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Neurodegenerative diseases
Neurodegenerative diseases are progressive and usually chronic conditions resulting from damage to the peripheral nervous system, the central nervous system, or both. Multiple sclerosis, Parkinson’s disease, amyotrophic lateral sclerosis, Guillain-Barré syndrome, Huntington’s disease, and dementia are included in this classification
Akinesia
impairment of voluntary and spontaneous movement initiation resulting in freezing, especially during gait activities
Bradykinesia
slowed motor movements
Dysmetria
decreased coordination of movements
Rigidity
muscle stiffness that impairs movement
Fasciculation
involuntary muscle contraction and relaxation; observed as a muscle twitch
Festinating gait
small rapid steps resulting from a forward-tilted head and trunk posture
Paresthesia
numbness and tingling because of sensory nerve changes
Occupational therapy evaluation for Neurodegenerative diseases
Evaluation begins with an occupational profile, with attention to understanding how the client is affected by the variable symptoms and progression of the disease. The occupational therapist thoroughly explores the client’s roles, occupational performance, daily habits, and routines. On the basis of the client’s occupational performance prioritization, the occupational therapist uses standardized and non-standardized assessments, observation, and interview to analyze the client’s occupational performance. The occupational therapist also includes skill assessments in the areas of motor and praxis ability, sensory–perceptual skills, emotional regulation, cognitive ability, and communication skills.
Occupational therapy intervention for Neurodegenerative diseases
1) Teach cognitive compensatory strategies.
2) Provide training in activity strategies and energy conservation.
3) Help the client delegate roles to family members to balance independence with assistance from others during occupational performance.
4) Provide environmental modifications and adaptive equipment training for home and work safety and independent task performance.
5) Recommend exercise programs that are within the client’s limitations and that promote a balance of activity performance and rest periods (e.g., shorter exercise periods every day may be better than longer exercise periods 3 times a week).
Cognitive Compensatory Strategies
a) Minimize distractions and interruptions during task completion.b) Use problem-solving techniques.c) Use memory aids and written instructions.d) Minimize multitasking.e) Allow increased time to complete tasks.
Training in Activiy Strategies and Energy Conservation
a) Alternate periods of rest with periods of activity (e.g., alternate sitting and standing during tasks).
b) Complete higher priority tasks in the morning.
c) Use appropriate equipment such as orthotics and powered mobility to minimize energy use.
d) Use ergonomic adaptations to provide head and arm support.
Multiple Sclerosis Etiology
a) Multiple sclerosis (MS) is a chronic, often progressive demyelinating disease of the central nervous system; a person’s own body attacks the myelin sheath that covers the neurons of the brain and spinal cord. This demyelination produces scar tissue or plaque (sclerosis) on the myelin sheath of nerve fibers that interferes with the axons’ ability to conduct impulses. The result is impaired nerve conduction and inflammation, which causes neurological dysfunction. The specific location of demyelination differs with each person and dictates symptoms.
b) MS is the most frequently diagnosed neurological condition that can cause disability in young adults, most often ages 20–40 years. Women are affected more than men by a ratio of almost 3:1. Early interventions in functional mobility and ADLs, fatigue management, and role and routine modifications are critical for preventing and delaying onset of disability
c) The exact cause is unknown; current research has suggested that an environmental factor or viral infection triggers an autoimmune response in people who are genetically susceptible
Signs and symptoms of Multiple Sclerosis
a) Clinical presentation
b) Motor Symptoms
c) Sensory symptoms
d) Visual symptoms
e) Communication symptoms
f) Bladder and Bowel Symptoms
g) Sexual Symptoms
h) Cognitive Symptoms
i) Emotional Symptoms
Clinical Presentation of Multiple Sclerosis
a) Often diverse and difficult to predict, with various combinations and patterns
b) Initial complaints: typically visual disturbances, dizziness, and weakness. Symptoms at times worsen (exacerbation) and at other times improve (remission). MS progresses over time and is eventually irreversible.
Motor symptoms of Multiple Sclerosis
a) Impaired balance and coordination (ataxia)
b) Partial or complete paralysis of a part of the body; muscle spasticity, especially in lower extremities
c) Muscle weakness
d) Fatigue: the most common complaint and debilitating symptom
e) Intention tremors
f) Dysphagia
Intention tremors
which occur when a person attempts to engage in meaningful activity, such as reaching for an object
Sensory symptoms of Multiple Sclerosis
a) Paresthesia
b) Vertigo
c) Pain (typically the result of musculoskeletal causes)
Paresthesia
a) numbness or tingling
b) Impaired vibratory, proprioceptive, pain, touch, and temperature sensations
c) Distorted superficial sensation
d) Impaired sensation, which may affect perceptual skills such as stereognosis, kinesthesia, or body scheme
Visual symptoms of Multiple Sclerosis
a) Diplopia
b) Optic neuritis
Diplopia
(double vision) or blurred or dimmed vision, with or without ocular pain
Optic Neuritis
which causes sudden loss of vision with pain in or behind the eye, with symptoms possibly subsiding after 3–6 weeks without residual impairments
a) Partial loss of vision (scotoma)
b) Nystagmus
c) Loss of visual acuity in 80% of people with Multiple Sclerosis
Communication symptoms of Multiple Sclerosis
a) Slurred speech
b) Scanning speech, or slow enunciation with frequent hesitations at the beginnings of words or syllables
6. Bladder and bowel symptoms of Multiple Sclerosis
a) Incontinence or urinary retention (failure to empty the bladder)
b) Increased urgency or frequency, as well as constipation
Sexual symptoms of Multiple Sclerosis
a) Men: erectile dysfunction
b) Women: decreased libido, lubrication difficulty, and inorgasmia, but ability to conceive and carry pregnancy to term remains intact
Cognitive symptoms of Multiple Sclerosis
a) Short-term memory loss
b) Attention deficits
c) Decreased processing speed
d) Impairment in visuospatial ability
e) Impaired executive functioning and judgment
f) Difficulty with attention, conceptualization, memory, or new learning. . . . difficulty with abstract reasoning and problem solving as well as difficulty with tasks that require either rapid or precise motor responses”
Emotional symptoms of Multiple Sclerosis
a) Depression (although whether it is a manifestation of the neurological condition vs. a reaction to the disease is uncertain)
b) Inappropriate euphoria
c) Lability, likely attributable to lesions in the frontal lobe
Diagnosis of Multiple Sclerosis
a) To make a definitive diagnosis of MS, physicians consider client history, laboratory studies, and neurological examination.
b) Diagnostic tests may include cerebrospinal fluid analysis, nerve conduction studies, and brain imaging such as MRI or CAT scans
c) The results of these procedures help contribute to a diagnosis, but the person must have “episodes of exacerbation and remission and slow or step-by-step progression over six months; there must also be evidence of lesions in more than one site in the white matter and no other neurological explanation for the clinical picture”
Multiple Sclerosis Disease course and prognosis
a) The disease course is unpredictable, and prognosis varies drastically. At this time, no cure or treatments that eliminate the disease are available. The goal of medical and rehabilitation treatment is “to minimize the severity, amount, and length of exacerbations in order to improve function”.
b) MS can be broken into categories on the basis of disease progression
c) MS is also occasionally described as either benign or malignant.
Multiple Sclerosis Categories of Disease Progression
1) “Relapse–remitting: fluctuating course of relapses with associated neurologic deficits, followed by periods of relative quiet
b) “Secondary progressive: cessation of fluctuations with slow deterioration
c) “Secondary progressive with relapses: fluctuation with relapses and deterioration between re-lapses
d) “Primary progressive: deterioration from beginning
e) “Progressive relapsing: progressive with relapses”
Benign Multiple Sclerosis
people have no functional limitations 15 years after onset.
