TBI Notes Test III

You will do totally badass on this!!!

You will do totally badass on this!!!

Alzheimer’s Disease (cortical dementia)

• Cortical type of dementia- outer portion of brain is where you see changes

• 6-30% in 65 years and older• Incidence doubles every 5 years after 65 (age 90

high incidence)• 2-3xs more common in females (because we live

longer)• Cause is unknown. (its genetic they think)• Affects hippocampus(WM) prefrontal area and

anterior temporal lobe (similar to TBI)

Alzheimer’s Disease

• THESE THINGS FOUND POSTMORDEM• Neurofibrillary tangles- axons & dendrites atrophy and

contorting• Senile plaque (internal structure of neurons)- changes

within the neuron itself-debris within the cytoplasm exclusive to Down syndrome

• Granulovacuolar degeneration (internal changes of the neuron)- look like sand and debris within cytoplasm exclusive to AD must have Senile and Granu. Usually affects pyramidal cells (responsible for: motor function) –for both SP and GD

Possible Causes of AD

• Aluminum Poisoning-• Immune System Problem- immune system

attacks brain• Slow virus- chimpanzees show signs of

Alzheimer’s.• Reduction in blood flow• Hereditary• Genetic

AD

• No cure• Early detection tests are better• Medications slow progression of AD,

particularly memory loss

AD- early stages

• Decreased WM• Problems with judgement & reasoning “should

I be driving?”• Disorientation to place and event• Changes in mood- more depressed• Communication- word finding deficits (anomia)• Decreased auditory comp• Difficulty with humor and sarcasm

Goals for the Clinicianearly diagnosis and intervention allow the clinician to:• Improve the family/pt’s understanding—about the changes that are taking

place in the family and pt.• Increase the family’s knowledge of AD.• Access community resources that help AD patients and caregivers.• Make plans for the future (e.g., financial and health care planning).• Increase your awareness of safety issues and health issues

Educating Carers about AD-early stages

• The following is a list of skills and tasks. The list is intended to help identify potential difficulties in order to help the family plan for future changes and continue living their life to the fullest.

• Memory for recent events. Examples: remembering appointments, details of a recent conversation and names.

• Carrying out tasks with multiple steps. Examples: managing money and balancing your checkbook, taking medications as prescribed, shopping and cooking.

• Decision-making and problem-solving. Example: making quick decisions in response to an emergency, such as responding to a flood or fire in your home.

• Spatial ability and orientation. Examples: following a map or following directions, judging the distance of objects while driving, and feeling lost in familiar environments.

• Language. Examples: finding the right word, writing letters, understanding what you have read or what others have said.

• Behavior and/or mood. Examples: loss of interest in new projects, withdrawing in social situations, feelings of anxiety and depression. Keep in mind that anxiety and depression are often treatable, so speak with your physician if these feelings arise.

AD- Middle Stages

• More about educating the caregiver, watching & monitoring for dysphagia

• SUNDOWNERS SYNDROME- your sense of time changes. You become more active in the night.

• Impaired intellect and cognition• Dysphagia- lack of initiation to eat, initiating

bolus itself. • Weight loss

AD- Middle Stages

• Incontinence and bladder problems• Perseveration of ideas• Paraphasias because anomia gets worse• Empty speech- really vague terms• Circumlocution• Jargon starts to emerge• Changes in pragmatic skills

AD- Late Stages• 1. Start to see motor problems• 2. Sensory perceptual issues- cant ask for help• 3. Incontinence- bladder and bowel• 4. Diminishing all cognitive skills• 5. Jargon- Rapid & incoherent speech• 6. Echolalia- repeat speech they’ve heard• 7. Perseveration of words or sounds• 8. Lose ALL lang abilities– Monitor for dysphagia- if they eat likely to get

pneumonia. – Likely to die or pneumonia or infection

Pick’s Disease (cortical)

• Occurs in adolescents• Unknown etiology• Begins in adolescence & early 20’s• Pick bodies- changes in the neuronal

cytoplasm• Enlarged neurons- anterofrontal & temporal

lobes.• NO CURE- some meds help symptoms

Pick’s Disease- initial stage

• Changes in personality & emotion• Affect social behavior• Executive functions will change• Exhibit stereotypic sequences= OCD. – same movement over and over again.

