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PTP 783 Jennifer Blackwood. Cognitive Changes in Aging. 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

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Cognitive Changes in Aging

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Ptp 783 jennifer blackwood

PTP 783

Jennifer Blackwood

Cognitive Changes in Aging


Cognitive changes

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 maintainthe ability to understand new experience & situations

    • Changes in this should NOT be dismissed as normal aging

      Personalities remain stable with aging: if it changes possible psychiatric dysfunction


Changes in cognition are linked to

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)


Intelligence learning capacity

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


Intelligence

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


Executive function

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


Benign senescent forgetfulness

Benign Senescent Forgetfulness

  • Memory loss with the normal older person

  • Functional decline isnot present with this

    • as opposed to it being present with dementia

  • PTs can play a role with assisting in dx


Age associated cognitive decline

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.


Mild cognitive impairment

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


The 3 d s

The 3 D’s

  • Delirium

  • Depression

  • Dementia


Delirium

Delirium

  • Acuteconfusional 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


Depression

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%


Screening for depression

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


Meds for depression

Meds for Depression

  • SSRIs- favored…. Why?

    • Zoloft, Paxil, Prozac

  • Tricyclic Antidepressants

  • Serotonin/Norepinephrine Reuptake Inhibitors

  • MAO Inhibitors


Dementia

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 B12deficiency, vascular origin, Lewy body disease


Vascular dementia

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


Pseudodementia

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


Lewy body dementia

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


Changes in cognition relate to

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)


Alzheimer s disease

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


Cognitive changes in aging

AD

  • Genetic risk factors: APOE e4 (apolipoprotein E allele)

  • Average life span: 8-10 yrs from symptom onset

  • Physical changes in the brain:


Fast scale for alzheimer s disease

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


Medications are they effective

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


Gait changes with ad

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)


Evaluate cognition with

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


Evaluate cognition mmse the mini cog

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


Cognitive changes in aging

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


Slums test

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


Slums norms

SLUMS norms:


Cognitive changes in aging

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)


Evaluate cognition trail making tests a b

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


Trail making tests a b

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)


Tmt a

TMT A

TMT B


Cognitive changes in aging

TMT A

Norm:29 seconds

Deficit: > 78 seconds

Most in 90 seconds


Cognitive changes in aging

TMT B:

Norm: 75 seconds

Deficit:> 273 seconds

Most in 3 minutes


2 things proven to slow cognitive decline

2 things proven to slow Cognitive decline:


The allen cognitive scale

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


Allen levels

Allen Levels

Cognition

High

  • Level 6Planned Activities

    • CEO

  • Level 5Independent Learning

    • teenager

  • Level 4Goal Directed Activities

    • Early level dementia ****

  • Level 3Manual Actions

    • Middle level dementia ****

  • Level 2Postural Actions

    • Late level dementia ****

  • Level 1Automatic Actions

    • Semi-comatose

  • Low


    Cognitive changes in aging

    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.


    Level 4 early dementia

    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


    Level 4 early dementia1

    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


    Level 4 interventions

    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.


    Level 4 treatment considerations

    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


    Level 3 middle dementia

    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


    Level 3 middle dementia1

    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.


    Level 3 interventions

    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.


    Level 3 treatment considerations

    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


    Level 2 late dementia

    Level 2Late 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


    Level 2 late dementia1

    Level 2Late 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


    Level 2 interventions

    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


    Level 2 treatment considerations

    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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