ALZHEIMER’S DEMENTIA

Chevahlyan Dozier

DESCRIPTIONDementia is a general term for a decline in mental ability severe enough to interfere with daily life

Alzheimer's Dementia (AD) is the most common form of dementia

AD leads to nerve cell death and tissue loss throughout the brain. Over time, the brain shrinks dramatically, affecting nearly all its functions.

AD is progressive, irreversible, and ultimately fatal

BACKGROUND & HISTORYBefore AD,

“senile dementia” or “senility” was

seen as a normal part of

aging

In 1901, German

psychiatrist and neurologist Dr. Alios Alzheimer identified the 1st

case of AD

Alzheimer’s diagnosis was confirmed In 1906 after

performing a brain autopsy

In 1910, Psychiatrist

Emil Kraepelin coined the term

“Alzheimer's disease”

ETIOLOGY OF CONDITION

Mutations on chromosomes 21, 14, and 1 cause familial AD (FAD). Most cases of FAD have an early-onset (ages 65 0r under)

The root causes “Young-onset” and “Late-onset AD” (ages 65 or over) is unknown

AD develops from neuritic plaques, neurofibrillary tangles, neuronal loss, and angiopathy in the brain

It is suspected that a mix of genetic (APOE ε4), environmental, and lifestyle factors influence a person's risk for developing AD.

Susceptibility genes do not cause the disease by themselves but, in combination with other genes or epigenetic factors

“Neuronal Forest” with healthy neurons unaffected by AD

Plaques and TanglesAD tissue has many fewer nerve cells and synapses than a healthy brain (bottom right).

Abnormal clusters of protein fragments (beta-amyloid) build up between nerve cells; these are called plaques.

Dead and dying nerve cells contain tangles, which are made up of twisted strands of another protein.

PREVALENCE OF ADAn estimated 5.4 million Americans of all ages have AD in 2011

This figure includes 5.2 million people aged 65 and older

200,000 individuals under age 65 who have younger-onset Alzheimer’s

One in eight people aged 65 and older (13 percent) has

Nearly half of people aged 85 and older (43 percent)

An estimated 4 percent are under age 65

6 percent are 65 to 74

45 percent are 75 to 84

45 percent are 85 or older

ANNUAL INCIDENCE OF ADApproximately 53 new cases per 1,000 people aged 65 to 74

Approximately 170 new cases per 1,000 people aged 75 to 84

231 new cases per 1,000 people over age 85

Scientific analysis indicates that dementia incidence may continue to increase

Annual total number of new cases of Alzheimer’s and other dementias is projected to double by 2050.

Every 69 seconds, someone in America develops Alzheimer’s

By mid-century, someone in America will develop the disease every 33 seconds

DETECTIONIncluding psychiatric history and history of cognitive and behavioral changes

medical and family history

• Assesses the individual's memory skills, orientation to time and place, and ability to do simple calculations• Also evaluates the nutrition level and overall condition of the patient

Tests the functionality of the brain and nervous systemNeurological and

Physical Examination• Evaluates coordination, eye movement, speech and reflexes• Also look for signs of other conditions that cause brain disorders (previous strokes, brain tumors, fluid accumulation in

the brain, Parkinson's disease, etc.)

Diagnose Alzheimer's disease by ruling out other conditionsBrain Scans and Laboratory Tests

• Tests for anemia, diabetes, kidney or liver problems, abnormal levels of certain vitamins and thyroid hormones in the body that can cause dementia

• ECGs look for evidence of seizures and other abnormal brain activity, CT scans and an MRIs look at brain images for indications of abnormalities (blood clots, strokes and tumors)

“ADVANCES IN DETECTION”—ALZ.ORG

“Recently, simple and inexpensive tests have been developed that can be used by primary care physicians for routine assessment of patients in the clinic.”

“Examples of such tests include the Mini-Cog test, the General Practitioner Assessment of Cognition (GPCOG) and others.”

“It must be noted, however, that such assessment is valuable only for identifying people requiring more complete testing; it is not sufficient to establish a diagnosis of dementia.”

