-info processing becomes slower

-ability to switch between inputs (shift attention) decreases

-long term memory declines (ST less so)

-language preserved:  vocab may increase, naming may decrease

-mental flexibility decreases

-visuo-spatial skills decline

-preserved crystallized IQ (mostly semantics)

-decreased fluid IQ (mostly episodic memory)

-relatively stable verbal IQ

-progressive decline in performance IQ

-Loss of mental functions.  An acquired persistent impairment in multiple areas of intellectual function

*beyond the deficits of Mild Cognitive Impairment (MCI)

A. Multiple Cognitive Deficits

-memory impairment

-one or more of: aphasia, apraxia, agnosia, impaired executive functioning

B. Impairment in social and occupational function

C. Gradual onset and cognitive decline

D. Deficits are not due to other central nervous system conditions

What is the most common cause of dementia?

The second?

-Alzheimers #1 (50%)

-Vascular dementia (2nd)

-Lab tests

-Brain imaging

-Autopsy (only definitive way)

Neurology/Neurospych (test cognition, memory, recall)

SLP (language)

Family history

Sensory input

-sensory memory + attention

-Working memory

-Encoding (via hippocampus) = long term memory

-naming difficulties

-paraphasias

-impaired comprehension

-fewer nerve cells and synapses

-plaques build between nerve cells

-dead and dying cells have tangles (twisted strands of protein)

What are plaques?

Where are they found?

-protein (beta-amyloid) clumps together blocking cell-to-cell signalling

-found in brains of AD pts

Memory:  defective new learning, remote recall may be impaired

Visuospatial Skills:  topographic disorientation, poor construction ability (may miss features when drawing common objects)

Praxis:  normal

Personality:  apathy, occasional irritability & sadness

EEG:  normal

CT: normal

Memory:  more severe impairment to recent and remote recall

Visuospatial Skills:  disorientation

Calculation:  acalculia

Praxis:  ideomotor apraxia

Personality:  indifference

Motor System:  restless (do same tasks over and over)

EEG:  slowing of background rhythm

CT:  normal or enlarging of ventricles

-restlessness

*able to do the same task over and over

Memory:  recent and remote memory severely impaired

Visuospatial Skills:  disorientation, consistent misperceptions, lack of construction skills

Praxis:  speech apraxia, severe limb and ideational apraxia

Personality:  withdrawal, confusion, lost sense of reality

Motor:  rigid limbs and flexed posture

Bodily functions:  double incontinence

CT:  marked cerebral atrophy, ventricular enlargement

A. Development of multiple cognitive deficits

-memory impairment

-one or more of aphasia, apraxia, agnosia, executive dysfunction

B.  Cognitive deficits above lead to social dysfunction (decline from previous level)

C.  Focal neurological signs and symptoms or positive neuroimaging

D. deficits do not occur exclusively during course of a delirium

What is the incidence of VaD?

Is it more common in men or women?

Incidence:  4-10/1000

Slightly more common in men

*depends on lesion location

-expressive worse than receptive

-phonemic paraphasias more common than semantic

-impaired comprehension of complex syntax

-frequent dysprosodic/dysarthric speech

-phonemic fluency worse than semantic

Phonemic:  name as many words as you can that start with /f/ in 1 min

Semantic:  name as many animals as you can in 1 min

-viral dementia

-changes to cortical, pyramidal and extrapyramidal systems

-rapid progression (weeks for dementia to develop)

-mid stages: prominent dysarthria & aphasia

-late stages: mutism

-lack of initiation

-unsuccessful problem solving

-impaired memory

-reduced rate of processing

Speech and Language:  NO aphasia, poor word list generation, hypokinetic dysarthria

Subcortical dementia with extrapyramidal symptoms

-early memory impairments

-personality changes

-chorea

Speech & Language:  NO aphasia, poor word list generation, dysarthria (hyperkinetic), failure on lang tests needing organization, sequencing and elaboration