Malignant Multiple Sclerosis
progresses rapidly, causing significant disability or death in a short period
Interdisciplinary team management of Multiple Sclerosis
a) Medications
b) Surgical options: not applicable
c) Physical therapy: strengthening, ROM exercises, modalities, massage, and tone-reduction interventions
d) Speech therapy: for dysphagia and swallowing difficulties and for speech or dysarthria or dysphasia symptoms, with assistive devices such as a communication board or voice amplifier; in some cases, for cognition
Medications for Multiple Sclerosis
a) Most often prescribed are antispasmodics, muscle relaxants, and anticonvulsants.
b) Methylprednisolone is prescribed for functional skills.
c) Interferon beta 1a can help with cognitive skills such as attention, memory, information processing, and learning.
d) Future treatments may include “antiviral medications; vaccinations; transplantation of Schwann cells, cell lines, or stem cells; and/or gene therapy”.
e) Steroids are occasionally prescribed, more often in acute stages, and only for temporary use.
f) Other medications include baclofen (for spasticity), antidepressants as needed, gabapentin (for pain), and oxybutynin (for selected urinary problems).
Occupational therapy evaluation and goal setting for Multiple Sclerosis
1) Develop an occupational profile that includes the client’s goals and history of symptoms and treat-ments. Assess pain, review medications from the medical records, and screen for cognitive deficits during questioning. Ask questions about dizziness, sensation, fine motor skills, incontinence, fatigue, sleep patterns, muscle cramping, falls, and balance issues; on the basis of the answers, evaluate further with appropriate diagnostic procedures.
2) Standardized evaluation tools
3) Because endurance and strength vary throughout the day depending on participation in occupations and timing of medications, evaluation and therapy should be scheduled for a time when the client reports feeling most energized.
4) Goals should address both the exacerbation and remission stages and should be compensatory because of the progressive nature of MS.
Standardized Evaluation Tools for Multiple Sclerosis
a) Modified Fatigue Impact Scale
b) Beck Depression Inventory–18
c) FIM™
d) Nine-Hole Peg Test or Purdue Pegboard Test for manual dexterity and fine motor coordination
e) Semmes–Weinstein monofilament testing for sensory function
f) Modified Ashworth Scale for spasticity
Occupational therapy interventions for Multiple Sclerosis
a) Contraindications to intervention
b) Vision
c) Sensory Disturbance
d) Urinary Incontinence
e) Muscle Weakness and other Motor Difficulties
f) Pain (from Spasticity)
g) Fatigue
h) Ataxia
i) Dysphagia and dysarthria
j) Cognitive and emotional disturbances
k) ADL Adaptions
l) Vocational adaptations
Contraindications to Intervention for Multiple Sclerosis
hot temperatures, heat modalities such as moist heat or fluidotherapy, increased emotional or physical stress, excessive physical activity or overexertion; alcohol use increases balance deficits and can be dangerous when mixed with medications used to treat the symptoms of MS
Vision Interventions for Multiple Sclerosis
a) Perform home safety assessment and make recommendations to reduce risk of falls, including removing clutter, clearing pathways, and using bright or contrasting tape to mark steps inside and out of the home.
b) Adaptive equipment may include optical devices, large-print reading material, large-button technology, talking watches, raised-dot markings for technology, and audiobooks.
c) Refer the client to a low vision specialist or to an ophthalmologist or an optometrist as indicated.
Sensory disturbances Interventions for Multiple Sclerosis
a) Provide sensory reeducation.
b) Introduce compensatory strategies such as relying on visual feedback to observe desensitized limb and testing the temperature of water for dishwashing or bathing using an unaffected body part.
Urinary incontinence Interventions for Multiple Sclerosis
a) Provide bladder training and instruction in self-catheterization or use of sanitary pads or absorbent underwear to avoid embarrassment with accidents.
b) Monitor times of days when fluids are consumed to ensure availability of bathrooms to minimize risk of incontinence.
Muscle weakness and other motor difficulties Interventions for Multiple Sclerosis
a) Monitor body mechanics to avoid stressing joints and increasing musculoskeletal pain.
b) Enroll in yoga and group exercise classes.
c) Stretch before beginning any exercise to decrease spasticity, improve flexibility and circulation, and prevent injury; warm up and progress to activities with proximal musculature before those with distal musculature d) Therapeutic exercise can improve overall health and well-being, but the occupational therapist should emphasize the importance of resting and avoiding fatigue; exercises are best completed “at submaximal resistance with frequent repetition in order to avoid overuse”.
e) Aquatic therapy can help reduce the effects of weakness while providing gentle exercise.
f) Instruct the client in use of assistive devices. Provide seating and positioning consultation if the client requires a wheelchair or power mobility.
Pain (from spasticity) Interventions for Multiple Sclerosis
a) Advise on a standing home program, such as using a standing frame.
b) Use resting splints.
c) Maintain hips at 90° or more of flexion to reduce extensor tone in the lower extremities.
d) Apply focal heat modalities on muscle trigger points.
Fatigue Interventions for Multiple Sclerosis
a) Educate clients on types of fatigue; once the type is identified, client-centered interventions emerge.
b) Instruct the client to keep a diary card throughout the day to monitor activity level and identify occupations and activities that result in fatigue, then collaborate to find activity and environmental modifications c) Reduce extended periods of standing or mobility by adapting tasks and using power mobility when appropriate.
d) Use appropriate equipment, such as an ankle–foot orthosis, to overcome weakness in dorsiflexors.
e) Instruct the client in ergonomic positioning and equipment use.
f) Instruct the client in the use of cooling techniques such as taking cold showers, wearing ice packs or a liquid cooling vest, and drinking iced beverages; use ice as a modality in therapy.g) Teach energy conservation and fatigue management tips
Type of Fatigue as a result of Multiple Sclerosis
a) Primary MS fatigue: a direct result of the MS disease process
b) Fatigue secondary to sleep disturbances (because of spasticity, depression, or bowel and bladder issues)
c) Fatigue secondary to depression or mood changes
d) Nerve fiber or motor fatigue, likely the result of poor nerve conduction
e) Fatigue from muscle weakness or spasticity
f) Fatigue related to medication side effects or infection
Teach energy conservation and fatigue management Interventions for Multiple Sclerosis
including planning, pacing, prioritizing, and positioning. In one study, an energy conservation course that covered the following topics improved quality of life and helped people with MS manage fatigue:
a) the value of rest
b) budgeting and banking energy;
c) incorporating rest periods throughout the day;
d) learning to communicate personal needs to others;
e) using good body mechanics and posture;
f) using energy-efficient appliances and organizing stations of activity;
g) separating fatiguing tasks into components;
h) prioritizing and setting standards for activities;
i) planning rest periods with self-care, productivity, and leisure activities so that a balance can be maintained;
j) reviewing course principles and setting short-term and long-term goals.
Ataxia Interventions for Multiple Sclerosis
a) Encourage proximal stabilization for improved distal movements.
b) Modify tasks by promoting hand-over-hand techniques for fine motor tasks (e.g., using the unaffected extremity over the hand with tremor when dialing a phone).
c) Use orthoses.
Orthoses Used for Multiple Sclerosis
a) Cervical collar to reduce the travel of the head and neck
b) Wrist splints to minimize travel and number of joints in motion in the presence of a tremor
Dysphagia and dysarthria
a) Collaborate with a speech therapist to enhance intervention strategies and maximize carryover.
b) Routinely screen for signs of choking, aspiration, or swallowing dysfunction because videofluoroscopy has shown that most people with MS who are asymptomatic have underlying impairments
Cognitive and emotional disturbances
a) Consider cognitive retraining, memory enhancement programs, cognitive–behavioral therapy, visual compensation strategies, or group therapy.
b) Eliminate distractions.
c) Use external memory aids such as day planners or electronic devices.
d) Write step-by-step instructions, printed in a reader-friendly font and size and worded clearly.
e) Advise the client to allow for increased time, delegation, and repetition when learning new ideas and perform difficult mental tasks earlier in the day.
f) Teach stress management and relaxation techniques; emotional and physical stress can temporarily worsen symptoms.
g) Explain coping strategies, which can help in handling exacerbations
ADL adaptations
a) Recommend adaptive equipment such as built-up handles, reachers, and sock donners to compensate for weak muscles and maintain joint integrity.
b) Use of weighted utensils for feeding or wrist weights during self-care activities to reduce tremors.
c) To reach the lower body during bathing and dressing, recommend use of adaptive equipment or a stool; maintaining hip flexion decreases extensor spasm.
