The Road to The Road to Prevention:Prevention:

Diagnosing early Diagnosing early Cognitive Decline and Cognitive Decline and Targeting Deficits with Targeting Deficits with the Implementation of the Implementation of

Cognitive TrainingCognitive Training

Barbara C. Fisher, Barbara C. Fisher, Ph.D. CBSMPh.D. CBSM

Neuropsychologist/Board Certified Neuropsychologist/Board Certified Behavioral Sleep Medicine Behavioral Sleep Medicine

United Psychological United Psychological ServicesServices

www.unitedpsychologicalservwww.unitedpsychologicalservices.comices.comI have nothing to disclose

Alzheimer’s Association Alzheimer’s Association 2015 Statistics2015 Statistics

Estimated 5.3 million Americans of all ages Estimated 5.3 million Americans of all ages have AD; includes 5.1 million age 65 years and have AD; includes 5.1 million age 65 years and olderolder

200,000 under 65 have earlier onset AD200,000 under 65 have earlier onset AD 1 in 9 people age 65 and older have AD1 in 9 people age 65 and older have AD One-third of people age 85 and older have ADOne-third of people age 85 and older have AD 81 percent who have AD are 75 years and up81 percent who have AD are 75 years and up In 2010 there were an estimated 454,000 new In 2010 there were an estimated 454,000 new

cases by 2030 number projected to 615,000cases by 2030 number projected to 615,000

Prevention is Something Prevention is Something That We Can DoThat We Can Do

A recent publication from AAN (2015) A recent publication from AAN (2015) 1. Cerebrovascular disease: Variables of 1. Cerebrovascular disease: Variables of hypertension, diabetes, obesity, hyperlipidemia, hypertension, diabetes, obesity, hyperlipidemia, metabolic syndrome, unhealthy diet, smoking and metabolic syndrome, unhealthy diet, smoking and lack of physical acitivity are predictors for ADlack of physical acitivity are predictors for AD2. Depression: Poor eating, lack of activity, poor 2. Depression: Poor eating, lack of activity, poor sleep; death of spouse.sleep; death of spouse.3. Traumatic Brain Injury: CTE, diffuse axonal 3. Traumatic Brain Injury: CTE, diffuse axonal injury, cellular changes, Tauinjury, cellular changes, Tau4. Cognitive Inactivity: Theory of cognitive 4. Cognitive Inactivity: Theory of cognitive reserve, high education, use of brainreserve, high education, use of brain5. Sleep Disorders: OSA, Insomnia, Poor sleep 5. Sleep Disorders: OSA, Insomnia, Poor sleep hygienehygiene

Filley, 2015

This Affects All of UsThis Affects All of Us

1 in 5 medicare dollars is spent on 1 in 5 medicare dollars is spent on dementiadementia

Approximately two thirds of the Approximately two thirds of the caretakers ae women (34 percent age 65 caretakers ae women (34 percent age 65 and older)and older)

85 percent of unpaid help for older adults 85 percent of unpaid help for older adults in the U.S. is from family membersin the U.S. is from family members

40 percent of the total number of years of 40 percent of the total number of years of AD is spent in the most severe stage; slow AD is spent in the most severe stage; slow progressionprogression

2015 Alzheimer Association Report

The need for Early The need for Early DiagnosisDiagnosis

If you want to keep people in their If you want to keep people in their homes then diagnosis needs to be homes then diagnosis needs to be early.early.

That is not going to occur when the That is not going to occur when the patient or spouse thinks the problem patient or spouse thinks the problem is present or when the children take is present or when the children take a trip and notice a differencea trip and notice a difference

It is only to occur during a routine It is only to occur during a routine visit to the PCP.visit to the PCP.

The Problem is TimeThe Problem is Time PCP’s have no time for the simplest PCP’s have no time for the simplest

measure to administer especially if measure to administer especially if unfamiliar.unfamiliar.

Many new measures targeted to PCP are Many new measures targeted to PCP are not being utilized. Doctors would rather not being utilized. Doctors would rather refer out.refer out.