-mutism in late stages

-unsteady gait

-cognitive impairments

-incontinence

-quiet, withdrawn, slow to respond

-Language similar to FTD Fv

-memory impairments (esp for new learning)

-slowness of responses

-forgetfulness

-disorientation

-impaired attn & concentration

-*omission of details on drawing tasks

-frequent "i don't know" responses

-difficulty generating a list of words

-impaired comprehension of complex material

-slow, hypophonic sp

-increased pause time in convos

-no cortical signs (apraxia, aphasia, agnosia)

-fluctuating alertness and/or cognition

-recurrent visual hallucinations

-fainting or falling spells

-disturbed sleep cycle

-PD symptoms

*LANGUAGE:  pattern like AD with PD speech (changes in strength and tone of voice)

-frontal (behavioural)

-temporal (language) variants

1. disinhibited (orbito-frontal)

2. apathetic type (dorsofrontal)

3. stereotypic type (orbitobasal-frontal)

-frontal (behaviour variant)

-inattentive, restless, inapprop jocularity, disinhibition, socially inappropriate

*no speech or language deficits (except pragmatics!)

-frontal (behavioural)

-amotivational state, lack of initiation (convo very one-sided)

-little facial expression

-sometimes echolalia

*no sp and lang deficits EXCEPT loss of sp prosody

-no sp or language deficits except lack of prosody

-may have echolalia

-frontal (behavioural)

-repetitive, ritualistic, ridged routines

-compulsive behaviour (w/o anxiety)

-perseveration

-verbal stereotypy

Fluent Progressive Aphasia (aka Semantic Dementia)

Nonfluent Progressive Aphasia (NPA) aka PPA (primary progressive aphasia

Logopenic Progressive Aphasia (LPA)

personality & emotions:  distractability, apathy, restlessness, loss of pragmatics, obsessions, mood swings

memory loss:  variable, usually intact

visuospatial:  don't get lost, ok spatial orientation, can draw (but perseverate)

-Described by Arnold Pick in 1892

onset: age 40-60

duration: 2-15 years

-more frequent in women

80% sporadic, 20% familial

etiology unknown

lab tests/imaging not helpful

Aka PPA

-word finding probs

-nonfluent and hesitant speech

-phonemic paraphasias

-impaired repetition

aka semantic dementia

-word finding probs

-fluent, well-artic speech

-semantic paraphasias

-preserved repetition

-2 yr history of progressive language decline

-prominent lang deficits with relatively preserved cognitive function

-independence in activities of daily living (ADL)

*usually connected with a neurodegenerative disorder

-Nonfluent Spontaneous sp with atleast one: agrammatism, phonemic paraphasias, anomia

*expressive lang impairment most dominant feature

Speech: halting, telegraphic, agrammatic

-AOS common

-writing better than speaking

-better naming objects than actions

-comprehend reading better than sp

-surface dysgraphia & dyslexia

-insidious onset & gradual progression

-impaired understanding of word meaning and/or object identity

-other aspects of cognition well-preserved

-language disorder

-progressively empty, fluent speech

-loss of word meaning (impaired naming & comprehension)

-semantic paraphasias

-perceptual disorder w propagnosia &/or associative agnosia

-intact macthing & drawing abilities

-compensate well for semantic issues with fluent speech/good syntax

-can carry out ADL, problem-solve, make decisions

Surface dysgraphia & surface dyslexia

-semantic probs occur in all modalities of language

In FPA, what might they call a skunk?

What does this demonstrate

A dog, and then later an animal

*superordinate info for naming stays intact longer

Anomia

-lose semantic information, the details get fuzzy, can no longer name.  Begin to lose salient features

-pragmatic skills

-spontaneous sp

-verbal expression

-auditory comprehension

-reading & reading comprehension

-written expression

-cognitive skills

-semantic knowledge

Verbal

-variety of sp acts (maintenance, introducing, approp topics, ask Qs, clarify, etc.)

