Post on 22-Jan-2016
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Cognitive Changes in Aging
PTP 783 Jennifer Blackwood
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Cognitive Changes
Cognition: defined as awareness by perception, reasoning, judgment, intuition, memory, and knowledge
25% of the population 65+ have a cognitive impairment Increases with advanced age
Elderly maintain the ability to understand new experience & situations Changes in this should NOT be dismissed as
normal agingPersonalities remain stable with aging: if it
changes possible psychiatric dysfunction
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Changes in cognition are linked to
Cardiovascular disease DM HTN Atherosclerosis Low blood pressure Dehydration, nutritional deficits Infection Genetic link: APOE, total cholesterol
(Panza et al, 2007)
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Intelligence & Learning Capacity
No age related decline in spatial learning abilities
A minimal amount of absent-mindedness is considered normal
No decrease in information processing in the absence of disease or mental dysfunction
Learning progresses slower with age, affected by sensory changes (vision)
Declines difficult to research
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Intelligence
Performance on IQ tests diminishes after a LONG period of time (55-70 yrs)
Fluid Intelligence: capacity to use unique ways of thinking to solve unfamiliar problems declines with age
Crystallized Intelligence: through education and acculturation remains stable through age 70
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Executive Function
Combines memory, intellectual capacity, and cognitive planning
Correlated with ADLs
PTs are concerned- decline in EF= decline in balance and increased fall risk
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Benign Senescent Forgetfulness
Memory loss with the normal older person
Functional decline is not present with this as opposed to it being present with
dementia
PTs can play a role with assisting in dx
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Age Associated Cognitive Decline
27% of those 68-78 have AACD Gradual cognitive decline over 6 mo 1 SD below the normal for
neuropsychological testing All areas of cognitive performance
are limited: memory, learning, attention, concentration, thinking, language, & visuospatial functioning.
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Mild Cognitive Impairment Deterioration of cognitive function greater
than expected for a person’s age and education level, does not meet criteria for dementia, and does not affect ADLs
Amnestic or multiple domain Increased risk with CV diseases or risk factors 12-28% progress to AD Difficult to detect with MMSE as it is not
sensitive Difficult to detect objectively as patient’s
behavior’s change
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The 3 D’s
Delirium
Depression
Dementia
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Delirium
Acute confusional state (aka acute brain syndrome)
Inattention, distractibility, drowsiness
Often accompanied by agitation
Sundowners: worse in evening & night More agitated in afternoon, therefore see in morning.
Hallucinations
STM very significantly affected: immediate recall, attention, and retention of new info
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Depression Episode: sub acute onset 1 in 4 women and 1 in 10 men
experience this 90% can be treated Symptoms: recent onset, flat affect,
decreased communication, feelings of sadness, helplessness, or despair, physical pains, suicidal thoughts, guilt, loss of interest or pleasure
Somatic concerns in 60%
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Screening for Depression
GDS Beck’s Inventory USPSTF-
‘Over the past 2 weeks, have you felt down, depressed, or hopeless?’
‘Have you felt little interest or pleasure in doing things?’▪ As effective as longer screening tools for risk
for depression
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Meds for Depression
SSRIs- favored…. Why? Zoloft, Paxil, Prozac
Tricyclic Antidepressants Serotonin/Norepinephrine Reuptake
Inhibitors MAO Inhibitors
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Dementia
More frequently in adults age 75+, women Defined as: Global impairment of intellect,
memory and personality in the absence of impaired consciousness (WHO, 1993)
Amnesia, aphasia, agnosia, apraxia, decreased executive functioning
Chronic, non-reversible, slow onset of STM loss.