Vocational adaptations
a) Collaborate with the client to advocate for reasonable accommodations under the Americans With Disabilities Act of 1990.
b) Educate the client to self-pace and perform higher-intensity activities when energy levels are higher; encourage taking rest breaks, breaking tasks down, simplifying work, adapting work hours, using energy-saving technology, and telecommuting, if applicable.
c) Help the client create an ergonomic workstation to minimize pain and fatigue
Parkinson’s Disease Etiology
a) Parkinson’s disease (PD) is a progressive, variable condition that occurs most frequently in later adulthood, with a mean onset age of 55–60 years. Major degenerative changes occur in the basal ganglia, the gray matter that contributes to complex movements. The substantia nigra becomes de-pigmented, affecting the production of dopamine, a neurotransmitter that influences the speed and accuracy of motor skills, postural stability, cognition, and affect and expression. The loss or reduction of dopamine leads to the disabling symptoms.
b) The exact cause is unknown; it has been attributed to both heredity and environment. Fifty percent of people with PD have a relative who is also affected, which may indicate a genetic factor.
Secondary parkinsonism
is a condition in which people experience symptoms similar to those of PD, but the cause is related to the ingestion of drugs or other toxic chemicals. Certain medications used to treat mental illness may produce parkinsonian symptoms if not monitored carefully.
Primary symptoms of Parkinson’s Disease
Primary symptoms are resting tremor, muscle rigidity, bradykinesia, and postural instability.
Tremor
A typical early sign is a resting tremor, which affects one side and is described as a “pillrolling” movement of the hand. Tremors vary, typically disappearing when the person is asleep or calm and increasing with stress or cognitive tasks. Tremors are often absent with voluntary movement.
Muscle rigidity or stiffness
Tone is increased, adversely affecting movement. People with PD may demonstrate cogwheel motions, which are jerky, sometimes painful movements with joint mobility, most commonly in the upper extremities. Fatigue becomes a barrier to occupational performance because of increased effort to produce voluntary movement.
Bradykinesia
Extreme slowness is observed when initiating or performing volitional movements. Common examples include shuffling gait, difficulty moving from sitting to standing, freezing, and increased time required for fine motor tasks such as shaving or fastening clothes.
Postural instability
Posture is stooped, with a lack of arm swing during mobility and loss of postural reflexes. Fall risk is increased, especially when balance is challenged.
Myriad secondary symptoms of Parkinson’s Disease
these are common, although their number and severity differ among people with PD.
a) Gait dysfunction (e.g., festinating gait, or shuffling steps with limited or no arm swing) that leads to balance issues
b) Fine motor and bimanual impairments
c) Freezing, or inability to initiate or continue movement, or overshooting a target, such as taking five or six small steps past the goal.
d) Cognitive deficits, including impaired executive functioning, memory loss, and visuospatial deficits; in later stages of PD, dementia
e) Communication difficulties, including smaller and smaller handwriting (micrographia), reduced volume of speech (hypophonia), muffled speech, lack of verbal inflection, and reduced facial expression or flat affect (e.g., infrequent eye blinking) affecting nonverbal communication
f) Sensory loss, including bowel and bladder as well as sexual dysfunction
g) Dysphagia causing an increase in saliva and subsequent drooling, slower and more intentional eating, and episodes of coughing and choking
h) Mood and behavior disturbances, including depression, apathy, lack of initiative, disinterest, social isolation, and withdrawal.
Diagnosis of Parkinson’s Disease
People with initial symptoms such as resting tremor are often referred to a neurologist, who observes the current symptoms, eliminates other diseases that may contribute to the symptoms, and assesses the person’s response to PD-related medications. At least one primary symptom must be present. CAT scans, MRI, and electroencephalography help eliminate other neurological causes. An autopsy confirms the diagnosis of PD.
Parkinson’s Disease course and prognosis
At this time, this progressive disease has no cure. Symptoms may take years to develop, but people with PD gradually experience a loss of function and increasing disability. Disease progression is not always linear; functioning may fluctuate and even show occasional improvement. Life expectancy is rarely affected by a diagnosis of PD as a result of medical advances.
Five clinical stages of Parkinson’s Disease
Stage 1: unilateral symptoms, typically a resting tremor, with no or minimal loss of function
Stage 2: bilateral symptoms; balance is not affected, although problems develop with trunk mobility and postural reflexes
Stage 3: impaired balance secondary to postural instability resulting in mild to moderate impairments in function
Stage 4: decrease in postural stability, decrease in function, impaired mobility, need for assistance with ADLs, poor fine motor and dexterity
Stage 5: total dependence for mobility and ADLs.
Interdisciplinary team management for Parkinson’s Disease
a) Medications
b) Surgical Options
c) Speech Therapy
d) Pysical Therapy
e) Occupational Therapy Evaluation
f) Occupational Therapy Intervention
Medications for Parkinson’s Disease
a) Levodopa (L-dopa, carbidopa), titrated to optimal dosage, can decrease symptoms by increasing amounts of dopamine in the brain. Side effects are nausea and dyskinesia.
b) Other medications are dopamine replacement medications, acetylcholine inhibitors, and antiviral compounds. Antidepressants may also be prescribed.
Surgical options for Parkinson’s Disease
If symptoms are not well controlled with medications, the person with PD may be a surgical candidate.
a) Thalamotomy is application of heat via an electrode or y-knife radiosurgery to destroy part of the thalamus, which contributes to movement, to reduce tremors. Effects last more than 10 years.
b) Pallidotomy is application of heat via an electrode or y-knife radiosurgery to destroy part of the globus pallidus, which contributes to movement, to reduce tremors, shuffling gait, flat affect, rigidity, and bradykinesia. Effects last about 5 years.
c) Deep brain stimulation is delivery of electrical impulses to areas of the brain through an implanted device similar to a pacemaker to reduce tremors; the electrode is tunneled under the skin to an external switch that the person with PD can turn on or off. The generator must be replaced every 3–5 years.
d) Tissue implantation using dopamine-producing fetal brain tissue or fetal pig tissue is a new, controversial procedure that requires more research to determine the long-term effects.
Speech therapy for Parkinson's Disease
addresses dysphagia, communication, and cognitive deficits.
Physical therapy for Parkinson's Disease
preventnon of complications or postural abnormalities of the trunk and extremities via passive stretching, muscle massage, resistive exercise, techniques to maintain normal gait, and assistive device training
Occupational therapy evaluation for Parkinson's Disease
a) In the initial stages of PD, occupational therapists play a role when functional limitations or psychosocial issues exist; they become essential interdisciplinary team members as the disease progresses. Occupational therapists review interests, roles, and routines and set goals to help the client maintain participation in life activities. Evaluation includes an interview to obtain a brief history and observation of how symptoms such as rigidity, bradykinesia, tremors, and postural instability impair areas of occupational performance. They also assess occupations or preferred activities that have been altered or eliminated.
b) Clients with PD may experience fluctuating energy levels during the day; symptoms tend to increase just before the next medication dose. Evaluating a person with PD at only one time of day may not provide an accurate picture of strengths and deficits. Use of a tool such as the Canadian Occupational Performance Measure to establish client-centered goals empowers clients and minimizes their stress. Further cognitive screening may also be warranted.
An evaluating occupational therapist may notice any of the following in Patients with Parkinson's Disease
a) Fine motor or dexterity difficulties affecting home, community, and work participation
b) Mobility impairments in home or in the community
c) ADL and IADL deficits related to primary or secondary symptoms
d) Swallowing or feeding issues that increase risk for choking or malnutrition
e) Sexual dysfunction because of rigidity, fatigue, depression, or other psychosocial issues
f) Disrupted sleep patterns
g) Social isolation, impaired relationships, and increased need for assistance from caregivers
Occupational therapy interventions for Parkinson's Disease
a) Energy conservation and pacing, including prioritizing and planning important activities around medication times to ensure participation when medications are most effective
b) Caregiver training
c) Support and advocacy groups
d) Home exercise programs—for example, walking a prescribed distance (with caregiver assistance and supervision or with assistive device, as needed) or doing simple calisthenics or AROM exercises
e) Safe functional mobility
f) Feeding and ADL adaptations
g) Communication adaptations
h) Bowel and bladder
i) Cognition
j) Group Therapy
k) Stress Reduction and Relaxation
l) Rigidity and Associated Pain
m) Vocational Interventions
Safety considerations for functional mobility for Parkinson's Disease
a) Train the client in sit-to-stand and bed mobility techniques.
b) Provide instruction in managing freezing, such as avoiding crowds, tight spaces, and turns or corners; reducing distractions and avoiding multitasking; eliminating clutter in pathways; and avoiding rushing to answer the phone or door.
c) Instruct the client in use of assistive devices such as a walker or cane. If a wheelchair is required, evaluate for proper positioning and train the client and family in its use, transport, and maintenance.
d) Use of a single auditory cue can help the person produce quicker and smoother movements. The rhythm of counting out loud and singing also helps clients fine-tune movements. Active music therapy can enhance motor skills (specifically bradykinesia), emotional health, ADL performance, and quality of life.