We need to catch people earlier in their We need to catch people earlier in their 50’s and 60’s not in their 70’s and 80’s50’s and 60’s not in their 70’s and 80’s

Our outreach effort: Writing articles, Our outreach effort: Writing articles, seminars, local papers, visiting the PCP’s seminars, local papers, visiting the PCP’s

Adult Signs Suggesting Need Adult Signs Suggesting Need for Neuropsychological for Neuropsychological

EvaluationEvaluation Memory problems: Memory problems: Daily tasks, appointments, Daily tasks, appointments,

cooking, routine activities, conversations, loss of cooking, routine activities, conversations, loss of items (keys, glasses, credit cards, check book)items (keys, glasses, credit cards, check book)

Getting lost and disoriented in familiar places Getting lost and disoriented in familiar places

Unable to make decisions, stuck and obsessed Unable to make decisions, stuck and obsessed Emotional: Accusations, paranoid, moodyEmotional: Accusations, paranoid, moody Conversations not making senseConversations not making sense Old personality emerges, deepened Old personality emerges, deepened

depressiondepression Actions occur without rhyme and reasonActions occur without rhyme and reason

Memory QuestionsMemory Questions

1.1. Difficulty remembering things that Difficulty remembering things that someone recently told you?someone recently told you?

2.2. Do you forget places where you Do you forget places where you have been?have been?

3.3. Do you forget the things that you Do you forget the things that you need to do?need to do?

4.4. Do you forget where you have Do you forget where you have placed something just that day placed something just that day before or even an hour ago?before or even an hour ago?

5.5. Do you keep getting lost, even if it is Do you keep getting lost, even if it is the same route to the same place the same route to the same place that you have been going to for that you have been going to for years and years?years and years?

Memory QuestionsMemory Questions

6.6. Do you find yourself forgetting what Do you find yourself forgetting what you wanted to say?you wanted to say?

7.7. Do you just think about things, Do you just think about things, becoming upset, unable to take action becoming upset, unable to take action to change things?to change things?

8.8. Do you forget names of people you Do you forget names of people you have known for years?have known for years?

9.9. Is it hard to learn new things?Is it hard to learn new things?10.10. Do you make the same mistakes? Over Do you make the same mistakes? Over

and over?and over?11.11. Do you continually ask for directions to Do you continually ask for directions to

be repeated?be repeated?

Purpose of Neuropsychological Purpose of Neuropsychological EvaluationEvaluation

Scientifically measures brain functioningScientifically measures brain functioning Paper and pencil tests to address brain Paper and pencil tests to address brain

behavior functioning.behavior functioning. Scientific method of predicting and assessing Scientific method of predicting and assessing

brain function that has stood the test of timebrain function that has stood the test of time Test patterns as opposed to standard scores Test patterns as opposed to standard scores

may suggest neurological deficits confirmed may suggest neurological deficits confirmed by radiological assessmentby radiological assessment

Neurocognitive Neurocognitive AssessmentAssessment

It is not uniformIt is not uniform Some are using broad brush: tests of Some are using broad brush: tests of

intelligence, attention, processing intelligence, attention, processing speed, memory, languagespeed, memory, language

Testing based upon decision tree for Testing based upon decision tree for the types of dementia: AD, Lewy the types of dementia: AD, Lewy body, Cardiovascular, Frontal, body, Cardiovascular, Frontal, FrontotemporalFrontotemporal

The Problem of Testing:The Problem of Testing:What test you use is what What test you use is what

you findyou find Findings depend upon the tests that you Findings depend upon the tests that you

useuse MEAMS versus the RBANSMEAMS versus the RBANS If too simplistic memory will appear intactIf too simplistic memory will appear intact Testing in the morning may be very Testing in the morning may be very

different from the later afternoondifferent from the later afternoon Different tests may yield different data Different tests may yield different data

that would be missed if reliant upon one that would be missed if reliant upon one measure.measure.

Testing for Donna, age 74; BA: Testing for Donna, age 74; BA: Global Systems Check vs. Global Systems Check vs.

Specific Assessment Specific Assessment First Testing:First Testing: Used Intellectual Assessment: Impaired Used Intellectual Assessment: Impaired

memory, average and above average memory, average and above average scoring for language (reading recognition) scoring for language (reading recognition) and attention (task of coding, sequential and attention (task of coding, sequential and cognitive flexibility) average and cognitive flexibility) average intelligence. intelligence.

