DEMENTIA Ashley Frazier M.S. CCC-SLP The University of North Carolina Greensboro.

DEMENTIA

Ashley Frazier M.S. CCC-SLP

The University of North Carolina Greensboro

Learner Objectives

Define dementia and its hallmark characteristics Describe ways in which dementias are

categorized Identify characteristics of language of dementia Use basic scales and bedside exams commonly

used in dementia care Describe SLP role in treatment of patients with

dementia Contrast compensatory therapy with

rehabilitation

Which most accurately defines and describes dementia?

O Progressive disease associated with old age that is characterized by impairment of speech, language, and swallowing

O Disease with various symptoms associated with Central Nervous System deterioration whose major impairments are in the areas of Cognition, Memory and Communication

O Degenerative disease associated with lesions to the brain which most often results in language, memory, and motor disturbance

O Devastating and heartbreaking

What is dementia?

Mixed bag of signs and symptoms of CNS degeneration, complicated by variability, progressive and persistent deterioration of intellectual function

Memory•Forgetfulness•Profound Impairment

Cognition•Problem Solving/Judgement•Orientation•ADL

Communication•Semantics most affected•More automatic structures spared

Various types of Dementia are often categorized into which of these?

O Cortical/Subcortical Types

O Reversible/Irreversible Types

O Both of these

Reversible vs. IrreversibleCortical vs. Subcortical

Categorizing Dementia

Cortical vs Subcortical Dementia

Examples of Each

DAThttp://

www.youtube.com/watch?v=7wbYEK7O14E&feature=related

Huntington’shttp://www.youtube.com/watch?v=JzAPh2v-SCQ

What differences do you notice between them?

Which Category?

O Cortical

O Subcortical

O Reversible

Alzheimer’s Disease

Alzheimer’s Characteristics

Cortical Dementia Disorientation Communication affected Short term memory impaired Long term memory impaired Impaired judgement and abstraction Personality Changes

Mini Mental State Exam

CLINICAL STAGING OF DAT: NYU/Silberstein Scale p427-428 in textbook

Stage 1 (No Cognitive Impairment) Normal mental and motor function.

Stage 2 (Very mild decline)

Stage 3 (mild cognitive decline) Early Stage Alzheimer’s can be diagnosed in some but not all individuals with these symptoms

Stage 4 (moderate cognitive decline) Mild or early-stage DAT

Stage 5 (Moderately severe cognitive decline) Moderate or mid-stage DAT

Stage 6 (severe cognitive decline) Mid Stage DAT

Stage 7 (Very severe cognitive decline) Late Stage DAT

“HIV is now becoming one of the leading causes of dementia worldwide…”

Sacktor, N. (2002). The Epidemiology of Human Immunodeficiency Virus-Associated Neurological Disease in the Era of Highly Active Antiretroviral Therapy. Journal of Neurovirology, 8(2), 115-121. doi:10.1080/13550280290101094  

“Confusion, forgetfulness, cognitive symptoms”HIVD: Acute vs. Chronic

Early on, dementia was acute and severe Entire course was often matter of weeks

Since mid-90’s, more often chronic cognitive involvement that spans life of disease May last for years

“Mental Disorders can develop into full-blown dementia in just a few days from the appearance of the first symptom, or take as long as two months.” (Lezak, 2004, p275)

HIV-D Characteristics

Subcortical dementia * Psychomotor slowing Memory deficits Impaired executive function Impaired visuospatial function Impaired recall/retrieval

*With cortical features – memory is one of the primary deficits

Cognitive Profile

Executive Function Effect on social skills, communication Work/Activities

Memory Effect on HAART adherence Recall & retrieval impact on function Co-morbidity factors

HIV Dementia Scale

Power, et al. (1995) HIV Dementia Scale: a rapid screening test. J Acquir Immune Defic Syndr Hum Retrovirol. 1995;8(3):273–278

CLINICAL STAGING OF ADC: Memorial Sloan Kettering Scale

Stage 0 (normal) Normal mental and motor function.

Stage 0.5 (equivocal/subclinical) Either minimal or equivocal symptoms of cognitive or motor dysfunction characteristic of ADC, or mild signs (snout response, slowed extremity movements), but without impairment of work or capacity to perform activities of daily living (ADL). Gait and strength are normal.