Feeding and ADL adaptations for Parkinson's Disease
a) Encourage the client to modify meals for smaller portions, remove distractions, eat more slowly, and use adaptive equipment such as built-up or weighted utensils, cups with lids, plate guards, and nonslip surfaces.
b) Educating the client and caregiver to allow for increased time for feeding and ADLs; stress from rushing increases symptoms.
c) Modify clothing to eliminate fasteners or switch to hook-and-loop closures; use button hooks, sock donners, zipper pulls, and elastic shoelaces.
d) Use distal wrist weights if effective in decreasing tremors.
e) Instruct the client to work on self-care activities as close to the body as possible and, when appropriate, with upper-extremity support on a table. Using proximal muscles can help stabilize distal joints and muscles, which may reduce tremors.
f) Recommend installation of durable medical equipment, raised toilet seat, grab bars, shower bench, and sink chair and use of soap on rope and a long-handled sponge.
Communication adaptations for Parkinson's Disease
a) Suggest that clients use larger paper and large felt-tip pens and rest before writing.
b) If handwriting is illegible and affects IADL tasks such as financial management, suggest adaptive techniques such as bill paying online or by phone.
c) Recommend use of speed dial or voice-controlled large-key telephones, dictation programs, and remote control systems for electronics.
d) Use a mirror to increase the client’s awareness of facial expression.
e) Instruct the client in articulation, speech volume, and breaking up sentences; advise the family to phrase questions in a way that elicits shorter responses.
Sexual routine Interventions for Parkinson's Disease
a) Educate the client to engage in sex after resting and voiding bowel and bladder and when symptoms are best controlled with medications.
b) Screen for depression if passivity, lack of interest, or general apathy is a factor.
Bowel and bladder Inerventions for Parkinson's Disease
a) Assist the client in creating a voiding schedule.
b) Instruct the client to wear absorbent underwear as needed.
Cognition Interventions for Parkinson's Disease
a) Train the client to use external or visual cues, rhythmic cues, and music and to practice with repetition.
b) Instruct the client in ways to reduce environmental distractions.
c) Educate caregivers to speak slowly and clearly with simple, one-step instructions and to introduce new concepts one at a time.
Group Therapy for Patients with Parkinson's Disease
Recommend participation in group therapy. Group approaches promote increased socialization and motivation; groups that focus on whole-body exercises, social skills, dexterity and fine motor activities, and functional and educational activities enhance wellness and prevent functional decline
Stress reduction and relaxation Techniques for Patients with Parkinson's Disease
Encourage use of stress reduction and relaxation techniques such as visualization, meditation, imagery, deep breathing, or yoga. Stress tends to exacerbate symptoms.
Home Assessment for Patients with Parkinson's Disease
Perform a thorough home assessment and recommend environmental modifications such as eliminating throw rugs and placing horizontal strips of contrasting tape on floor where freezing occurs, decreasing furniture congestion, and ensuring uniform lighting, especially in narrow spaces or thresholds and doorways.
Rigidity and Associated Pain Interventions for Patients with Parkinson's Disease
a) Use moist heat, stretching, and gentle ROM. The masklike facial expression of people with PD makes it imperative to diligently monitor pain during all exercise and stretching.
b) For clients with contractures, an antispasticity splint or a dynamic or static progressive splint gives a low-intensity stretch against the contraction of the antagonist muscles . Advise the client on a wearing schedule and skin integrity checks to prevent breakdown.
c) Help the client advocate for better control over the environment; family or coworkers may prefer a cool home or work environment, but colder temperatures increase muscle stiffness.
Vocational Interventions for Patients with Parkinson's Disease
Provide intervention to enable clients to maintain employment. a) A sedentary job that requires minimal verbal communication is a better fit for a person with PD over the long term. Jobs to be avoided are those that require extensive gross motor movements, such as walking, reaching, or bending (because of balance and gait deficits) and entail high stress levels.
b) Encourage clients to take rest periods and stretch.
c) Advise clients on streamlining the workload to perform difficult tasks when medication is at optimal effect.
Amyotrophic Lateral Sclerosis Etiology
a) Also known as Lou Gehrig’s disease, after a professional baseball player who died from it in 1941, amyotrophic lateral sclerosis (ALS) is a progressive, degenerative disease in which the motor neurons in the brain, spinal cord, and peripheral system are destroyed and replaced by scar tissue. The resulting plaques lead to progressive muscle atrophy.
b) The exact cause is unknown, but evidence has suggested a combination of genetic, viral, retroviral, autoimmune, and neurotoxic factors.
c(Men are affected more often than women, at a ratio of 1.7:1.
Signs and symptoms of ALS
a) Signs and symptoms are progressive and move distal to proximal. Symptoms depend on the part of the nervous system affected.
b) The most typical initial symptom is weakness of the small muscles of the hand or an asymmetrical foot drop with or without night cramps, usually in the calves. A person may report tripping or stumbling when walking or running or difficulty fastening clothes. If the bulbar tract is affected, initial symptoms might include difficulty breathing, slurred speech, decreased volume in speech, or impaired swallowing.
c) People eventually develop all the symptoms, becoming progressively weak and immobile.
d) Lower motor neuron symptoms are focal and multifocal weakness, muscle atrophy (progressing from distal to proximal musculature), and cramping and twitching of muscles.
e) Corticospinal tract symptoms are spasticity (which contributes to muscle pain) and hyperreactive reflexes.
f) Corticobulbar tract symptoms are dysphagia (difficulty swallowing) and dysarthria (difficulty with speech).
g) Cognition, sensation, vision and hearing, and bowel and bladder control typically are not affected.
h) ALS has six stages, broken down by their clinical features.
6 Stages of ALS
Stage I: The person can walk, is independent with ADLs, and has some weakness.
Stage II: The person can walk and has moderate weakness.
Stage III: The person can walk but has severe weakness.
Stage IV: The person requires a wheelchair for mobility, needs some assistance with ADLs, and has severe weakness in the legs.
Stage V: The person requires a wheelchair for mobility, is dependent for ADLs, and has severe weakness in the arms and legs.
Stage VI: The person is confined to bed and dependent for ADLs and most self-care tasks.
Diagnosis of ALS
A physician or neurologist reviews the person’s clinical symptoms and their progression, electromyogram results, and other tests to rule out other causes to make a definitive diagnosis.
ALS course and prognosis
a) ALS often progresses rapidly. After diagnosis, life expectancy ranges from 1 to 5 years, with a mean survival of 3 years; the disease course may be longer for younger people whose symptoms are milder.
b) Death usually occurs secondary to respiratory failure.
Interdisciplinary team for ALS
a) Medications
b) Surgical options
c) Respiratory Therapy
d) Speech Therapy
e) Physical Therapy
f) Palliative care
g) Occupational Therapy Evaluation
h) Occupational Therapy Intervention
Medications for ALS
a) Medications do not alter the fatality of the disease but help manage the symptoms.
b) Antispasmodics, nonsteroidal anti-inflammatory medications, and antibiotics may be prescribed.
c) Riluzole may help people remain in the mild stages longer.
Surgical options for ALS
a) Gastrostomy, tracheotomy, and noninvasive positive-pressure ventilation improve quality and possibly length of life.
b) Low-dose radiation and botulinum toxin injections into salivary glands sometimes help reduce drooling.
Respiratory therapy for ALS
therapists help clients learn techniques to aid in respiratory management.
Speech therapy for ALS
therapists recommend adaptive techniques to help clients with speech impairments communicate and manage dysphagia.