Second Testing:Second Testing: RBANS, Doors and People, BVMT-R, Three RBANS, Doors and People, BVMT-R, Three

Word Three Shape: More severe picture: Word Three Shape: More severe picture: confusion, word retrieval, delayed recall, confusion, word retrieval, delayed recall, verbal memory worse, not retaining verbal memory worse, not retaining informationinformation

Testing Needs to Match Diagnosis Testing Needs to Match Diagnosis you are Ruling Outyou are Ruling Out

AD: Memory, Word Retrieval, VisuospatialAD: Memory, Word Retrieval, Visuospatial Cardiovascular/Frontal Temporal: Memory and Cardiovascular/Frontal Temporal: Memory and

Executive ReasoningExecutive Reasoning Frontal: Apraxia, Aphasia, Executive DeficitsFrontal: Apraxia, Aphasia, Executive Deficits Lewy Body: Visual Perceptual, Executive, Lewy Body: Visual Perceptual, Executive,

PsychosisPsychosis Huntington’s: Executive reasoning, psychosis, Huntington’s: Executive reasoning, psychosis,

motoricmotoric MS: memory and attention, speeded processing MS: memory and attention, speeded processing

motoric motoric It is not uniform for every personIt is not uniform for every person

Neuropsychological Testing of Neuropsychological Testing of the Brain:the Brain:

Frontal Processes: Word retrieval, planning, integration, Frontal Processes: Word retrieval, planning, integration, ability to shift sets, perseveration, problem solving, ability to shift sets, perseveration, problem solving, concrete thinking versus abstract reasoning, deductive concrete thinking versus abstract reasoning, deductive and inductive logical analysis, selective attention. and inductive logical analysis, selective attention.

Memory: Ability to learn new information; storage, Memory: Ability to learn new information; storage, retrieval and recognition (of learned information from retrieval and recognition (of learned information from distracter items). Verbal or Visual information: Stories, distracter items). Verbal or Visual information: Stories, word lists or names/ Designs, Doors, Names and Faces. word lists or names/ Designs, Doors, Names and Faces. Short versus learning and long term delayed memory, Short versus learning and long term delayed memory, working memory, memory confusion versus lack of recall, working memory, memory confusion versus lack of recall, ability to cluster information for recall.ability to cluster information for recall.

Neuropsychological Testing of Neuropsychological Testing of the Brainthe Brain

Language: Comparing expressive and Language: Comparing expressive and receptive, word retrieval application and receptive, word retrieval application and subtleties of language concepts, pragmatic subtleties of language concepts, pragmatic social language. social language.

Visual Perceptual: Discrimination, closure Visual Perceptual: Discrimination, closure (close up design using component parts), (close up design using component parts), visual spatial analysis, visual memory visual spatial analysis, visual memory recognition of designs (re-shown amongst recognition of designs (re-shown amongst distracter items) figure ground (finding distracter items) figure ground (finding objects against busy background) form objects against busy background) form constancy (seeing objects as constant constancy (seeing objects as constant despite change in size or shading). despite change in size or shading). Distortions in the copying of designs. Distortions in the copying of designs.

Neurocognitive Thinking Neurocognitive Thinking Problems typically seen with Problems typically seen with

Alzheimer’s Dementia:Alzheimer’s Dementia: Memory loss severe in the beginning stagesMemory loss severe in the beginning stages Misplaced objects- cannot find anything or Misplaced objects- cannot find anything or

remember where it wasremember where it was No recall of conversations, new learning No recall of conversations, new learning

problem problem Memory of the past remains intactMemory of the past remains intact Visuospatial functioning immediately Visuospatial functioning immediately

affected: affected: Lost in familiar places, route findingLost in familiar places, route finding Word retrievalWord retrieval

Neurocognitive Symptoms of Neurocognitive Symptoms of Cardiovascular DementiaCardiovascular Dementia

Memory confusion, poor efficiency, stepwise Memory confusion, poor efficiency, stepwise learninglearning

Executive reasoning: selective attention, integrationExecutive reasoning: selective attention, integration Poor cognitive flexibility, black white thinking, rigidPoor cognitive flexibility, black white thinking, rigid Getting stuck on one issue or thing, perseveration Getting stuck on one issue or thing, perseveration Difficulty with any step by step, sequential Difficulty with any step by step, sequential

instructioninstruction Problems planning, organizing or making decisionsProblems planning, organizing or making decisions Emotional reactivity, impulsive, judgmental, criticalEmotional reactivity, impulsive, judgmental, critical

Emotional Symptoms of Emotional Symptoms of Cardiovascular DementiaCardiovascular Dementia

Social withdrawal, depression, social mistakes, Social withdrawal, depression, social mistakes, wrong thing at the wrong time. Past behavior or wrong thing at the wrong time. Past behavior or extremesextremes