Stage 1 (mild) Unequivocal evidence (symptoms, signs, neuropsychological test performance) of Functional intellectual or motor impairment characteristic ADC, but able to perform all but the more demanding aspects of work or ADL. Can walk without assistance.

Stage 2 (moderate) Cannot work or maintain the more demanding aspects of daily life, but able to perform basic activities of self-care.Ambulatory, but may require a single prop.

Stage 3 (severe) Major intellectual incapacity (cannot follow news or personal events, cannot sustain complex conversation, considerable slowing of all output) or motor disability (cannot walk unassisted, requiring walker or personal support, usually with slowing and clumsiness of arms as well).

Stage 4 (end stage) Nearly vegetative. Intellectual and socialcomprehension and output are at a rudimentary level. Nearly or absolutely mute. Paraparetic or paraplegic with double (urinary and bowel) incontinence.

Assessment

Full Neuropsych Evaluation likely SLP may be “front line” in early stages Differential dx from similar looking

diseases ABCD (AZ Battery Comm Dementia) Global Deterioration Scale “Bedside Eval” – quick tests

“Clock Drawing” & Visuospatial Tests

Practice: MMSE

3 objects: AppleTablePenny

Close Your Eyes

Practice: MMSE Scoring

Normal score: 24 or higher

There are published norms based on age, education, gender. There are norms for native Spanish speakers, and the “very old” population

Example: Eighth Grade Education

Ages 18 to 69: Median MMSE Score 26-27Ages 70 to 79: Median MMSE Score 25Age over 79: Median MMSE Score 23-25

High School EducationAges 18 to 69: Median MMSE Score 28-29Ages 70 to 79: Median MMSE Score 27Age over 79: Median MMSE Score 25-26

College Education

Ages 18 to 69: Median MMSE Score 29Ages 70 to 79: Median MMSE Score 28Age over 79: Median MMSE Score 27

Comfort with MMSE?

O Very Comfortable

O Sort of Comfortable

O Not very comfortable

O Can’t figure it out

Impact of Dementia

"For me, disabled is not being able to keep up, not being able to fully function, and feeling the guilt, and feeling the sadness and the emptiness, the loss. That's disability – just feeling exhausted and worn out"

(study participant, O'Brien, Bayoumi, Strike, Young, & Davis, 2008)

Impact of Dementia

Disruption in self-care abilities Slowed information processing Impaired problem solving Changes in affect Reduced social functioning

Failure to adhere to medication regimen Very difficult for caregivers

Which describes the role of the SLP in the treatment of clients with dementia?

O Build memory skills so that patient can function more effectively at work and home

O Help patient become more focused and clear in conversations with friends and family members to reduce frustration

O Develop compensatory strategies for deteriorating skills to support participation in daily activities and connection to loved ones

Role of SLP

Develop strategies to compensate for cognitive changes

Critical to maintain medical compliance Support for family/caregiver

Increased responsibilities as disease progresses

Society not very supportive Enabling meaningful connection with

patient vital

Role of SLP (ASHA)

Increase reliance on spared systems and decrease dependence on impaired ones

Strengthening of knowledge and processes that have the potential to improve

Design interventions that will evoke a positive emotion in the client

http://www.asha.org/docs/html/TR2005-00157.html

Role of SLP (ASHA)

Must consider the cultural background of their clients

Direct intervention: work directly with individuals who have dementia

Indirect intervention: environmental modifications, development of therapeutic routines and activities, and caregiver training

http://www.asha.org/docs/html/TR2005-00157.html

Role of SLP - Strategies

Restorative Promote recovery and restore function

Compensatory Internal

Enhanced Learning Mnemonics

External Environmental Modifications External Aids

Parsons & Robertson http://www.medscape.com/viewarticle/513278

http://www.youtube.com/watch?v=J4S_FX9bieg&feature=BF&playnext=1&list=QL&index=3

Singing For The Brain

The “Other” Role of SLP

ASHA has a progressive nondiscrimination statement which includes “sexual orientation” as a protected status and strongly urges the membership to develop cultural competence as a matter of ethical service delivery.

CounselingEducationAdvocacy

http://www.asha.org/docs/html/PS2005-00118.html