-topics

-fluency

-motor sp probs (dysarthria, apraxia)

-word/sound substitutions (semantic? phonemic? nonwords?)

-types of errors

-syntax

-cohesion (may be lost in late stage AD)

-picture description (gives pt of reference)

-repetition

-naming to confrontation (what is this?)

-responsive naming (not as NB, gets more right answers -> ex. what do you use for writing?

-automatic sp (indicator of residual skills for tx)

-OME (normal in SD, usually in AD)

FUNCTIONAL COMMUNICATION

*a semantic disorder, won't be able to tell what something is or what it is used for

-comprehension of convo

-auditory word recognition (PPVT)

-yes/no Qs

-sentences of varying length and/or grammatical complexity

-paragraph length material

-premorbid reading skills/habits (could they read before?)

-mechanics

-single words (regular, irreg, nonwords) - helps determine type of dyslexia

-sentences (variety of morphosyntax structure)

-paragraphs

-premorbid writing skills/habits

-mechanics/functional writing

-copying *residual skill that can be built upon in therapy

-writing to dictation (type of dysgraphia) - reg, irreg or nonwords

-written picture description

-free narrative

-orientation (time, place & person)

-insight *progressive aphasia has good insight into own deficits - AD & FTD not good judges of own deficits

-attention & concentration

-memory (autobio, working m)

-learning (encoding, storing, retrieval of verbal info)

-verbal fluency

-visuo-perceptual skills

Which dementias have good insight into their own deficits?

Which have poor?

-Good insight:  progressive aphasias

Poor: AD & FTD

-access to semantic store

-receptive vocab

-lexical decision

-synonym judgment, semantic associations

-word definitions

-category-specific impairment

Case History

Aphasia Battery/Other Lang Tests

-Cognitive Screening

-Eval of Semantics/Phonology

Eval of Behavioural/Other Changes

-symptoms (time of onset, rate of pregression, changes over time)

-medical/diagnostic procedures completed (dates & results)

-speech and lang symptoms (any past SLP Tx)

-nutrition & swallowing history

*get history from two different sources if possible

-maintains employment?

-keeps appointments?

-manages own money?

-independent at home?

-independent outside?

-still driving? getting lost?

-cooking and cleaning?

-Hx of vascular disease (VaD? Stroke?)

-high blood pressure (VaD? Stroke?)

-diabetes

-past illnesses and surgeries

-medications (possible sp/lang effects)

-family history of memory issues (AD or Downs)

-eliminate distractions

-approach person slowly and from front

-use short simple sentences

-yes/no Qs better than open-ended Qs

-speaking slowly

-elderspeak (simple vocab, shorter sentences, slow sp)

-repeat & rephrase (mixed evidence)

-encouraging person to talk around word (not much research)

3 General Principles of Intervention

1.       Maintenance of independent functioning as long as possible

2.       Maintenance of QoL w supported participation

3.       Emphasis on personal relevance and contextual training

-reduce distrations by simplifying enviro

-TV, Radio, etc. (paging systems can be confusing, relevant stimuli)

*associated with fewer communication breakdowns

-in a well-lit space

-introduce yourself each time

-establish and maintain eye contact

-slowly and from the front

-minimal demands on working memory

-fewer communication breakdowns with caregiver

Is speaking slowly an effective strategy?

Why or why not?

-not effective

-may place more demands on working memory (overriding benefits of extra processing time)

-older people tend to react negatively to this

-may have more negative Ax of their own and caregivers' communicative competence

-resistance to care

Should you only use closed-ended questions?

Why or why not?

-no, closed and open are both good

Closed: good for everyday living tasks

Open: encourage convo, emotional responses

Is communication more successful with more open or closed ended Qs?

With more episodic Qs?

-better with more closed-ended

-avoid episodic ("Do you remember") questions

JUST TELL THEM

Face-to-face

Orientation

Continuity

Unsticking

Structure

Exchange

Direct

How can FOCUSED help?