Inappropriate sexual behavior and comments.Inappropriate sexual behavior and comments. Problems communicating thoughts due to lost wordsProblems communicating thoughts due to lost words Loss of inhibition, they feel it, they do itLoss of inhibition, they feel it, they do it Loss of a sense of self, connection to the past, values, Loss of a sense of self, connection to the past, values,

morals and beliefs morals and beliefs Difficulty anticipating consequences of one’s actionsDifficulty anticipating consequences of one’s actions

Neurocognitive Symptoms and Neurocognitive Symptoms and Primary Signs of Lewy Body Primary Signs of Lewy Body

Dementia:Dementia: Executive Deficits: Problem solving, word retrieval, Executive Deficits: Problem solving, word retrieval,

sequential learning, selective attention, distracted by sequential learning, selective attention, distracted by noveltynovelty

Visual spatial, visual perceptual, visual constructional Visual spatial, visual perceptual, visual constructional Problems drawing and copying of designsProblems drawing and copying of designs Distorted perception, May affect balance and drivingDistorted perception, May affect balance and driving Thinking not logical, not processing things in realityThinking not logical, not processing things in reality Misinterpretation of conversation, confused with Misinterpretation of conversation, confused with

directionsdirections Mental illness or frank psychosis is immediately Mental illness or frank psychosis is immediately

evidentevident

Emotional Primary Signs of Lewy Emotional Primary Signs of Lewy BodyBody

Suspicious, accusatory of others, paranoidSuspicious, accusatory of others, paranoid Socially uncomfortable, dislike crowdsSocially uncomfortable, dislike crowds Agitated, restless, unpredictable Agitated, restless, unpredictable

emotions, feelings do not fit the situation, emotions, feelings do not fit the situation, easily upseteasily upset

Deep depression, fantasy, living in the Deep depression, fantasy, living in the movies, living inside themselvesmovies, living inside themselves

Empowered by God, visual hallucinations, Empowered by God, visual hallucinations, Auditory hallucinations, conversations Auditory hallucinations, conversations with Godwith God

Neurocognitive Signs of Frontal Neurocognitive Signs of Frontal Lobe Dementia (Frontotemporal Lobe Dementia (Frontotemporal

Dementias)Dementias) Executive reasoning: Selective attention, Executive reasoning: Selective attention,

perseveration, integration, poor sequential perseveration, integration, poor sequential processingprocessing

Apraxia, skilled movementApraxia, skilled movement Aphasia: Receptive versus expressive; Aphasia: Receptive versus expressive;

incorrect comprehension or use of languageincorrect comprehension or use of language Emotional, social, personal conduct, emotional Emotional, social, personal conduct, emotional

blunting, loss of insightblunting, loss of insight Symptoms appear in the 50’s and result in Symptoms appear in the 50’s and result in

poor financial judgment with significant poor financial judgment with significant consequencesconsequences

Right Frontal Process: The Cornerstone Right Frontal Process: The Cornerstone of Self-Regulation:of Self-Regulation:

Guidance system for one’s behavior Guidance system for one’s behavior Internal drive state or driven by the Internal drive state or driven by the

moment moment Social Emotional Intelligence: self-Social Emotional Intelligence: self-

awareness, sense of self, nuances of awareness, sense of self, nuances of social conduct, empathysocial conduct, empathy

When compromised:, Irritability and When compromised:, Irritability and impulsiveness, difficulty understanding or impulsiveness, difficulty understanding or predicting the impact of their behavior; predicting the impact of their behavior; hedonistic, lacking an internal drive hedonistic, lacking an internal drive state, driven by minor irrelevancies, state, driven by minor irrelevancies, inappropriate habits and routines. inappropriate habits and routines.

