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Alzheimer's Dementia vs. Occupational Therapy
 

Alzheimer's Dementia vs. Occupational Therapy

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This is a presentation I did last spring in which I discuss how the OTPF applies to Alzheimer's Dementia. I collected data from scholarly as well as non-scholarly resources. I hope you find this to be ...

This is a presentation I did last spring in which I discuss how the OTPF applies to Alzheimer's Dementia. I collected data from scholarly as well as non-scholarly resources. I hope you find this to be helpful.

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  • Alzheimer's disease (AD) is a progressive neurodegenerative disease which is characterized by decreases in cognitive functions and abilities of daily life activities, behavioral changes and psychiatric symptoms (Özkay, Öztürk, & Can, 2011). The prevalence of AD, causing a significant decrease in individuals’ quality of life and eventually to leading their death, is gradually increasing at an alarming rate. In this review multiple areas of AD and its effects on human occupation are summarized to provide an overview of the occupational therapy process for adults with Alzheimer's disease.
  • Dementia is a general term for a decline in mental ability severe enough to interfere with daily life (American Psychiatric Association [APA], 2000, p. 154). Alzheimer’s dementia (AD) (the most common form of dementia) is an irreversible, progressive brain ailment that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks of daily living (Alzheimer's Association, 2012).
  • Before AD, “senile dementia” or “senility” was seen as a normal part of aging. Alzheimer’s dementia was discovered more than 100 years ago by a German physiatrist and neurologist named Alios Alzheimer (Berrios, 2004, p. 357). One of Dr. Alzheimer’s patients died after years of severe memory problems, confusion and difficulty understanding questions. Upon her death, while performing a brain autopsy, the doctor noted dense deposits surrounding the nerve cells (neuritic plaques). Inside the nerve cells he observed twisted bands of fibers (neurofibrillary tangles). In 1910, Emil Kraepelin coined the term “Alzheimer's disease;” the term first appeared in public in print in Kraepelin’s book “Psychiatrie: EinLehrbuchFürStudirende und Aerzte” and has been widely used since (Berrios, 2004, p. 362).
  • Scientists don’t yet fully understand what causes Alzheimer’s disease, but it has become increasingly clear that it develops because of a complex series of events that take place in the brain over a long period of time (Dhikav, 2011). Neurofibrillary tangles, neuritic plaques, neuronal loss, and amyloid angiopathy in the brain. The destructive aspects include neurochemical deficits that disrupt cell-to-cell communications, abnormal synthesis and accumulation of cytoskeletal proteins (e.g., tau), loss of synapses, pruning of dendrites, damage through oxidative metabolism, and cell death. Mutations on chromosomes 21, 14, and 1 cause familial AD (Berrios, 2004; Bashar, Yan, & Peng, 2012). Susceptibility genes do not cause the disease by themselves but, in combination with other genes or epigenetic factors, modulate the age of onset and increase the probability of developing AD. i.e., it is a combination of genetic, environmental, and lifestyle factors that influence a person's risk for developing the disease (http://www.alz.org).
  • Picture taken from alz.org
  • Picture taken from alz.org
  • An estimated 5.4 million Americans of all ages have Alzheimer’s disease 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 Alzheimer’s disease. Nearly half of people aged 85 and older (43 percent) have Alzheimer’s disease. Of those with Alzheimer’s disease, an estimated 4 percent are under age 65, 6 percent are 65 to 74, 45 percent are 75 to 84, and 45 percent are 85 or older (Alzheimer's Association, 2012).
  • The estimated annual incidence (rate of developing disease in a one-year period) of Alzheimer’s disease appears to increase dramatically with age, from approximately 53 new cases per 1,000 people aged 65 to 74, to 170 new cases per 1,000 people aged 75 to 84, to 231 new cases per 1,000 people over age 85. Analyses indicate that dementia incidence may continue to increase. Because of the increase in the number of people over 65 in the United States, the 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 (Alzheimer's Association, 2012).