Who is it for?

Training for caregivers

-teaching communication strategies gives caregivers more confidence/satisfaction in communication = more communication with PWD = better QoL

1. cognitive stimulation (disabilty-handicap)

2. cognitive training (impairment level)

3. cognitive rehab (disability-handicap)

-meet social needs

-feel useful

-purposeful use of time

-give a sense of control

-use residual skills

-maintain current abilities

-promote verbal and nonverbal communication

-mnemonic devices (memorizing lists using first letter of words)

-localization method (associating items with familiar places)

-imagery (remember events by imagining sounds, sights, smells)

-exercise

-music therapy

-art therapy

-pet therapy

-baking

-horticulture

-reminiscence

-communication groups

Repeated Exposure (SRT, errorless learning)

Multi-sensory (memory books, music/art/pets, montessori)

Retrieval (reminiscence, memory training, priming)

What type of direct therapy is Spaced Retrieval Technique?

What is the theory behind it?

It is a direct intervention

-rely on nondeclarative memory (motor, procedural, stim-response)

*supposedly intact in AD patients, capitalize on this

What do we expect from SR technique?

What can't we expect?

We expect improved acquisition, retention & generalization of trained info and/or skills (one day to up to several months) - generalize learned skills to very specific context

We should NOT expect:  change in global functioning or general memory function

-patient must be engaged and respond for each retrieval attempt

-brings info into consciousness many times

-engage implicit/procedural memories

Use of a variety of strategies:

spaced retrieval

vanishing cues (your mom's name is June, Ju, J)

forced choice (your mom's name is June or Lynn?)

-learning new info

-relearning info

-face and name associations

-biographical info

-using a calendar and electronic memory aids

What type of therapy is pet therapy?

What are the benefits?

Multi-sensory

-no training

-pets take on role of initiator

-improves QoL

-positive impact on caregiver

What type of therapy is music?

What are some benefits?

Multi-sensory

-some training

-improves QoL

-positive impact on caregiver

-progresses from simple/concrete activities to complex/abstract

-breaks down a task into small parts, train one part at a time (reduces errors, little risk of failure)

-real life, tangible materials that are functional and aesthetically pleasing

-emphasize aud, visual & tactile discrim through activities

-provide meaningful stimulation

-engage and increase social interaction

-involvement in ADL

-improvements in attention, object permanence & memory

-prevent agitation and behavioural disturbances

*NO LANG Improvement

What type of therapy is Reminiscence?

What is it?

-retrieval

-clients share memories evoked by prompts (songs, photos, smells)

-helps with QoL, value their lives

-improves cognition & ADL

-orient to reality (improve cognition & behaviour)

-repeatedly

CAVEAT:  may become agitated

-bio info, pics, artifacts, descriptions of key events

-recognition cues & topic ideas (improve quality of convos)

-all AD stages

language deficits:  intelligbility issues, topic initiation and maintenance issues, perserverators

-increase positive verbal behaviour

-provides thematic structure & increases # ideas produced

-enrich convo

-portable & easy to modify

What are limitations of memory books?

What can't they do?

*often forget to include desireable content

-needs org'l, visuo-spatial, fine motor, memory & reading skills

What are benefits of pager systems?

Who are they good for?

Benefits:  promote independence, increase self-esteem, eliminate need for direct supervision, ensure patients are meeting their daily needs

Who: all stages of AD (way better for early & mid)

*may forget to charge/check batteries

-increase independence

-still have manual dexterity to use them

-remind for NB events & schedules

-can be programmed by client or 3rd party

-increased reliance on external cues

-remind about basic needs & functions (eating, showering, meds)

-pts need simpler systems (fewer buttons)

-neuropage: one button for all messages, programmed by 3rd party

-requires high level of self motivation

-major cognitive difficulties may forget to access info or record anything

-requires recall (what is a pager? what does the beep mean?)

-batteries?