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Beyond Memory Books MSHA 2012.Pdf 3/6/2012 Outline y Review of Dementia; Language, Cognitive, Behavior changes y Brief discussion of Assessment for Functional Treatment y Theoretical Models underlying Functional Treatment y Treatment approaches: Evolution of Memory Books Michelle S. Bourgeois, Ph.D., CCC‐SLP Ohio State University y Developing Functional Goals for Long‐term Care [email protected] y Case Examples Diagnostic Criteria for Dementia: Diagnostic and Statistical Manual of Mental Disorders ‐IV Differentiating the effects of normal aging from (DSM‐IV; APA, 2000) dementia y Memory impairment and related changes in another cognitive domain y Reversible and/or Treatable Conditions (language, abstract thinking, judgment, executive functioning) that are y Rule out and treat metabolic and nutritional disorders, depression, other disease processes and medical conditions y sufficiently severe to cause impairment in social and occupational functioning, y Age‐Associated Memory Impairment y and that reflect a decline from a previously higher level of y Rule out depression and dementia functioning. y < 1 standard deviation below mean of young adult scores on cognitive tests y Cognitive and behavioral symptoms are y Slower psychomotor speed; benign forgetfulness y chronic and progressive, y Preserved occupational and social functioning y may be correlated with specific neuropathology of an organic basis, y Mild Cognitive Impairment y are differentiated from disturbances of consciousness (e.g., delirium) y Increased frequency of memory complaints or psychiatric etiologies (e.g., depression, anxiety disorders) for which y Preserved occupational and social functioning there are pharmacological treatments (Ballard, 2000). y < 1.5 standard deviations below mean of age and education matched healthy controls on cognitive tests Alzheimer’s Disease (AD) Vascular Dementia (VaD) Frontotemporal Dementia (FTD) Characteristics of Cognitive‐Communication changes in Prevalence 60-70% of cases 15-30% of cases 8-20% Aphasia and Dementia: Dementia Onset Slow, Gradual progression Abrupt, stepwise progression Slow, Gradual Cognition Memory Deficits: Focal symptoms: Variable word finding (early) Some early; others late Disorder of Cognition Short-term (mid) y Memory Loss is the Core Symptom of most types of Long-term (late) Executive dysfunction (early) Mild executive dysfunction; Selective and sustained Dementia Severe & early in attention deficits (early) Binswanger’s disease Greater deficits than AD y Other Symptoms include: Language Intact; mild word finding (early) Focal language deficits variable Intact (early) y Language problems Perseverative, echolalic, Semantics, pragmatics, reading Co-occurs with extrapyramidal mutism (late) y comprehension, perseveration symptoms, gait problems, Primary progressive aphasia: Attention, Executive function, visuospatial (mid) paresis, facial weakness early, nonfluent, language difficulties deficits Affective responses only (late) Semantic Dementia: late, y Troublesome behaviors: wandering, agitation, fluent language deficits irritability, delusions, day‐night disorientation Visuospatial Progressive decline Visual field deficits Intact (early) Behavior Personality, mood changes (early) Depression, agitation, anxiety, Profound early changes in y Depression Delusions, hallucinations, apathy (early) mood, personality and social agitation, repetitive (mid) conduct Ambulation, sleep, eating (late) 1 3/6/2012 Dementia with Lewy Bodies Dementia in Parkinson’s (DLB) Disease Prevalence 20-30% 18-40% of Parkinson’s patients Onset Slow, Gradual Slow, Gradual and fluctuating More dementia types Cognition Intact (early) Similar to DLB Gradually fluctuating Fluctuating Cognition y Dementia in Huntington’s disease Similar to AD y Human immunodeficiency virus‐associated dementia Attention (early) Executive dysfunction (early) Executive dysfunction (early) (HIV‐D) Language Verbal fluency deficits (early) Less language impairment than y Creutzfeldt‐Jakob disease (CJD) Otherwise intact (early) AD y Similar to AD Early pragmatic deficits Pseudo dementia Extrapyramidal symptoms: y Other Co‐morbidities resting tremor, bradykinesia, cogwheel rigidity y Heart disease Visuospatial Deficits (early) y Hip Fracture y Diabetes y CVA, stroke Behavior Visual hallucinations, delusions, Depression, mood changes depression (early) Medication related delusions y Lung diseases and hallucinations Communication and Cognitive Deficits and Strengths of Persons with AD Communication and Cognitive Deficits Communication and Cognitive Strengths Early Stage Behavior Problems Mild expressive language deficits related to word- Phonology, Syntax, Pragmatics intact finding problems for names, places Oral reading and writing intact Receptive language: difficulty