  • Medical ExaminationA probable Alzheimer's disease diagnosis is made through the process of elimination. The first step in detecting Alzheimer's disease is to undergo a complete medical evaluation by a physician (Özkay et al., 2011). Both the individual and family members will be interviewed to provide a complete picture of the patient's medical history and the level of his current physical and mental functioning. The physician looks at the individual's memory skills, his understanding of time and place, and his ability to do simple calculations. The physician also evaluates the nutrition level and overall condition of the patient (Bashar et al., 2012).Neurological ExamIf Alzheimer's disease is suspected after the medical evaluation, the patient will usually be referred to a neurologist to test the functionality of her brain and nervous system (http://www.alz.org). The evaluation will test coordination, eye movement, speech and reflexes. The physician will also look for signs of other conditions that cause brain disorders, such as previous strokes, brain tumors, fluid accumulation in the brain and Parkinson's disease (Dhikav, 2011).Laboratory TestsSeveral laboratory tests may be ordered to diagnose Alzheimer's disease by ruling out other conditions. Blood counts will be analyzed to look for anemia, diabetes and kidney or liver problems (http://www.alz.org). Testing will also look for abnormal levels of certain vitamins and thyroid hormones in the body that can cause dementia. The patient may undergo an EEG (electrocardiogram) to look for evidence of seizures and other abnormal brain activity. A CT (computerized tomography) scan and an MRI (magnetic resonance imaging) may be conducted to look at images of the brain for indications of brain abnormalities such as blood clots, strokes and tumors (Bashar et al., 2012).
  • Information from alz.org
  • Mild cognitive impairment (MCI) is the stage between normal forgetfulness due to aging, and the development of AD; does NOT interfere with daily life. Symptoms of MCI include: difficulty performing more than one task at a time; difficulty solving problems; forgetting recent events or conversations; and taking longer to perform more difficult activities (http://www.alz.org). However, to qualify as having Alzheimer’s “these cognitive deficits must be sufficiently severe to cause impairment in occupational or social functioning and must represent a decline for a previously higher level of functioning” (APA, 2000, p. 148).
  • As the AD becomes worse, symptoms are more obvious and interfere with the ability to engage in self-care (Özkay et al., 2011). Symptoms can include: change in sleep patterns, often waking up at night; delusions, depression, agitation; difficulty doing basic tasks, such as preparing meals, choosing proper clothing, and driving; difficulty reading or writing; forgetting details about current events; 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 (http://www.alz.org). People with severe AD can no longer understand language, recognize family members, and perform basic ADL’s. Incontinence and swallowing problems are other symptoms that may occur with AD (Özkay et al., 2011).
  • Information from: http://www.alz.org/national/documents/checklist_10signs.pdf
  • Factors brought on by AD that could contribute to problems with primary support group, problems related to the social environment, educational problems, occupational problems, housing problems, economic problems, and problems with access to health care services may include: abuse by an over-stressed caregiver; bedsores; loss of muscle function that causes inability to move joints; and 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; and malnutrition and dehydration (Letts, et al., 2011; http://www.alz.org).
  • Cultural and educational background should be accounted for in the evaluation of a consumer’s 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 (APA, 2000, p. 138).
  • Medicines are used to help slow down the rate at which symptoms become worse. The benefits from these drugs are typically small (http://www.alz.org). The consumer and his/her family may not notice much of a change. There is no cure for AD. The goals of treatment are to: 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; and support family members and other caregivers (Dhikav, 2011).
  • Drug Treatments used to treat the symptoms of AD include Donepezil (Aricept), Rivastigmine (Exelon), Galantamine (Razadyne), Memantine (Namenda), and Cognex (Tacrine). Drug treatments used to control aggressive, agitated, or dangerous behaviors may also be necessary (e.g., Haloperidol, Risperidone, Quetiapine) and are usually given in very low doses due to the risk of side effects (Özkay et al., 2011).