Test Specifics: Frontal Processes and Test Specifics: Frontal Processes and LanguageLanguage

Rambling sentences- structure & grammar, Rambling sentences- structure & grammar, omissions, substitutionsomissions, substitutions

Proverbs, interpreting them literally (glass Proverbs, interpreting them literally (glass houses)houses)

Integrating information in sentences or Integrating information in sentences or paragraphs paragraphs

Tangential output, rambling, non-completion of Tangential output, rambling, non-completion of thoughts ,spontaneous changing of subjectthoughts ,spontaneous changing of subject

Pragmatic or social language: Nuances, Pragmatic or social language: Nuances, subtleties, expression, what to say in a given subtleties, expression, what to say in a given social situation social situation 

Speech comprised of articulation irregularities Speech comprised of articulation irregularities

Assessment for Specific Assessment for Specific Types of DementiaTypes of Dementia

Cardiovascular: Memory (Retrieval, Cardiovascular: Memory (Retrieval, Recognition, Short term and delayed) Recognition, Short term and delayed) and Executive Reasoning (planning, and Executive Reasoning (planning, integration, selective attention, integration, selective attention, sequencing, word retrieval)sequencing, word retrieval)

Frontal: Executive Reasoning (planning, Frontal: Executive Reasoning (planning, integration, selective attention, integration, selective attention, sequencing, abstract reasoning and sequencing, abstract reasoning and problem solving, word retrieval, problem solving, word retrieval, aphasias)aphasias)

Assessment for Specific Assessment for Specific Types of DementiaTypes of Dementia

Lewy Body: Visual perceptual (visual Lewy Body: Visual perceptual (visual closure, figure ground, visual closure, figure ground, visual discrimination, visual sequential memory) discrimination, visual sequential memory) and Executive Reasoning (planning, and Executive Reasoning (planning, integration, selective attention, integration, selective attention, sequencing, abstract reasoning and sequencing, abstract reasoning and problem solving, word retrieval, aphasias)problem solving, word retrieval, aphasias)

Frontotemporal: Emotional Assessment Frontotemporal: Emotional Assessment (loss of sense of self) Memory (Retrieval, (loss of sense of self) Memory (Retrieval, Recognition, Short term and delayed) and Recognition, Short term and delayed) and Executive Reasoning (planning, Executive Reasoning (planning, integration, selective attention, integration, selective attention, sequencing, word retrieval)sequencing, word retrieval)

Examples of Memory Examples of Memory TestingTesting

Verbal Retrieval: Learning tasks; word lists, Verbal Retrieval: Learning tasks; word lists, stories, names of peoplestories, names of people

Verbal Recognition: Names, names and Verbal Recognition: Names, names and facesfaces

Visual Retrieval: Learning tasks; visual Visual Retrieval: Learning tasks; visual designsdesigns

Visual Recognition: Shapes, designs, Visual Recognition: Shapes, designs, picturespictures

Short term memory, Working memoryShort term memory, Working memory Sequential memorySequential memory Delayed recall and recognitionDelayed recall and recognition

Rey Complex Figure Recall and RecognitionRey Complex Figure Recall and Recognition

What you think isn’t: A score is not the total pictureWhat you think isn’t: A score is not the total picture

Three Word Three Shape: Three Word Three Shape: Hospital Bedside MeasureHospital Bedside Measure

Incidental Incidental MemoryMemory

Following 1Following 1stst Study PeriodStudy Period

Pre-TreatmentPre-Treatment

Louise

IncidentalIncidentalMemoryMemory

Following 1Following 1stst Study PeriodStudy Period

Post-TreatmentPost-Treatment

Louise

RBANS: Repeatable RBANS: Repeatable Assessment of Assessment of

Neuropsychological StatusNeuropsychological Status Immediate Memory: List learning, short Immediate Memory: List learning, short

story story Delayed Memory: List learning recall and Delayed Memory: List learning recall and

recognition, short story, visual figure recallrecognition, short story, visual figure recall Visuospatial/Constructional: Copying visual Visuospatial/Constructional: Copying visual

figure, line judgmentfigure, line judgment Language: Naming, word retrievalLanguage: Naming, word retrieval Attention: Short term recall number Attention: Short term recall number

sequences, Coding sequences, Coding Total ScoreTotal Score

RBANS:RBANS:List Learning: Verbal Retrieval TaskList Learning: Verbal Retrieval Task

RBANS:RBANS:Story Memory: Verbal Retrieval TaskStory Memory: Verbal Retrieval Task

List Learning TasksList Learning Tasks

Those with memory difficulties or Those with memory difficulties or dementia do not pick up the inherent dementia do not pick up the inherent categories in the lists of words.categories in the lists of words.

List are more difficult that do not List are more difficult that do not use inherent categories.use inherent categories.