“The medical community has not yet developed a consensus regarding which single test is best for routine assessment”—alz.org

SIGNS AND SYMPTOMS

Personality changes and loss of social skills

Change in sleep patterns, often waking up at night

Delusions, depression, agitation

Difficulty performing IADL’s

Difficulty reading or writing

Forgetting details about current events

Difficulty performing familiar tasks that take some thought, but used to come easily

Getting lost on familiar routes

Language problems, such as trouble finding the name of familiar objects

Losing interest in things previously enjoyed, flat affect

Misplacing items

SIGNS & SYMPTOMS CONT.…

Forgetting events in your own life history, losing awareness of who you are

Hallucinations, arguments, striking out, and violent behavior

Poor judgment and loss of ability to recognize danger

Using the wrong word, mispronouncing words, speaking in confusing sentences

Withdrawing from social contact

Problems Understanding language

Inability to Recognize family members

Inability to Perform basic activities of daily living, such as eating, dressing, and bathing

Incontinence

Swallowing problems

S&S: 10 WARNING SIGNS OF ADMemory loss that disrupts daily life

Challenges in planning or problem solving

Difficulty completing familiar home, work or leisure tasks

Confusion with time or place

Trouble understanding visual images and spatial relationships

New problems with words in speaking or writing

Misplacing things and losing the ability to retrace steps

Decreased or poor judgment

Withdrawal from work or social activities

Changes in mood and personality

ACCOMPANYING HEALTH/PSYCHOSOCIAL PROBLEMS

Abuse by an over-stressed caregiver

Bedsores

Loss of muscle function that causes inability to move your joints

Infection, such as urinary tract infection and pneumonia

Other complications related to immobility

Falls and broken bones

Harmful or violent behavior toward self or others

Loss of ability to function or care for self

Loss of ability to interact

Malnutrition and dehydration

CULTURE SPECIFIC INFORMATION

Cultural and educational background should be accounted for in the evaluation of a consumers level of mental functioning

Individuals from certain backgrounds may be unfamiliar with the material used in certain tests of general knowledge, memory, and orientation

The prevalence of different factors that contribute to the risk of AD varies substantially across cultural groups

MANAGEMENT OF CONDITION

Slow the progression of the disease (although this is difficult to do)

Manage symptoms, such as behavior problems, confusion, and sleep problems

Adapt the home environment in order to better perform daily activities

Support family members and other caregivers

There is no cure for AD. The goals of treatment for AD are to:

MANAGEMENT OF CONDITION CONT.…

Drug Treatments used to treat the symptoms of AD

Drug treatments used to control aggressive, agitated, or dangerous behaviors

Donepezil (Aricept)

Rivastigmine (Exelon)

Galantamine (Razadyne)

Memantine (Namenda)

Cognex (Tacrine)

Haloperidol

Risperidone

Quetiapine

These are usually given in very low doses due to the risk of side effects

MANAGEMENT OF CONDITION CONT.…

Direct-care workers comprise the majority of the formal (paid) healthcare delivery system for individuals with AD, including assistance with ADL’s and IADL’s (bathing, dressing, housekeeping, food preparation etc.)

These workers include nurse aides, home health aides and personal- and home-care aides

“Their work is difficult, and they typically are poorly paid and receive little or no training to assume these responsibilities.”—alz.org

MANAGEMENT OF CONDITION CONT.…

Alzheimer's Association - www.alz.org

Alzheimer's Disease Education and Referral Center - www.nia.nih.gov/alzheimers

Alzheimer's Disease Research - www.ahaf.org/alzheimers

Support groups

The following organizations are good resources for information on Alzheimer's disease:

COURSE OF CONDITION

Stage IV: Mild or early-stage AD

Moderate cognitive decline

Stage III: early-stage ADMild cognitive decline; AD may be diagnosed in

some, individuals

Stage II: earliest signs of ADmay be normal age-related changes; Very mild

cognitive decline

Stage I: No impairment normal function

The progression of AD takes approximately 8-10 years

Stage VII: Severe or late-stage ADVery severe cognitive decline

Stage VI: Moderately severe or mid-stage ADSevere cognitive decline

Stage V: Moderate or mid-stage ADModerately severe cognitive decline

COURSE OF AD IN THE BRAIN

Emotional regulation part of brain

Decreased control over moods and feelings

Logical thought part of the brainDeclining ability to problem solve, grasp concepts,

and make plans

Language processing part of the brainDiminished capacity to use words correctly

Memory forming part of the brainDecreased ability to form new memories

Automatic functions part of brain

Affects breathing, digestion, heart rate and blood pressure.