Physical therapy for ALS

therapists help clients maintain their level of function and reduce pain from muscle spasms.
Palliative care for ALS for end-of-life issues and hospice

Occupational therapy evaluation for ALS
a) Obtain specific levels of function and the client’s goals and priorities; write goals that focus on minimizing symptoms’ effect on occupational performance. As the disease advances, interventions expand from the person with ALS and his or her performance to the physical and social environment.
b) Use appropriate tools for evaluation.
c) Complete reevaluations as needed as the disease progresses
Appropriate Tools for the Evaluations of ALS
a) ALS Functional Rating Scale
b) Purdue Pegboard Test
c) Multidimensional Fatigue Inventory
d) Dysphagia screening and testing
Occupational therapy intervention for ALS
a) Treatment approaches should be compensatory, “focusing on adapting to disability and preventing secondary complications. Goals center on keeping the person as active and independent as possible for as long as possible”.
b) Home evaluations and home safety assessments should be conducted.
c) The occupational therapist collaborates with the client and family on many aspects of intervention.
d) Exercise can include active, active-assisted, and passive ROM; strengthening; endurance; stretching; and home breathing exercise programs, depending on the stage of ALS. Clients should be instructed on ways to avoid overexertion and muscle spasms and monitor fatigue.
e) The occupational therapist works with the client to select adaptive equipment and technology.
Important considerations for ALS Interventions
a) Safety, including positioning, transfers, and skin integrity
b) Augmentative communication equipment
c) Assessment and management of dysphagia
d) Social participation
e) Equipment and environmental modification needs (e.g., first-floor setup)
f) The occupational therapist provides techniques to address dysphagia
Selecting Adaptive Equipment for Patients with ALS
The occupational therapist works with the client to select adaptive equipment and technology.
a) A neck collar or universal cuff is used for upper-extremity stability during self-care or fine motor tasks.
b) Mobility aids (foot-drop splint, cane, walker) minimize exertion during ambulation, compensate for lower-extremity weakness, and reduce risk of falls.
c) The ideal wheelchair is high backed and reclining, lightweight, turns in a small space, and offers support for the head, trunk, and extremities. As ALS advances, the client may consider a power wheelchair with adaptable controls that is easily maneuvered with tilt or recline and head, trunk, and extremity support.
d) Voice-operated or hands-free technology can be used for everyday tasks such as using the computer, making phone calls, or locking doors.
e) Physical demands at work should be minimal and sedentary
Addressing Dysphagia
The occupational therapist provides techniques to address dysphagia.
a) Minimize distractions during mealtime.
b) Adapt food consistency (thicken liquids, downgrade diet to soft foods).
c) Use manual swallowing techniques.
d) Allow sufficient time for meals.
e) Ensure that nutritional needs are met, and use alternatives to feeding if issues arise.
Physical Demands for Patients with ALS
Physical demands at work should be minimal and sedentary, and the environment should be wheelchair accessible.
Guillain-Barré Syndrome Etiology
a) Guillain-Barré syndrome (GBS) is an inflammatory disease that causes demyelination of axons in peripheral nerves. The cause is uncertain; evidence has disproved genetic vulnerability or vaccinations as a possible cause, but some suggestion exists that previous viral infections, enteritis, respiratory tract infections, and HIV/AIDS may precede GBS.
b) According to the Centers for Disease Control and Prevention, an estimated two-thirds of people who develop GBS symptoms do so days or weeks after diarrhea or a respiratory illness. A bacterial infection, Campylobacter jejuni, is one of the most common risk factors, but people can develop GBS after having the flu or other infections (e.g., cytomegalovirus and Epstein-Barr virus). Infrequently, people develop GBS shortly after being vaccinated.
c) Age of onset is most often in adults ages 20–24 and 70–74 years, with men at a slightly higher risk than women.
d) In the United States, approximately 3,000–6,000 people develop GBS each year (CDC, 2012).
Signs and symptoms of Guillain-Barré Syndrome
a) It has three phases
b) Rapid progression of symptoms, typically in a symmetrical ascending pattern of flaccid paralysis that begins in the feet; paralysis may occur in respiratory muscles
c)Pain, mostly in the lower extremities
d) Fatigue
e) Edema
f) Absence of deep tendon reflexes
g) Mild sensory loss in the hands and legs (“glove-and-stocking distribution”)
h) Dysfunction of cranial nerves, including possible facial palsy
i) “Autonomic nervous system (ANS) involvement [that] can result in postural hypotension (when one rises from a horizontal position, blood pressure may drop to precariously low levels), arrhythmias, facial flushing, diarrhea, impotence, urinary retention, and increased sweating”.
j) Bladder dysfunction
The Three Phases of Guillain-Barré Syndrome
1) Onset and acute inflammatory phase: Acute weakness occurs in at least two extremities that advances and reaches its maximum in 2–4 weeks; 20%–30% of people with GBS need mechanical ventilation.
2) Plateau phase: Symptoms are at their most disabling, with little or no change over a few days or weeks.
3) Recovery phase: Remyelination and axonal regeneration occur over a period as long as 2 years. Recovery tends to start at the head and neck and travel distally. Most people experience significant if not complete return of function, with fatigue as the most commonly reported residual symptom.
Diagnosis of Guillain-Barré Syndrome
The physician obtains a detailed history of symptoms and provides a thorough physical and neurological examination, which includes nerve conduction velocity tests and cerebrospinal fluid analysis.
Guillain-Barré Syndrome course and prognosis
a) GBS has no cure. The rate of recovery is variable; 50% of people with GBS fully recover, 35% report residual weakness, and 15% have more permanent dysfunction.
b) Fatigue is the most frequently reported symptom in 93% of people with GBS, and minor cognition difficulties, such as impaired executive functioning, short-term memory, and decision making, may occur.
Interdisciplinary team for Guillain-Barré Syndrome
a) Medication and medical procedures
b) Respiratory therapy
c) Speech therapy
d) Physical therapy
e) Occupational Therapy
Medications and medical Procedures for Guillain-Barré Syndrome
Medications and medical procedures are indicated to reduce severity and speed recovery.
a) Intravenous immunoglobulin
b) Plasma exchange (plasmapheresis)
c) Steroids to combat inflammation (Forwell et al., 2008, p. 1096)
Respiratory therapy
Respiratory therapists may be a part of the team to advise on appropriate breathing treatments and exercises if respiratory muscles have been paralyzed or compromised.
Speech therapy
Speech therapists may be needed if speech production or swallowing impairments exist; speech therapists may train clients to “improve speech patterns or facilitate swallowing”.
Physical therapy
Physical therapists address mobility needs, help prevent muscle atrophy, and aid in the prevention of contractures or skin breakdown.
Occupational therapy evaluation for Patients with Guillain-Barré Syndrome
a) Referrals to occupational therapy commonly occur when GBS is moderate to severe, typically involving 40% of those affected.
b) In the plateau phase, screening and evaluation often occur in intensive care because the client is receiving extensive medical care. Assessment covers communication, control of the physical environment, comfort and positioning, and anxiety management.
c) In the recovery phase, evaluation focuses on mobility, self-care and ADLs, communication, leisure, and workplace and community reintegration; it typically occurs in inpatient rehabilitation, outpatient rehabilitation, and home or work settings.
Occupational therapy intervention for patients with Guillain-Barré Syndrome
a) In the plateau phase, modifications are deemed temporary.
b) In the recovery phase, interventions aim to help the client resume occupations and roles, rituals, and routines.
Occupational therapy for patients with Guillain-Barré Syndrome in the plateau phase
a) Develop and train the client in the use of communication tools, such as signs or picture boards.
b) Provide environmental modifications to ensure access to the call button, remote controls, and phone.
c) Adapt the telephone for hands-free use.
d) Adjust (and train caregivers on) supine and sitting positions that optimize function and comfort and reduce risk of skin breakdown.
e) Position the client for trunk, head, and upper-extremity stability.
f) Educate the client and family about the health condition and anxiety reduction techniques.