  • 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. Support groups ( e.g., 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) are encouraged (Alzheimer's Association, 2012).
  • Chart from alz.org
  • Chart from alz.org
  • Information from:http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp
  • The slow, fairly predictable progression of AD symptoms is attributed to the manner in which the plaques and tangles course through and invade areas of the brain. The plaques and tangles first form in the hippocampus, the part of the brain where memories are formed. Destroying this part of the brain, AD terminates the ability to remember recent events or conversations (http://www.alz.org). From the hippocampus, the plaques and tangles invade the Language processing center of the brain. This accounts for the language difficulties experienced by the individual. Next, the plaques and tangles move to the front of the brain, where logical thought takes place. At this juncture, marked declines in the ability to problem solve, grasp concepts, and make plans become observable. The plaques and tangles then make their way to the emotional regulation section of the brain—causing the individual to become labile or “emotionally incontinent.” Thereafter, the sensory processing part of the brain is invaded. This event wreaks havoc on the senses and spark hallucinations (http://www.alz.org; Dhikav, 2011; Bashar et al., 2012). The plaques and tangles then reach the part of the brain responsible for storing memories. Once this happens, the individual loses their oldest and most precious memories. Towards the late stages of the disease, the cerebellum, responsible for coordination and balance, is destroyed—leading to an inability to perform basic ADL’s. Finally, AD begins to destroy the brainstem, the part of the brain that controls automatic functions such as circadian rhythm, digestion, breathing and heart rate—eventually leading to death, typically by causing the individual to develop pneumonia (Bashar et al., 2012; http://www.alz.org).
  • Picture from alz.org
  • Instrumental activities of daily living.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, and/or having unpaid bills because of financial mismanagement (American Occupational Therapy Association, Inc. [AOTA], 2010). In the early stages of AD concerns about the consumer’s ability to perform tasks in this area of occupation are typically raised by family members and/or close friends (Thinnes & Padilla, 2011; Padilla & Jensen, 2011; Montine, et al., 2012).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 (AOTA, 2008). The consumer may be able to Don simple clothing items such as a sweater, but may wear multilayer clothing inappropriately. Behavioral concerns such as resistance or combativeness may impede task completion (this is especially true with bathing or showering activities) (Thinnes & Padilla, 2011; Montine, et al., 2012).
  • Rest and sleep.Sleep changes in Alzheimer’s may include, difficulty sleeping, daytime napping and other shifts in the sleep-wake cycle, and “sundowning—an onset of increased agitation and restlessness that occurs during the late evening or at night (http://www.alz.org). Along with bowel and bladder control, information about sleep–rest cycles is paramount in making informed decisions about residential settings for the consumer. Studies suggest that this area of occupation has one of the greatest effects on family decisions regarding home versus residential placement (Thinnes & Padilla, 2011; Padilla & Jensen, 2011; Montine, et al., 2012; http://www.alz.org).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 (AOTA, 2010). This is especially true for consumers with early/young onset AD (Letts, et al., 2011). The compromised ability to perform satisfactorily in these areas of occupation may result in a profound sense of decreased self-worth and a low quality of life for younger consumers with AD (Padilla, 2011).