• Weight gain

Pick’s Disease- Middle stages

• Decreased intellect• Anomia• Circumlocution• Empty speech• Echolalia• Perseveration of ideas• Reduced comprehension both reading and

auditory

Pick’s Disease- final stages

• Person becomes mute• Severe cognitive deficits• Die because of pneumonia or infection

TREATMENT• Early stages- patients can work with you• Cognitive/comm Tx- if they can’t communicate we

shouldn’t treat for comm.• Compensation of skills• Gradual decline- goals and responsibility fall on

caregiver• Maintain skills- reminiscing therapy LT memories• Family education- will be difficult to family• Quality of life- if we aren’t there, they might have no

one• Dysphagia- this is most important

Subcortical Dementia’s(motor component!)

• Basal ganglia, thalamus, brainstem• Problems with motor movement• Declining cognition

• Based on family report (ie cognitive changes)

Parkinson’s Disease (PD)• 1% of population• Changes in movement= different body parts• 50-65 yrs• Men> women• Can become disabled w/in 5 years of symptoms

(rare)• 10-20 years after diagnosis- that’s when person

can’t do their normal function• On/off symptoms• 40 types of PD (some with dementia)

CAUSES OF PD

• Degeneration of substantia nigra- loss of 90% of dopamine

• Viral (encephalitis)- awakenings movie• Arteriosclerosis- hardening of the arteries• Carbon monoxide poisoning- looks like PD• Syphilis• Tumors-after removal, might get better

Positive symptoms of PD

• Not seen in a normal adult• Tremor at rest (pill rolling tremor) btwn thumb

and index finger• Muscular rigidity• Involuntary movements- changes in posture,

head turning, eye movement.

Negative symptoms of PD (Absence of the behavior)

• Poor posture• Difficulty with Righting- trouble getting out of bed.• Locomotion- shuffling of feet• Speech- changes in vocal intensity, they think they’re

yelling at you. LSVT Therapy• Akinesia- slowness of movement• Lack of affect- can’t tell if happy or sad• Monotone• Festination- increasing speed• Dysphagia

Treatment of PD

• Sinemet, symmetrel- drugs for parkinson’s. Treats tremors.

• Thalamotomy- sugery to remove tremors. Heated electrode ablates(kills tissue) area. Symptoms OK for 5 years.

• Pallidotomy- globus pallidus, meant to reduce tremors.

• Deep brain stimulation (pace maker)- implnt close to clavicle.

Huntington’s Chorea(named after George Huntington)

• 35-50 years• Hereditary- can do genetic testing• Rapid Progression• Rare• Chorea- involuntary movement, person figits and is

restless.• Dementia- affects cognition• Personality changes- constantly complaining, finding

fault, irritable, emotional outbursts.• Dysarthria- signs of weakness (as they talk.)

Stages of HC

• Cognitive change- change in WM & attention.• Language- appear intact, dysarthria present• Final Stages- – person becomes mute– Dysphagia– Incontinence– All cognitive areas affected

AIDS related dementia(Acquired immunodeficiency virus encephalapathy)

• HIV positive• Protease inhibitors- drug cocktails• Extrapyramidal symptoms- difficulty walking,

signs of ataxia.• Cognitive deficits- similar to Alzheimner’s

Disease.• Dementia

Mixed Type Dementia(cortical & subcortical)

• Vascular dementia• TIA’s- transient ischemic attack• Multiple CVA’s• Also have aphasia, apraxia dysarthria• If RCVA= left neglect, also cognitive deficits,

hemiplegia or hemiparesis

Mixed Type Dementia(cortical & subcortical)

• Lacunar State- affect smaller arteries that supply blood to the subcortical areas (basal ganglia)

• Lenticulostriate arteries– Dysarthria– Dysphagia– Pseudobulbar palsy- uncontrollable laughing or crying– Tremors– Intellect and language are preserved until later stages

of the disease

Questionable types of dementia

• Isolation- from communication partners. SNF• Depression- if depression is severe enough it

looks like dementia.• Poor nutrition• Medication• Health issues (diabetes)– Discussion of Korsakoff’s syndrome: dementia that

looks like aphasia. From excessive drinking.