Balance and coordination part of brain Loss of ability to ambulate and perform most ADL’s

Memory storage part of brainLoss of oldest memories

Sensory processing part of brainWreaks havoc on senses; sparks hallucinations

Brain Changes in AD

A brain without AD

A brain with advanced AD

How the two brains compare

OT FRAMEWORK APPLICATION

AREAS OF OCCUPATION

Instrumental Activities of Daily Living

Activities of Daily Living

The cognitive capacity to plan, initiate, and complete ADL’s in a safe, consistent (predictable), and efficient manner may be compromised; e.g., dressing, bathing, grooming, and bowel/bladder control. May wear multilayer clothing

inappropriately. Behavioral concerns such as

resistance or combativeness may impede task completion (especially true with bathing or showering activities)

AD may compromise the ability to perform IADL’s (drive, manage finances, self-administer medications, make a meal, etc.)

The consumer may experience incidents of: Getting lost while driving to a

familiar location Leaving the stove on Having rapid weight loss Having a medical crisis because of

poor medication management having unpaid bills because of

financial mismanagement.

AREAS OF OCCUPATION CONT.…

Rest and Sleep Education and Work

Among other factors, the inability to problem solve, grasp new concepts, communicate effectively, and execute more complex tasks impact performance in these areas of occupation

Sleep changes in Alzheimer’s may include: Difficulty sleeping Daytime napping and other

shifts in the sleep-wake cycle

May experience “sundowning”

AREAS OF OCCUPATION CONT.…

Leisure and Social Participation

With AD, there is a gradual withdrawal from leisure activities due to an inability to perform or frustration caused by increased cognitive challenges.

A tendency for occupational deprivation may occur if the activity demands are not reformed to meet the consumers reduced abilities.

There is a tendency to socially isolate Language problems such as expressive or receptive aphasia or agnosia

may affect social communication May desire to hide the disease from former acquaintances. “Some individuals with dementia show disinhibited behavior, including

making inappropriate comments or jokes, neglecting personal hygiene, exhibiting undue familiarity with strangers, or disregarding conventional rules of social conduct.” (American Psychiatric Association, 2000, p.148)

PERFORMANCE SKILLS

Sensory Perceptual Skills Motor and Praxis Skills

Motor skills begin to decline in the middle stages—especially in the areas of motor planning, sequencing, and executing new movements Cognitive deficits impede motor function.

In the middle to later stages, the risk of falls increases as the consumer develops apraxia Falls may be caused by lack of judgment in

the ability to descend a staircase, perceptual dysfunction, or failure to set the brakes on a wheelchair when transferring.

Motor skills in the later stages of the disease are severely impaired, and the consumer may require a positioning evaluation for bed, wheelchair, or Geri-Chair.

Progressively affected throughout the course of Alzheimer's disease.

all sensory areas may be affected (visual, auditory, tactile, proprioceptive, vestibular, olfactory, and gustatory) may report visual perceptual

disturbances may report an aversion to

certain foods or food textures Astereognosis is not unusual

PERFORMANCE SKILLS CONT.…

Emotional Regulation Skills

Cognitive Skills

The primary impact in performance skills is with cognitive deficits.

Although the primary cognitive challenge is memory, clients also lose executive function, including: Judgment Problem-solving ability Sequencing Organizing Prioritizing Planning Initiating

May have a sense of loss and grieving if the person has a self-awareness of memory loss.

Can range from mild depression to overt anger and aggression.

Families may encounter increasing frustration as the person has difficulty verbalizing the experience of memory loss or expressing fears about the future.

Feelings of confusion may alter emotions

In the later stages of the disease, these behaviors may escalate to aggression or catastrophic reactions

PERFORMANCE SKILLS CONT.…

Communication and Social Skills

May lose the ability to interact This symptom may be manifested as receptive or expressive

aphasia Agnosia or problems recalling recent events impair the flow of

conversation, and the individual may retreat from group discussions

May be embarrassed by the challenges of communicating and may attempt to hide the problem by withdrawing from social situations

Repeating questions or perseverating on a recent event or health problem can lead to annoyances for the primary caregiver

PERFORMANCE PATTERNS

Performance patterns are the habits, routines, rituals, and roles in daily activity.