Occupational therapy for Patients with Guillain-Barré Syndrome in the Recovery Phase
In the recovery phase, interventions aim to help the client resume occupations and roles, rituals, and routines.
a) Design activities and dynamic splints to help maintain ROM, especially for the wrist, fingers, and ankle (hinged drop-foot orthosis).
b) Instruct the client in safe mobility with appropriate assistive devices (if necessary), and help improve independence and safety with functional transfers, such as to the toilet or tub or out of bed.
c) Suggest modified techniques for self-care and other adaptations for the client’s daily routine.
d) Continue to adapt modes of communication on the basis of the client’s priorities (e.g., voiceoperated text messaging).
e) Educate the client on adaptive equipment and behavior modification techniques for home, leisure, community, and work activities.
f) Provide strategies for energy conservation and fatigue management.
g) Develop a client-centered fine motor program to maximize strength, coordination, and sensation in the hands and fingers.
h) Complete a home assessment and recommend modifications as appropriate to help ensure the client’s safe return home.
Huntington’s Disease Definition
Huntington’s disease (HD) is a hereditary neurological disorder that leads to severe physical and mental disabilities. Over time, HD causes progressive loss of nerve cells in the brain, affecting movement, cognition, emotions, and behavior.
Primary signs and symptoms
a) Motor Difficulties
b) Deterioration of Cognitive and Behavioural Abilities
c) Slowing of saccadic eye movements and ocular pursuits
d) Dysphagia
Types of Motor Difficulties of Huntington's Disease
a) Involuntary Motor difficulties
b) Voluntary Motor difficulties
c) During later stages, hypertonicity replacing chorea.
d) In the middle stages, gait and balance problems, such as wide-based gait pattern and difficulties walking on uneven terrain
e) Difficulties with smaller movements and hand–eye coordinationg) During later stages, large bursts of movement when small movements are intended.
Involuntary Motor difficulties of Huntington’s Disease
a) Involuntary movement patterns
b) Choreiform movements of hands
c) Chorea, Akathisia, Dystonia
Chorea
rapid, involuntary, irregular movements, increasing during stressful situations and lessening or absent during voluntary motor activities and sleep
Akathisia
motor restlessness
Dystonia
abnormal, sustained posturing of a body part, typically the arms, head, or trunk
Voluntary Motor difficulties of Huntington’s Disease
a) Bradykinesia
b) Akinesia
c) Incoordination of movement
Bradykinesia
slowed movement
Akinesia
delayed initiation of movement, caused by changes to the functioning of the basal ganglia
Incoordination of movement
alteration of rhythmical, repetitive movements
Deterioration of cognitive and behavioral abilities in Patients and Huntington's Disease
a) Forgetfulness
b) Difficulty concentrating
c) Difficulty with mental calculations, sequencing of tasks, and memory
d) In the initial stages, difficulty maintaining work performance
e) In the middle stages, disturbances in memory and decision making
f) In the later stages, compromised pronunciation because of dysarthria
g) Irritability and depression. Depression, possibly leading to suicide
Progression of Huntington's Disease
1) HD is a progressive disorder.
2) Symptoms usually appear in the third or fourth decade of life.
3) Symptoms progress over a 15- to 20-year period.
4) With progression, the client eventually requires long-term care or hospitalization.
5) Death results from secondary causes related to the disease.
Medical management of dementia caused by Huntington's Disease
a)No effective course of treatment has been identified to arrest the progression of HD. Medical management addresses symptoms.
b) Intervention to replace deficient neurotransmitters changes the course or rate of progression.
c) Tricyclic antidepressants are used to treat depression.
d) Haloperidol is used to decrease chorea during performance of functional activities.
e) The client requires continuous evaluation of symptoms and progression.
Effects of Huntington's Disease on occupational performance
a) Environmental change or additional task demands compromise occupational performance.
b) Deterioration of cognitive disabilities may lead to dismissal from employment.
c) The client may have difficulty sequencing tasks.
d) Loss of function may contribute to depression.
e) Performance of voluntary motor tasks is slowed.
f) Initiation of voluntary movements for a task is compromised.
g) At the later stage of HD, the client is usually unable to talk, walk, or perform basic ADLs without significant assistance.
h) Loss of small motor control and hand–eye coordination affects ability to use tools and utensils, write, and use a keyboard. Loss of oral–motor control causes indistinct speech, drooling, choking, and difficulty eating.
i) Weight loss can be a consequence of the movement disorder.
Occupational therapy evaluation for Huntington's Disease
a) The Unified Huntington’s Disease Rating Scale assesses changes in the areas of motor function, cognitive function, and functional capacity and behavioral abnormalities.
b) Occupational therapy evaluation should include functional daily living skills, cognitive abilities such as problem solving, motor performance, strength, personal interests, and values.
Occupational therapy interventions for Huntington's Disease in its Early stages for Cognitive and Emotional disability
a) Address cognitive components of memory and concentration.
b) Establish a daily routine, use of checklists, and task analysis to break down tasks into more manageable steps.
c) Avoid open-ended questions during therapy sessions.
d) Use word association to aid with retrieval of information.
e) Perform a work site evaluation.
f) Introduce home and work environmental modifications (e.g., label items with their name and function).
g) Write down all steps in a logical order.
h) Review steps so the client clearly understands them.
i) Encourage completion of each step before moving on to the next step.
j) Consider additional stress resulting from HD such as loss of employment or decreased income
k) Encourage involvement with support groups, engagement in community activities, and use of virtual resources through the Internet.
l) Refer the client for a driving evaluation, and discuss possibilities for other forms of community mobility.
Occupational therapy interventions for Huntington's Disease in its Early stages for Motor disability
a) Provide modifications to diminish the effect of chorea and fine motor incoordination on performance of functional activities.
b) Introduce a home exercise program to address flexibility and endurance of the entire body.
Occupational therapy interventions for Huntington's Disease in its Early stages for Safety at home
a) Provide techniques to improve safety in the kitchen.
b) Provide techniques to improve safety in the living room and bedroom.
Safety techniques in the kitchen for Huntington's Disease
a) Using unbreakable dinnerware
b) Storing commonly used items in accessible cabinets
c) Using a kitchen timer as a reminder to turn off appliances
d) Lowering the hot water temperature to prevent scalding
e) Using covered mugs for hot liquids
f) Using oven mitts rather than potholders
g) Provide techniques to improve safety in the bathroom.
h) Using a nonskid mat in the shower
i) Using soap on a rope
j) Using a shower chair
k) Using safety bars
Safety techniques for safey in the Living Room and Bedroom for Huntington's Disease
a) Stabilizing furniture so it does not move
c) Using chairs with high backs and armrests
d) Clearing rooms of unnecessary furniture
e) Removing scatter rugs or thick carpet
f) Keeping tables and lamps away from walkways
g) Padding doorways and furniture when contact with them is frequent
Occupational therapy interventions for Huntington's Disease in its Middle stages
a) Focus on engagement in purposeful activities (leisure activities).
b) ncourage the client to arrange for others to handle finances.
c) Instruct the family to use simple written cues or words to promote completion of self-care and simple household activities.
d) Encourage the client to use ambulatory devices (i.e., walker or wheelchair).
e) Recommend taking routine breaks to deal with fatigue.
f) Educate the client and family to use positioning techniques and adaptive equipment during feeding
g) Encourage changes in dietary consistency as appropriate—for example, switching to soft foods to accommodate changes in oral–motor function.
h) Provide techniques for maintaining good hygiene.
i) Provide techniques to aid in dressing
Positioning techniques and adaptive equipment during feeding for middle strage Huntington's disease
a) Sitting in a sturdy chair as close to the table as possible
b) Wrapping the legs around the chair legs to stabilize the pelvis and placing the elbows on the table to stabilize the upper trunk
c) Using utensils with built-up handles
d) Putting utensils down after each bite to rest muscles and prevent fatigue
e) Using a nonskid placemat
f) Using covered cups or mugs
g) Engage the client in oral–motor exercises.
