontation w/care recipient |
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Home & environmental safety measures for AD PT
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1.ID various objects, cabinets, etc
2.Wandering: lock doors, alarms, ID bracelet 3.Prevent falls: good lighting, remove rugs & low tables, install hand rails 4.Supervise cooking, remove stove knobs 5.Lock firearms, matches & car keys 6.Driving: state laws & mandatory reporting* |
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Primary caregiver/support system education for AD PT
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1.Keep care recipient's mind & body active during the day
2.Avoid stress & frustration w/simple directions & tasks for care recipient 3.Reinforce progressive decline of dz 4.Monitor caregiver health/prevent burnout |
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Treatment management of AD PT
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1.Adult day care/respite care - OT, PT, music therapy, pet therapy, massage, aromatherapy
2.Medications: cholinesterase inhibitors and glutamate regulation |
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cholinesterase inhibitors
delay AD... |
symptom progression 6-12 months
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donepezil
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cholinesterase inhibitor: can be given during all stages
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rivastigmine
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cholinesterase inhibitor: for mild to moderate AD
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galantamine
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cholinesterase inhibitor: for mild to moderate AD
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side effects of cholinesterase inhibitor
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N/V, loss appetite, inc'd bowel movement frequency
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memantine
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Glutamate regulation for moderate to severe AD
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sidde effects of memantine
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HA, constipation, confusion, dizziness |
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