comprehending abstract Intact comprehension of concrete language are symptoms of Memory, Language, & Cognitive Deficits language and complex conversation Good reading comprehension Memory: Mild declarative/explicit memory retrieval Intact nondeclarative/implicit and sensory memory deficits Aware of language and memory lapses Executive function: inconsistent problems with IADLs Good sustained attention and concentration y Frequency, intensity, severity, and pattern vary by (finances, shopping) Divided and selective attention lapses person, etiology, stage of disease, and Mild visuospatial deficits Middle Stage environmental factors Increasing expressive language deficits; word-finding Phonology and Syntax intact problems, lack of content in conversation Oral reading for familiar text preserved y Early stage –memory issues, fearful, irritable, Pragmatic difficulties with topic maintenance Reading comprehension good for familiar words and Receptive language: difficulty comprehending complex phrases instructions, tasks Adequate nondeclarative/implicit and sensory memory personality changes, mood swings Reading comprehension difficulties Memory: Increasing declarative memory retrieval deficits y Middle stages –problems more diverse, frequent, Executive function: lack of inhibition, planning and set shifting problems and difficult to manage Attention: impaired in all domains Visuospatial: increasing problems Late Stage y Late stages –behaviors slow down, more Expression of needs and wants: may be inappropriate Appropriate affective responses to sensory stimuli, verbal or vocal productions; mutism at end music (smiles, pleasant vocalization) predictable and manageable, related to nursing stage Cooperates with appropriate cues (tactile, visual, Repetitive vocal and physical behavior affective) care Severely limited auditory comprehension Basic needs for attention, communication, touch present Severe memory deficits across domains Impaired attention, fluctuating alertness Assessment: The Role of SLP in Dementia Need‐Driven Compromised Behavior Model (Algase et al, 1996) y Diagnosis vs. Treatment: Historical perspective y Theory of Unmet Needs y International Classification of Functioning, Disability and Health (ICF) (WHO; 2001) y Personal, social, environmental, physical, y Body structures and function/Impairment emotional needs y Physiology and anatomy y Activity/Activity Limitations y Cannot communicate effectively due to y Execution of a task or action by an individual language and cognitive changes y Participation/Participation Restriction y Involvement in a life situation y Behaviors are expressions of need y y Assessment for Treatment Planning Misinterpreted as maladaptive y Determine preserved skills & deficits y MOST Behavior problems can be addressed with y Planning Functional Assessment to Address Functional Communication‐based treatments Outcomes y Determine desired outcomes for maintaining function 2 3/6/2012 Assessment at the Activity & Participation Levels Purposes of Assessment y Identify patient y To provide a baseline measure of cognitive‐ y limitations in communication & activities of daily communicative functioning against which to measure living progress y strengths in communication & functioning y To identify and profile cognitive‐linguistic strengths and y problem behaviors (anxieties, repetitive questions and weaknesses around which goals and a treatment plan are behaviors, social isolation) developed y environmental barriers for communication y To provide a diagnosis and prognosis, when possible y desired activities and participation y Assessment should not take place only at pre and post y treatment evaluation sessions, but whenever there is a Interview the Caregivers for behavior complaints documented change in status and expectations y These will lead to potential goals for treatment programs Determine frequency of problem: Identify Problem Behaviors Behavior Diary Behavior Log Date Time Describe the Behavior How Day Count Problem: Count y Identify, describe, and count frequency of Often? Cannot find Problem: room Asks what caregiver and patient complaints. time it is. y What are the specific problems? Monday y Where do they occur; what time of day? Tuesday y How often do they occur? y What is the consequence of the problem; who says and Wednesday does what; does it work? Thursday y What is causing this problem; activity limitation? y What impact does this problem have on quality of life Friday (participation in desired activities)? Saturday Sunday Identify Environmental Barriers Determine Desired Range of Participation Environment/ People Frequency Problems Environment & Activity of Contact Communication Home Me 24-7 Lots of Wife, Mary arguments Assessment Toolkit Loss of intimacy for Dementia Care Church
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