Techniques for maintaining good hygiene for middle stage Huntington's Disease
a) Writing out separate lists for morning and evening tasks
b) Posting a list of steps for completing each task in a visible place.
c) Implementing use of
-Shower bench
-Shower mitt or soap on a rope
-Electric razor or chemical hair removal
-Built-up handle on toothbrush or hairbrush
Techniques to aid in dressing for middle stage Huntington's disease
a) Reducing tasks to simple steps
b) Pairing favorite items and labeling them to keep decision making to a minimum
c) Using clothing with simple fasteners
d) Putting a ring on zippers for easier fastening
e) Sitting in a sturdy chair
Occupational therapy interventions for Huntington's Disease in its Final stages
a) Pay attention to positioning.
b) Use splinting to prevent contractures.
c) Facilitate a smooth transition to tube feedings.
d) Put environmental controls into place.
e) Use consistent daily schedules and routines.
Dementia Types
a) Alzheimer's disease
b) Vascular dementia
c) Frontotemporal dementia
d) Dementia with Lewy bodies
Alzheimer’s disease (AD) Pathology
cortical atrophy of the frontal, parietal, and temporal lobes as well as the hippocampal region caused by an accumulation of amyloid-beta senile plaques and tau protein neurofibrillary tangles
Clinical features of Alzheimer's disease
a) Progressive impairment of memory, executive function, attention, language, visual processing, and praxis
b) Commonly, behavioral disturbances (Atchison & Dirette, 2012, p. 103)
Course and prognosis of Alzheimer's disease
a) Slow and progressive until death
b) Three stages: early stage, middle stage, and late stage.
c) The symptoms of AD gradually lead to behavior and personality changes; a decline in cognitive abilities, such as decision-making and language skills; and problems recognizing family and friends.
Medical management of Alzheimer's disease
a) Supportive care for the client and caregiver
b) Disease treatment to slow the progression
c) Symptom treatment targeting cognitive decline, psychiatric symptoms, and behavior disturbances
d) Pharmacotherapy to manage symptoms such as cognition, depression, delusions and hallucinations, and agitation and aggression
e) Behavioral and environmental management to restore the balance between challenges presented and the client’s current level of function.
Vascular dementia Pathology
a)cerebrovascular disease (often a series of small strokes) leading to focal lesions on the brain and neurotransmitter disruption
Clinical features of Vascular dementia
a) Cognitive decline similar to AD but often less severe memory involvement
b) Commonly, gait disturbance
c) Abrupt or stepwise (rather than continuous) decline.
Course and prognosis of Vascular dementia
a) Sudden appearance of symptoms, with a stepwise pattern of increased symptoms
b) May also progress slowly, similar to AD
Medical management of Vascular dementia
a) Immediate emergency medical treatment necessary
b) Treatment of cardiovascular factors (i.e., management of diabetes, high cholesterol, and heart disease)
c) Pharmacotherapy to prevent future blood clots
d) In some cases, surgery to remove blockages in blood vessels.
Frontotemporal dementia Pathology
neuronal, intranuclear inclusions
Clinical features of Frontotemporal dementia
progressive aphasia, corticobasal syndrome, or symptoms similar to AD or Parkinson’s disease.
Course and prognosis of Frontotemporal dementia
a) Immediate, distinct onset
b) Progressive
c) Varied symptom patterns among individuals
Medical management of Frontotemporal dementia
a) Future research needed; medications currently in development
b) Treatment of some disinhibited behaviors with selective serotonin reuptake inhibitors.
Dementia with Lewy bodies Pathology
Lewy body proteins present in the brain, usually predominant in the limbic or neocortical areas; overall decline in acetylcholine and dopamine levels
Clinical features Dementia with Lewy bodies
a) progressive deficits in attention and executive function, memory impairment, fluctuating cognition, visual hallucinations, parkinsonism, autonomic dysfunction, and falls; rapid eye movement sleep behavior disorder as a possible prodromal symptom.
Course and prognosis Dementia with Lewy bodies
a) Gradual and insidious
b) Early disease symptoms: problems in executive function, visuospatial abilities, attention, and memory function
c) Symptoms over time: aphasia, apraxia, and spatial disorientation
Medical management of Dementia with Lewy bodies
a) Similar to that for AD
b) Increased family involvement; safety assessment
c) Neuroleptics
d) Cholinesterase inhibitors: some evidence available of effectiveness.
Primary signs and symptoms of Dementia
a) Memeory impairment
b) Cognitive deficits
c) Other cognitive or personality symptoms
d) Motor deficits
e) Symptom severity: sufficient to affect occupational performance and represent a decline from previous functional level.
Memory impairments caused by Dementia
a) Recent memory
b) Procedural memory
c) Personal episodic memory
d) Semantic memory
Recent memeory
recall of recent events; affected first (e.g., the person misplaces things)
Procedural memory
recall of information on how to perform a task, such as knowing how to write or ride a bike; remains intact
Personal episodic memory
recall of time-related information about oneself, such as where and whether one ate breakfast; shows deficits
Semantic memory
ability to remember the names of objects; shows deficits
Cognitive deficits caused by Dementia
a) Aphasia
b) Apraxia
c) Agnosia
d) Disturbance in executive functioning
Aphasia
difficulty with expressive language, receptive language, or both
Apraxia
loss of skilled, purposeful movements that cannot be attributed to either deficits in primary motor skills or problems in comprehension; can affect ideation and concept formation as well as programming and planning of movement
Agnosia
inability to recognize the importance of sensory impressions despite being able to recognize the elemental sensation of the stimulus
Disturbance in executive functioning
disruption of the broad band of skills that allow a client to engage in independent, self-directed behavior, including volition, planning, purposeful action, and self-awareness
Other cognitive or personality symptoms of Dementia
a) Difficulty with topographic orientation (i.e., orientation of the self within the environment; can cause the person to get lost easily
b) Difficulty with spatial tasks
c) Poor judgment
d) Anxiety and defensiveness
e) Disinhibited behavior
f) Psychotic symptoms
Motor deficits of Dementia
a) Gait disturbances.
b) Hyperflexia
c) Paratonia
d) Dysphagia
Hyperflexia
overflexion of a limb
Paratonia
involuntary resistance to passive movement of the extremities.
Dysphagia
difficulty swallowing
Early stage Effects of dementia on occupational performance
a) During the early stage, ADLs remain intact.
b) The first signs of memory loss manifest in IADLs.
c) Dementia affects orientation to place, which affects community mobility.
d) The person may become disoriented while traveling away from home.
e) Financial management is impaired
f) Shopping is impaired.
g) Meal preparation is impaired.
h) Health management is impaired.
i) Driving skills need to be reevaluated.
j) Learning and reading become difficult.
k) Work performance is impaired.
l) Relationships with coworkers and supervisors are affected and may cause unemployment.
m) Leisure exploration becomes difficult.
n) The person withdraws from social participation.
o) Intimacy and sexual expression deteriorate.
p) Communication is impaired because of language problems.
q) The person clings to old habits and repetitive routines.
r) The person neglects old habits and routines.
s) Roles change.
t) Cultural and spiritual context remain intact, but participation declines.
Middle stage Effects of dementia on occupational performance
a) Impairments occur in all areas of occupation.
b) The person can no longer live alone.
c) The person may no longer attend to ADLs.
d) Eating problems and weight loss occur.
e) IADLs are neglected or performed out of sequence.
f) Simple home management tasks can be completed with assistance.
g) The person is dependent in community mobility, financial management, and shopping.
h) Some cleaning and cooking tasks can be done with supervision.
i) Safety is a major concern; risks include wandering, letting a stranger in the house, or causing a fire.
j) The person cannot perform work or education activities.
k) Leisure participation is limited.
l) Social participation is typically limited to caregivers.
m) The person can no longer differentiate days.
n) Roles continue to be lost.
o) The cultural context begins to diminish.
p) Personal and temporal contexts may be confused.
Late stage Effects of dementia on occupational performance
a) All areas of occupation are lost.
b) The person is dependent in all ADLs.
c) The person can no longer ambulate safely.
d) Communication is lost.
e) The person has no understanding of the cultural, social, or spiritual contexts.