Are they learning from the list and Are they learning from the list and benefiting from each learning trial benefiting from each learning trial

Line Judgment TaskLine Judgment Task

RBANS: Repeatable RBANS: Repeatable Assessment of Assessment of

Neuropsychological StatusNeuropsychological Status

Visual Construction: Figure Copy and RecallVisual Construction: Figure Copy and Recall

Review of the Research for Review of the Research for Cognitive Cognitive

Rehabilitation/TrainingRehabilitation/Training Current and early life engagement in Current and early life engagement in

cognitively stimulating activities was cognitively stimulating activities was shown to independently slow late life shown to independently slow late life decline. decline. (Wilson, Boyle, Barnes, et al., 2013)(Wilson, Boyle, Barnes, et al., 2013)

Cognitive activity slowed the rate of Cognitive activity slowed the rate of decline years before death: Cognitive decline years before death: Cognitive activity offers activity offers protection against protection against decline and may help preserve decline and may help preserve cognitive function despite the cognitive function despite the presence of pathologypresence of pathology

Review of the Research for Review of the Research for Cognitive Cognitive

Rehabilitation/TrainingRehabilitation/Training Consistent benefit of treatment of cognitive Consistent benefit of treatment of cognitive

function over and above medication effectsfunction over and above medication effects Specificity of the training appears to be a Specificity of the training appears to be a

primary variable for improved functioningprimary variable for improved functioning Effectiveness and durability of cognitive Effectiveness and durability of cognitive

training intervention improves functioning training intervention improves functioning even if limited in time and durationeven if limited in time and duration

Overall agreement that cognitive Overall agreement that cognitive therapy (cognitive stimulation, therapy (cognitive stimulation, cognitive training or rehabilitation) is cognitive training or rehabilitation) is an efficacious method to address an efficacious method to address dementia with or without medicationdementia with or without medication

Our ProgramOur Program Neuropsychological testing completed as a Neuropsychological testing completed as a

baseline and re-evaluation at distinct baseline and re-evaluation at distinct intervals throughout the cognitive training intervals throughout the cognitive training has resulted in significant improvement has resulted in significant improvement suggesting the benefit of this treatment. suggesting the benefit of this treatment. We have an ongoing study (51 subjects) We have an ongoing study (51 subjects) since 2007, ages 51 to 90 years, high since 2007, ages 51 to 90 years, high school to college, more often on medication school to college, more often on medication (Donepezil and Memantine) which began (Donepezil and Memantine) which began following testing or had been instituted following testing or had been instituted prior to the initial testing. prior to the initial testing.

Cognitive TrainingCognitive Training Specific and individualized tasks based Specific and individualized tasks based

upon the test resultsupon the test results Targeting visual perceptual, memory Targeting visual perceptual, memory

processes, executive reasoning, languageprocesses, executive reasoning, language Tasks of short term recall, recognition, Tasks of short term recall, recognition,

verbal and visual, working memory, word verbal and visual, working memory, word retrievalretrieval

Over 200 exercisesOver 200 exercises Re-testing every three months to change Re-testing every three months to change

program program

Nancy, Age 64 years: DX: Nancy, Age 64 years: DX: AD AD

Nancy has continued to struggle with daily living skills Nancy has continued to struggle with daily living skills despite making positive progress. Therapy goals are to despite making positive progress. Therapy goals are to increase activities decrease depression (watching old increase activities decrease depression (watching old movies as primary activity) and increase physical movies as primary activity) and increase physical hygiene. Some scores declined while others improved hygiene. Some scores declined while others improved significantly suggesting possible further decline in significantly suggesting possible further decline in areas not addressed in treatment. areas not addressed in treatment.

RBANS 8-2014 5-2015

Immediate Memory

94 (34th %tile) 109 (73rd %tile)

Visuospatial/Const 96 (39th %tile) 96 (39th %tile)

Language 85 (16th %tile) 64 (1st %tile)

Attention 94 (34th%tile) 85 (16th %tile)

Delayed Memory 89 (23rd%tile) 121 (92th tile)

Total Scale 87 (19th%tile) 92 (30th %tile)

RBANS: Delayed Figure RBANS: Delayed Figure Copy: NancyCopy: Nancy

Pre-TreatmentPre-Treatment

Post-TreatmentPost-Treatment

Nancy

Brenda, Age 53 years: Brenda, Age 53 years: DX: AD DX: AD

She remains in treatment. Quality of life is much She remains in treatment. Quality of life is much improved; she retired due to the memory improved; she retired due to the memory problems and she is spending time with her problems and she is spending time with her children and grandchildren. Self-esteem is children and grandchildren. Self-esteem is significantly better and depression is significantly better and depression is significantly less. significantly less.