Habits become strengths that the consumer can draw from when he or she is no longer able to remember how to perform.

May have to step down from current roles due to cognitive declines

Experience a decreased capacity or complete inability to learn new routines

May become unable to participate in rituals that are complex and/or more cognitively demanding

CONTEXT AND ENVIRONMENT

Cultural Context Personal Context

Alzheimer's disease is an age-related disease in that the greater majority of people in the early to middle stages of the disease are in late adulthood

Individuals tend to become disoriented to person—becoming confused about their age, marital status, and family composition

Younger-onset (before age 65) poses a particular challenge because decisions regarding workforce involvement are emotional and may negatively affect self-worth

Alzheimer’s disease may viewed as normal aging among Black/African American and Hispanic/Latino culture

Alzheimer’s disease may be looked at as “punishment” for past sins, bad blood or mental illness

Families may not seek out services because they do not wish to bring shame upon the family

Alzheimer’s disease may be attributed to “el mal de ojo” –the evil eye or “nervios” –nerves.

CONTEXT AND ENVIRONMENT CONT.…

Temporal Context Virtual Context

The virtual context can keep a person safe within his or her own home or in a residential facility.

behavioral issues related to wandering or exiting safe areas or potentially hazardous activities may require monitoring (home surveillance system).

Circadian rhythms are altered due to the prevalence of "sundowner's syndrome" in people with AD

CONTEXT AND ENVIRONMENT CONT.…

Physical Context Social Context

Relationships with spouse, friends, and caregivers may become strained

Relationships with systems (e.g., political, legal, economic or institutional) that are influential in establishing norms, role expectations, and social routines may dissolve

Consumer may experience difficulty negotiating and navigate his or her physical environment due to increased cognitive impairment Lighting, visual contrasts,

colors may affect the consumers functional level

CLIENT FACTORSDue to the debilitating nature of AD, values, beliefs, spirituality, body functions, and body structures that reside in the consumer and influence occupational performance may be compromised

Each client with Alzheimer's disease is a unique individual with a distinct set of underlying factors, both physical and motivational.

Barriers to optimal performance on the basis of physiological functions of body systems or personal values and beliefs should be identified by the OT practitioner

The individual may have visual deficits that impede unsupervised community mobility

The person with Alzheimer's may have apraxia that contributes to an unsafe environment but may not have the cognitive ability to learn to use a mobility support.

A strong belief in self-determination may influence the desire to remain independent, but poor judgment because of cognitive decline may create an unsafe situation for living alone.

The consumer's desire to pursue engagement in spiritual activities should influence recommendations in the intervention planning process.

GUIDE FOR INTERVENTION

MOHO, OA and CMOP Models of Practice

Cognitive Disabilities Frame of Reference With AD, it is paramount to obtain

a measure of the consumer’s cognitive functional abilities, or how the consumer draws from thinking and memory to organize and execute daily tasks.

Because of the debilitating and progressive nature of AD, new learning is not the focus of the intervention; rather, caregiver education, environmental adaptations, and compensatory strategies in a family-centered care approach are recommended.

Viewing human occupation using the concepts of MOHO, OA and COPM will guide practitioners in providing the most comprehensive treatment interventions for consumers (both patients and caregivers) within the AD population

CONCLUSIONThe limitations of having Alzheimer’s Dementia

influence the level and quality of engagement in all areas of occupation. With more knowledge about this condition and its limitations, occupational therapy practitioners can better help these individuals link their specific abilities with purposeful and meaningful patterns of engagement in occupations, allowing participation in desired roles and daily life situations at home, school, work, and the community. Moreover, the practitioner will be able to advocate on behalf of the consumer and help caregivers attain the support they need to care for this population.

Thank you

RESOURCES

http://www.alz.org

http://www.livestrong.com

http://www.guideline.gov

http://www.tangledneuron.info

http://www.pubmed.com

http://aboutalz.org

http://health.nytimes.com

http://ajot.aotapress.net/

http://occupational-therapy.advanceweb.com

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