Diagnosis & Assesment

• Blessed Dementia Rating Scale (Hachinsky et. al) • Info from family caregivers, medical chart• Section 1- general ADL’s- how they function overall• Section 2- specific activities (ex- communication)• Severity and prescence of impairment ((might not be

too accurate)• < or = unimpaired• Score up to 28 (total score) • Similar to a lot of outcome measures• VERY SUBJECTIVE

Global Deterioration Scale(Reisberg et. al)

• Completed by clinician or rehab team• Patient/family interview• SUBJECTIVE- more thorough that BDRS. • Info from other disciplines• Check Brookshire book for details.

GDS stages• GDS stage 1 – NORMAL• GDS stage 2- very mild (forgetfulness, concerned about

symptoms)• GDS stage 3- mild cog. deficits (early confusional with loss)• GDS stage 4- moderate (late confusional)• GDS stage 5- moderately severe (early dementia, requires

assistance from others for survival)• GDS stage 6- severe (middle dementia) behavioral issues.

Echolalia, jargon.• GDS stage 7- very severe (late dementia) no therapy. Bed

bound, not eating safely

Early Signs of Dementia

• Scared about memory loss• Interview patient and family• Refer to neuropsych• Refer to gerontologist• Gradual onset- no sudden change• NO improvement over time.– Quality of life, most important thing…

Dementia Tests• Arizona Battery for Communication Disorder of

Dementia. (ABCD) for mild to moderate dementia.– Hard to give

• Functional Linguistic Communication Inventory (FLCI) for moderate to severe dementia.– Includes greetings, writing naming, gestures etc. – Easy to score

• Mini Mental Status Examination (MMSE) Score of 26 points or less (for cog deficits)

Treatment of Dementia

• Education- not rehab, but maintaining skills for as long as possible.

• Stimulate all modalities of communication:– Auditory- music they like, things they heard on radio

back in the day.– Visual- pictures. Can’t be portrait pics. Special

moments.– Tactile- anything they played with as a child.

Treatment of Dementia

• Minimize distractions- if attentio is poor, can’t have lots going on.

• Use short simple sentences when communicating with dementia patients.

• Give ample time for responses. Their processing is slow.

Dementia Continued…

– Episodic Memory- emotional component LT stronger– Procedural Memory- great way to get convo going.– Semantic Memory- LT good, newer memories not so

much.• MOST IMPAIRED: WM, Prospective memory

(things in the future), temporal (time) knowledge.

• MILD STAGES: compensate, use strategies• LATER STAGES: multi-modality communication

Dementia Continued…• Organization, sequencing• Problem solving/judgement– Supervision– Safety

• Language= hidden meanings? GDS 5/6 look for hidden meanings in words. Something they say might be important to them.

• Redirect behaviors- BE CREATIVE• Talk to the family members• Change the subject• Give patient something else to do

Memory Books• Names of family members• Personal Info- address, DOB, phone #• Names of medical professionals- that will be

seeing them.• Calendar- simple to complex; day or month)• Pictures- action better than portrait.• Portable?• Simplify over time• Teach family to use it

Counseling with Dementia• Family will start to feel inconvenienced and feel guilty

about it.• We don’t counsel feelings- we DO counsel

communication.• Validate feelings of anger.• We can educate them about what’s going to happen in

the future• Prepare family & patient for what will happen.• They have to accept more responsibility.• They need a lot of repetition, things written down.– Alzheimer’s association website rocks..

• Early Stages: – refer to other professionals as needed. – Remember to discuss living will.

• Middle Stages: – introduce idea of SNF. – Talk about what is necessary to supervise at home.– Still validate person’s feelings. – Continue to refer out as needed. – Start behavior mod (because they are verbally abusive or

hitting). – Problem solve about safety issues. – Wandering an issue. – Still talk about a living will.

• Late Stages: – Dysphagia (eating safely)– Validate feelings of guilt– Support them– Talk about heroic measures (feeding, life support)– Consider hospice care. Dying with dignity.