Don’t confuse confusion with dementia Causes: Alzheimer’s, alcoholism, NPH,
cerebral infarct, pernicious anemia, vit B12 deficiency, vascular origin, Lewy body disease
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Vascular Dementia
AKA Multi-Infarct Dementia (multi-TIA-”mini stoke”)
Organic mental disorder with cerebrovascular disease
Cognitive decline is due to multiple infarcts that produces a loss of brain tissue
In addition to memory impairments personality changes occur
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Pseudodementia
Dementia like behavior is actually the result of a major depressive episode
Flat affect, disinterest in events
Depressed persons respond in a slow, labored manner but provide accurate responses
Patients with dementia are unable to produce the correct response ‘Don’t know’ study
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Lewy Body Dementia
Carotid sinus hypersensitivity (as high as 50%)
Symptoms of both AD and Parkinson’s Disease type Dementia Cognitive decline and motor symptoms
Fluctuating levels of cognition throughout the day
Motor changes similar to PD Hallucinations
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Changes in cognition relate to
Increased fall risk (1.5-3 x the risk of cognitively normal fallers) Study by Tinetti found 67% with MCI fell
over a year Decreases on the MMSE relate to a
reduction in survival probability Every point decrease on MMSE: adjusted
odds ratio for mortality was .95 (95% CI: .93-.97) and for institutionalization: .91 (95% CI: .90-.94)
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Alzheimer’s Disease
60% of those with dementia Diagnosed post morbidly Inclusionary criteria: memory loss, aphasia,
apraxia, and disturbance in executive functioning Severe enough to impair social or occupational
function Difficult to diagnose in the early stages Masked by those with more education Affects 25-30% those 65 y.o;
Older than 85 y.o.: 50% incidence
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AD
Genetic risk factors: APOE e4 (apolipoprotein E allele)
Average life span: 8-10 yrs from symptom onset
Physical changes in the brain:
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FAST scale for Alzheimer's Disease
Stage 1: no change in function Stage 2: deficits with word finding or recall of
objects Stage 3: difficulty in unfamiliar environments,
missed appts. Hides it well. Stage 4: needs help with complex community
or domestic tasks (finances/shopping) Stage 5: not able to live alone, decreased
safety awareness, simple tasks affected (changes in gait speed, tone, reaction time)
Stage 6: assistance nec for most basic ADLs (eating, grooming, toileting)
Stage 7: dependence for all care, incoherent speech, disorientation of time, place, person
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Medications: are they effective
Anticholinergics Can only be used for certain levels of
dementia
Psychotropic meds (antipsychotics, benzodiazepines, tricyclic antidepressants, and hypnotics): increase fall risk in those with dementia by 2x
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Gait changes with AD
Compared to age and sex matched controls: Shorter step length Slower gait speed Lower step frequency Increased step to step variability Greater double support ratio Greater sway path *Peripheral impairments less likely as a source, but more central processing and integration of perceptual information (Franssen et al, 1999)
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Evaluate Cognition with:
MMSE Mini-Cog SLUMS MOCA Trail Making Test A, Trail Making Test B Others
Folstein et al, 1975, Galantino et al, 2006
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Evaluate Cognition: MMSE & the Mini-Cog
MMSE: 30 total points Assesses orientation, attention,
calculation, recall, and language
Mini- Cog: 3 minute instrument to screen for
cognitive impairment: 3 item recall test Clock drawing test
Folstein et al, 1975; Borson, 2000
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MMSE
AKA: Folstein 0-30, median score for those 80+ is 25 24-30: Minimal cognitive impairment 18-23: Mild to Moderate cognitive
Impairment 0-17: Severe impairment Median score for those who completed 4th
grade: 22 or less Ceiling effect with MCI Sensitivity: 82% and Specificity: 99% in
detecting dementia
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SLUMS Test
St. Louis University Mental Status Examination
Created because MMSE not good at detecting MCD, MCI, or MNCD
Maximum score of 30 Addresses attention, recall, calculation, and
executive function (clock drawing) Addresses the difference between those
who have more education versus less Sensitivity & Specificity: 100% in detecting
dementia
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SLUMS norms:
High School Education Less Than High School
Normal functioning 27 to 30
25 to 30
MNCD 21 to 26 20 to 24
Dementia 1 to 20 1 to 19
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MoCA
Montreal Cognition Assessment MCI Assesses executive function, visuospatial
abilities, memory, attention, concentration, working memory, language, & orientations
Scores range from 0-30 Adjusts for education level Sensitivity (100%) & Specificity: 87% in
detecting MCI in the general population using a cutoff score of 26
Less than 24: MCI (sensitivity: 83.3%, specificity: 29.6% in those with CV disease)
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Evaluate Cognition: Trail Making Tests A & B
TMT A- Assesses processing speed Paper/pencil, timed test to connect a
trail of numbers in ascending order TMT B- Assesses Executive Function
Paper/pencil, timed test to connect a trail of alternating numbers/letters in ascending order
Norms stratified by age and education See Tombaugh 2004 article for norms
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Trail Making Tests A & B
Addresses Executive function via: visual-conceptual, visuospatial, and visual-motor tracking, attention, and task alteration
Scores increase with age and education Performance in the TMT is a strong
predictor of: Mobility impairment Accelerated decline in LE function Increased fall risk Mortality in community dwelling older adults
(Vazzana et al, 2010)
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TMT A TMT B
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TMT A
Norm:29 seconds
Deficit: > 78 seconds
Most in 90 seconds
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TMT B: Norm: 75 seconds
Deficit:> 273 seconds
Most in 3 minutes
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2 things proven to slow Cognitive decline:
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The Allen Cognitive Scale
Created by Claudia Allen, OTR Level determined by how an
individual performs on a leather lacing test
Flows from TOP to bottom with regards to cognitive abilities
Has 6 scales with 5 subscales for each identifying criteria
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Allen Levels Level 6 Planned Activities
CEO
Level 5 Independent Learning teenager
Level 4 Goal Directed Activities▪ Early level dementia ****
Level 3 Manual Actions ▪ Middle level dementia ****
Level 2 Postural Actions ▪ Late level dementia ****
Level 1 Automatic Actions Semi-comatose
High
Low
Cognition
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We will focus on LEVELS 2 through 4 with regards to dementia and physical therapy practice!