BVMT-R 2-2015 8-2015

Trial 1 41 (18th %tile) 31 (3rd %tile)

Trial 2 43 (24th %tile) 43 (24th %tile)

Trial 3 53 (62nd %tile) 42 (21st %tile)

Total Recall 44 (27th %tile) 37 (10th %tile)

Delayed Recall 50 (50th %tile) 60 (84th %tile)

BVMT-R: Brenda 2-2015: Pre-Treatment

BVMT-R: Visual Retrieval TaskBVMT-R: Visual Retrieval Task

BVMT-R: Visual Retrieval TaskBVMT-R: Visual Retrieval Task

BVMT-R: Brenda 8-2015: Post-Treatment

Brenda, Age 53 years: H.S.: Pre and Brenda, Age 53 years: H.S.: Pre and Post Testing Post Testing

MAS 2-2015 8-2015

Visual Reproduction

6 (Below Average)

11 (Average)

List Recall 7 (Below Average)

12 (High Average)

Verbal Span 7 (Below Average)

10 (Average)

Immed. Prose Recall

1 (Impaired) 6 (Below Average)

Delayed Prose Recall

3 (Well Below Average)

6 (Below Average)

Index Scores 2-2015 8-2015

Verbal Memory 66 (1st %tile) 95 (37th %tile)

Visual Memory 83 (13th %tile) 98 (45th %tile)

Global Memory Scale

71 (3rd %tile) 96 (40th %tile)

MAS: Visual Recall Task: Brenda 2-2015

Visual Memory Pre-Treatment

MAS: Visual Recall Task: Brenda 8-2015

Visual Memory Post-Treatment

Brenda, Age 53 years: H.S.: Pre and Brenda, Age 53 years: H.S.: Pre and Post Testing Post Testing

WRAML-2 2-2015 8-2015

Visual Memory

77 (6th %tile) 100 (50th %tile)

Verbal Memory

76 (5th %tile) 100 (50th %tile)

Screening Memory

72 (3rd %tile) 100 (50th %tile)

Verbal Recognition

85 (16th %tile)

122 (93rd %tile)

Visual Recognition

100 (50th %tile)

90 (25th %tile)

General Recognition

90 (25th %tile)

107 (68th %tile)

Brenda: Pre and Post-Brenda: Pre and Post-TreatmentTreatment

CVLT-II 2-2015 8-2015

Learning Trial 1-5 43 66

Interference List -1.0 -0.5

Short Delay Free Recall

-1.0 +0.5

Short Delay Cued Recall

-1.5 +1.0

Long Delay Free Recall

-2.0 0

Long Delay Cued Recall

-1.5 +0.5

Verbal Learning Test

Syeed, Age 66 to 67 years: Syeed, Age 66 to 67 years: Diagnosed with Cardiovascular Diagnosed with Cardiovascular

Dementia Dementia MAS 8-2013 11-2013 12-2014

Verbal Memory

63 (1st%) 66 (1st%) 83 (13th

%)

He went on medical leave for three months due to dementia and returned to work at the end of 2014. Testing was completed after he had returned from being overseas for three months contracting malaria. He was referred to a sleep neurologist and diagnosed with sleep apnea.

Sayeed, Age 66 to 67years: Sayeed, Age 66 to 67years: DX: Cardiovascular DX: Cardiovascular

Dementia Dementia

Door/People 8-2013 11-2013 12-2014

Doors ￬ 4 4 5

Shapes 4 6 10

Visual Memory

3 4 7

BVMT-R 8-2013 11-2013 12-2014

Trial 1 25 (1st%) 49 (46th%) 33 (4th%)

Trial 2 ￬ 20 (1st%) 37 (10th%) 37 (10th%)

Trial 3 ￬ 20 (1st%) 41 (18th%) 47 (38th%)

Total Recall ￬ 20 (1st%) 41 (18th%) 44 (27th%)

Delayed Recall

￬ 20 (1st%) 27 (1st%) 54 (66th%)