Assessing a client with dementia: Clinical observation
a) Standardized function-based cognitive screening instruments
b) Standardized cognitive screening instruments
c) Memory assessments
Standardized function-based cognitive screening instruments used for Dementia
a) Allen Cognitive Level Screen or the enlarged Allen Cognitive Level Screen.
b) Assessment of Motor and Process Skills
c) Cognitive Performance Test
d) Executive Function Performance Test.
e) Independent Living Scales
f) Kitchen Task Assessment
d) Árnadóttir OT–ADL Neurobehavioral Evaluation
Standardized cognitive screening instruments used for Dementia
a) Blessed Dementia Scale (Blessed, Tomlinson, & Roth, 1968)
b) Cognitive Competency Test
c) Lowenstein Occupational Therapy Cognitive Assessment
d) Middlesex Elderly Assessment of Mental State (Golding, 1989)
e) Mini-Mental State Examination (Folstein, Folstein, & McHugh, 1975)
f) Modified Mini-Mental State Examination (Teng & Chui, 1987)
g) Neurobehavioral Cognitive Status Screening Examination
h) Repeatable Battery for the Assessment of Neuropsychological Status
Memory assessments used for Dementia
a) Contextual Memory Test
b) Hopkins Verbal Learning Test–Revised (Brandt & Benedict, 2001)
c) Prospective Memory Screening (Sohlberg & Mateer, 1989)
d) Rivermead Behavioural Memory Test–Extended Version
Occupational therapy interventions for Dementia using:
a) Claudia Allen’s Cognitive Disability Theory
b) Behavior management
c) Intervention approaches are: Cognitive functioning, Affective functioning, Sensory–perceptual functioning, Social functioning, Self-care functioning, Sleep functioning, Nutrition and elimination functioning, Motor functioning, Environmental structuring,
Occupational therapy interventions for Dementia using Behavior management: commuication
a) Avoid reasoning with the client.
b) Listen.
c) Maintain a trusting relationship.
d) Offer choices when possible.
e) Decrease demanding social situations (Lewis, 2003, p. 137).
f) Simplify approaches and environment during sundowning, an increase in activity and often agitation that begins in the late afternoon and extends into the evening or night.
Occupational therapy interventions for Dementia using Behavior management for Sundowning behaviors
a) Use adequate lighting.
b) Provide a safe area for physical activity.
c) Provide reassurance in a calm and caring manner.
d) Provide the client with fluids during the day.
e) Reduce noise and clutter.
f) Avoid using restraints.
Occupational therapy interventions for Dementia using Behavior management for Anger
a) Anticipate problems and stressors.
b) Rephrase negatives as positives.
c) Distract the client by using food or asking for assistance.
d) Adhere to familiar routines.
e) Simplify tasks.
f) Allow time for response.
g) Allow physical movement.
h) Reduce stimuli in the environment.
Occupational therapy interventions for Dementia using Behavior management for Wandering
a) Assess the reason for wandering.
b) Use a calm approach.
c) Provide signs in the environment for cueing.
d) Use distraction techniques to interrupt pacing (i.e., familiar pictures on the wall)
e) Provide opportunities for activities and movement.
f) Simplify tasks.
g) Provide a rocking chair.
h) Ensure good lighting.
i) Keep areas uncluttered and safe.
j) Monitor fatigue.
k) Monitor fluid intake.
l) Monitor the client’s feet.
m) Use a MedicAlert identity wristband.
n) Provide reassurance, attentiveness, and acceptance.
o) Walk with the client.
Occupational therapy interventions for Dementia using Behavior management for Pillaging and rummaging
a) Provide security within the home so the client’s needs are met.
b) Learn the client’s favorite hiding places.
c) Give the client a familiar item to hold.
d) Use straightening up as a meaningful activity.
e) Provide cloth scrapbooks for the client.
f) Involve the client in activities that involve sorting items.
g) Mark the client’s name on personal items.
h) Monitor the client for unsafe items.
i) Provide the client with rummaging closets or areas.
j) Accompany the client to make it fun.
k) Do not scold, tease, or punish the client or respond with anger.
l) Fabricate busy boxes with safe items for handling (Lewis, 2003, p. 140).
m) Use distraction.
n) Use discretionary assistance with ADLs.
Occupational therapy interventions for Dementia using Behavior management for Activities and occupations
a) Focus activity on the client’s abilities, not limitations.
b) Be purposeful.
c) Provide the client with a sense of belonging.
d) Promote positive behaviors.
e) Promote appropriate verbal and nonverbal communication.
Occupational therapy interventions for Dementia using Behavior management for choosing Activities
a) Activities should be Safe for everyone
b) Activities should be Modifiable and adaptable
c) Activities should be Repetitive, familiar, and routine
d) Activities should be Pleasurable
e) Activities should be Dignified (Lewis, 2003, p. 142)
Occupational therapy Intervention for dementia using Cognitive functioning approach
a) Psychoeducation during the early stages for family and caregivers
b) Cognitive facilitation and stimulation (i.e., reminiscing groups)
c) Relaxation techniques (i.e., rocking chairs, soothing music)
d) Structured communication approaches
e) Environmental structuring to compensate for functional deficits (e.g., visual aids, home setup
f) Sensorimotor therapy
Occupational therapy Intervention for dementia using Affective functioning approach
a) Psychoeducation during the early stages for family and caregivers
b) Relaxation activities
c) Appropriate medication intake
d) Structured and planned socialization (e.g., adult day care center)
e) Structured activities (e.g., leisure interests with family or caregivers
f) Movement and exercise
g) Intergenerational activities
h) Spiritual expression activities
i) Milieu therapy
Occupational therapy intervention for dementia using Sensory–perceptual functioning approach
a) Appropriate physical aids (e.g., hearing aids, glasses)
b) Environmental structuring
c) Adaptive techniques and equipment
d) Sensorimotor therapy
e) Structured activities
f) Adjunctive therapy (e.g., dance and art therapy)
Occupational therapy intervention for dementia using Social functioning approach
a) Counseling during the early stages
b) Milieu therapy
c) Adjunctive therapies
d) Structured socialization
e) Intergenerational activities
f) Structured verbal and nonverbal communication techniques
Milieu therapy
Milieu therapy is the treatment of mental disorder or maladjustment by making substantial changes in a patient's immediate life circumstances and environment in a way that will enhance the effectiveness of other forms of therapy. The goal of milieu therapy is to manipulate the environment so that all aspects of the client’s hospital experience are considered therapeutic.Within this therapeutic community setting the client is expected to learn adaptive coping, interaction and relationship skills that can be generalized to other aspects of his or her life.
Occupational therapy intervention for dementia using Self-care functioning approach
a) Adaptive techniques and equipment
b) Caregiver education
c) Caregiver training in activities to enhance the client’s fine and gross motor abilities; provide sensory stimulation; reinforce old learning, self-image, and dignity; and improve sense of reality
d) Exercise and sensorimotor therapy
e) Environmental structuring
f) Behavior modification
f) Milieu therapy
Occupational therapy intervention for dementia using Sleep functioning approuch
a) Promotion of physical activity
b) Reinforcement of appropriate sleep patterns through good sleep hygiene and routines
c) Relaxation activities
d) Sensorimotor and exercise therapy
e) Structured activities
f) Environmental structuring
g) Medication monitoring
h) Education on natural sleep inducers
Occupational therapy intervention for dementia using Nutrition and elimination functioning approuch
a) Positioning
b) Appropriate chair and table height
c) Adaptive equipment
d) Environment conducive to eating
e) Formal eating programs
f) Behavior modification
g) Exercise and movement therapy
h) Medication monitoring
Occupational therapy intervention for dementia using Motor functioning approuch
a) Simple movement
b) Exercise and sensorimotor therapy
c) Adaptive techniques and equipment
d) Environmental structuring
e) Medication monitoring
Occupational therapy intervention for dementia using Environmental structuring approuch
a) Sensory–perceptual modifications
b) Memeory enhancement
c) Structured common areas
d) Consistency and calm
e) Simplified and structured environment to promote ADL task performance
f) Inconspicuous locks on cabinets and doors
Occupational therapy sensory-perceptual modifications used during Enviormental structuring approuch to intervention for dementia
a) Appropriate lighting
b) High-contrast coloring or textured surfaces
c) Objects for stimulation
d) Varied, safe, and tactile objects
e) Visual blocks
f) Soundproofing
Occupational therapy Memory enhancement used during Enviormental structuring approuch to intervention for dementia
a) Large-print calendars
b) Daily schedules
c) Seasonal decorations
d) Familiar furniture
e) Photographs
f) Favorite music
g) Notices of current events
h) Safe indoor walking space or garden
i) Monitoring system