Each Level will be broken down in to ‘high’ and ‘low’ portions.
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Level 4 Early Dementia Needs cues to fully complete self care Poor safety awareness May wear same clothes or not comb back
of head Can sequence a routine, but not set up or
clean up (procedural memory) May not follow complex commands All talk but no action Very social
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Level 4 Early Dementia
Low level 4 Oriented to
person, place, and routine
Reads, but not functional
Cues to calendar Likes structure
and schedules Can potentially
learn to use a standard walker
High level 4 Oriented to
person, place, and time
Reads instructions with errors
Can live alone if no stove and becomes a ‘couch potato’
Able to learn 3-4 steps but without safety
Can learn to use a quad cane
Can follow a list
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Level 4 Interventions Striking visual cues
needed to learn new tasks.
Functional exercises needed to prevent boredom
Amb with device, but don’t expect to follow safety precautions.
Gait training with scanning the environment
Practice negotiating corners and other barriers.
Need consistent
repetition for HEP/exercise learning.
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Level 4 treatment considerations
Needs structure and routine for increased safety and independence
Establish schedules, lists, and other memory aids
Needs cues for any precautions in order to follow
HEP considerations
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Level 3 Middle Dementia
Easily distractible Limited visual field Follows 1 step directions Loss of ability to complete basic
ADLs (eating/grooming) Constantly doing something with
hands Confused, wanders
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Level 3 Middle Dementia
Low Level 3 One minute attention
span Visual field 12-14” Needs constant
cueing for participation
Attempts to climb over bed rails
Requires supervision when walking on uneven surfaces
High Level 3 Learns
destination/routine after 3wks of consistency
Performs tasks without completion
Needs verbal cues for sequencing
Can change body position to prevent loss of balance when asked.
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Level 3 Interventions Gait training with
various sensory conditions and cues to start/stop.
Closed chain exercises (low level 3)
Supervised stair climbing.
Open chain exercises (high level 3)
Most likely will NOT remember any precautions indicated
Consistent repetition with use of an assistive device for ambulation.
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Level 3 Treatment considerations
Shorten activity to decrease risk of combativeness
Use clear concise directions Reduce distractions by removing
extraneous objects from view (mirror, other patients)
Provide a calming environment Focus on training caregiver for HEP
follow through
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Level 2 Late Dementia Postural insecurity with fear of falling
(balance issues) Agitated if hurried Cognitively processes 2-3 times slower Disrobes if uncomfortable Tends to wander, resists confinement Follows people or goes where pointed to
go Tunnel Vision No awareness of a physical disability
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Level 2 Late Dementia
Low Level 2 Overcoming
gravity (provides 75% effort to move)
Uses one word to initiate communication
Loves reciprocal movement
Avoids barriers above knees, bends at waist
High Level 2 Fearful Uses intense grip
on railings/grab bars or you
Walks to identified location
Confused by floor contrasts
Likes to push objects
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Level 2 Interventions Sitting activities to
work on postural control
Sit<->stand activities with weight shifting (count to 3)
Rhythmic repetitive movements for gait training
Will need supervision with amb with device
Use slow music to encourage ambulation
Use of wide colored tape on stairs/uneven surfaces to increase visibility
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Level 2 Treatment Considerations
Teach caregivers proper cues for HEP completion with appropriate amount of time for processing
Responds better to tactile cues than verbal instructions
Prevent falls, contractures, wounds, and positioning issues (wedge cushions, lap tray)
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