Doors: Visual RecognitionDoors: Visual Recognition

BVMT-R: Visual Retrieval TaskBVMT-R: Visual Retrieval Task

BVMT-R: Sayeed 8-2013: Pre-Treatment

BVMT-R: Sayeed 11-2013: Post-Treatment

BVMT-R: Visual Retrieval TaskBVMT-R: Visual Retrieval Task

BVMT-R: Visual Retrieval TaskBVMT-R: Visual Retrieval Task

BVMT-R: Sayeed 12-2014: Post-Treatment

He did not recall anythingafter a delay of time

Doors and People Test: Visual Recall Task: Sayeed: 8-2013: Pre-Treatment

Doors and People Test: Visual Recall Task: Sayeed: 11-2013: Post-Treatment

Doors and People Test: Visual Recall Task: Sayeed: 12-2014: Post-Treatment

Constance, 71 to 72 Constance, 71 to 72 years: DX: HDyears: DX: HD

DKEFS 1-2014 6-2014 2-2015

Trail Making 3 5

Tower Test 6 6 7

Connie loves coming in for therapy describes it as the highlight of her week. She began to drive again after being in therapy for six months. She is pleased with her progress.

Composite scoresComposite scores

MAKES EVERYONE MAKES EVERYONE HAPPYHAPPY

Catching Dementia EarlyCatching Dementia Early

Grandma and Grandpa Grandma and Grandpa continue hosting the holidays continue hosting the holidays

in their home. The family in their home. The family system remains integrated.system remains integrated.

Grandchildren sleep over at Grandchildren sleep over at their grandparents. their grandparents.

Parents are provided Parents are provided with help.with help.

Grandchildren learn wisdom Grandchildren learn wisdom from their grandparents and from their grandparents and

receive the total unconditional receive the total unconditional love which forms a love which forms a

platform for self-esteem and platform for self-esteem and self-worthself-worth

Grandparents are afforded Grandparents are afforded the ability the ability

to remain revered and to remain revered and honored. They honored. They

are allowed to age are allowed to age gracefully and to die with gracefully and to die with

their boots on.their boots on.

1 of every 5 dollars spent by 1 of every 5 dollars spent by Medicare is for Dementia patients.Medicare is for Dementia patients.

Over 5 million people are living Over 5 million people are living with Alzheimer’swith Alzheimer’s

16 million is estimated by 205016 million is estimated by 2050It is the country’s most expensive It is the country’s most expensive

conditionconditionProjected as 214 billion for 2014 Projected as 214 billion for 2014

and 1.2 trillion by 2050 and 1.2 trillion by 2050

(Alzheimer’s Association Disease (Alzheimer’s Association Disease Facts and Figures Report, 2014, Facts and Figures Report, 2014,

2015)2015)

The referral system that The referral system that provides provides

relief. The PCP remains the relief. The PCP remains the hub but hub but

does not have to hold up the does not have to hold up the system system alone.alone.

While dementia may not be While dementia may not be curable: curable:

It can be contained.It can be contained.The Alzheimer’s The Alzheimer’s

Accountability Act Accountability Act introduced in Congress introduced in Congress

authorizes NIH authorizes NIH to submit a budget to to submit a budget to

Congress Congress justifying funding for justifying funding for critical AZ research. critical AZ research.

Take Home MessageTake Home Message There is something that can be done to There is something that can be done to

provide treatment for dementia: The provide treatment for dementia: The diagnosis of dementia does not mean diagnosis of dementia does not mean that the disease course is fixed and that the disease course is fixed and untreatableuntreatable

Perhaps if this concept was propagated Perhaps if this concept was propagated as opposed to the latter, more people as opposed to the latter, more people would be willing to undergo early would be willing to undergo early evaluationevaluation

Early evaluation = Increased prognosis Early evaluation = Increased prognosis for changefor change

Take Home MessageTake Home Message Concept of focused treatment providing Concept of focused treatment providing

individualized activities based upon brain behavior individualized activities based upon brain behavior relationships addressing specific aspects of relationships addressing specific aspects of memory, executive reasoning, language and visual memory, executive reasoning, language and visual perceptual functioning. perceptual functioning.

Cognitive or brain enhancing activities address Cognitive or brain enhancing activities address memory (short and long term, retrieval and memory (short and long term, retrieval and recognition, visual and verbal) executive reasoning recognition, visual and verbal) executive reasoning processes (selective attention, integration, processes (selective attention, integration, perseveration, sequential analysis, cognitive perseveration, sequential analysis, cognitive flexibility) language (word retrieval) and visual flexibility) language (word retrieval) and visual perceptual. perceptual.

Cognitive training and medication are Cognitive training and medication are becoming the gold standard.becoming the gold standard.

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