  • With AD, there is a gradual withdrawal from leisure activities due to an inability to perform or frustration caused by increased cognitive challenges. Activities that were formerly easy to do may now seem very difficult, which causes anxiety (AOTA, 2010). Occupational deprivation can occur if the activity demands are not reformed to meet the consumers reduced abilities. Moreover, there may be a tendency to socially isolate, either because of language problems such as expressive or receptive aphasia or agnosia—word-finding problems—, or in an attempt to hide the ailment from former acquaintances; this negatively impacts social interaction (Letts, et al., 2011; Thinnes & Padilla, 2011; Montine, et al., 2012) “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.” (APA, 2000, p.148)
  • Sensory perceptual skills.Sensory and perceptual skills are progressively affected throughout the course of AD. Although each sensory functions may be compromised (visual, auditory, tactile, proprioceptive, vestibular, olfactory, and gustatory), the deficits vary depending on the individual. Astereognosis—an inability to identify objects by touch—may also occur (AOTA, 2010). The degree and type of sensory impairment may be correlated to the area of the brain that is most affected (Montine, et al., 2012; Bashar, Yan, & Peng, 2012; Thinnes & Padilla, 2011).Motor and praxis skills.Motor skills typically begin to decline in the middle stages—especially in the areas of motor planning, sequencing, and praxis skills. Motor function impediment is caused by cognitive deficits. In the middle to later stages, the risk of falls increases as the consumer develops apraxia—the inability to motor plan (AOTA, 2010). 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 (Montine, et al., 2012; Bashar, Yan, & Peng, 2012; Thinnes & Padilla, 2011). Motor skills in the later stages of AD are severely impaired, and the consumer may require a positioning evaluation for bed, wheelchair, or Geri-Chair (Padilla, 2011). In the presence of comorbidities, the consumer may experience these declines in performance in these areas during earlier stages of the disease (Letts, et al., 2011).
  • Emotional regulation skills.When diagnosed early, the consumer typically has a sense of loss and grieving if the he or she has a self-awareness of memory loss (Letts, et al., 2011). Emotional reactions may vary from mild depression to overt anger and aggression. Some behaviors may be manifesting underlying feelings of confusion or fear which the consumer is unable to verbalize effectively. Family is also affected, experiencing rising frustration as the consumer’s symptoms worsen. Later in the disease, AD affects the consumer’s ability to regulate his or her emotions effectively (Letts, et al., 2011; http://www.alz.org).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, and sequencing, organizing, prioritizing, planning, and initiating (AOTA, 2010). For instance, in the middle stages of AD, the consumer may be perplexed by the command "get ready for church." By contrast, the caregiver may offer a coat, initiate donning, and the client will continue through completion (Montine, et al., 2012; Bashar, Yan, & Peng, 2012; Thinnes & Padilla, 2011).
  • Communication and social skill deficits vary greatly among people with AD. Albeit some individuals maintain the ability to hold an organized conversation into the middle stages of AD, others lose the capacity for social interaction early in the disease (http://www.alz.org). This symptom may be manifested as receptive aphasia—problems understanding others—or expressive aphasia—trouble using words and sentences. Agnosia—word finding difficulties—or problems recalling recent events impair the flow of conversation, causing the individual to retreat from group discussions (AOTA, 2010). The person may be embarrassed by the challenges and may attempt to hide the problem by withdrawing from social situations. Repeating questions or perseverating—the repetition of a particular response, such as a word, phrase, or gesture, despite the absence or cessation of a stimulus—on a recent event or health problem can lead to annoyances for the primary caregiver (Montine, et al., 2012; Bashar, Yan, & Peng, 2012; Thinnes & Padilla, 2011).
  • Performance patterns are the habits, routines, rituals, and roles in daily activity (American Occupational Therapy Association [AOTA], 2008). Habits become strengths that the consumer can draw from when he or she is no longer able to remember how to perform. Even in the later stages of the disease, the consumer may be able to function optimally when he or she is able to draw from early learning in long-term memory and replicate skills that are well rehearsed. Conversely, the individual becomes unable to learn a new routine may be able to carry out former routines successfully (Montine, et al., 2012; Bashar, Yan, & Peng, 2012). The consumer may have to step down from current roles due to cognitive declines. The consumer may also experience a decreased capacity or complete inability to learn new routines and may become unable to participate in rituals that are complex and/or more cognitively demanding (AOTA, Inc., 2010).
  • Cultural context.Cultural context includes customs, beliefs, activity patterns, behavior standards, and expectations accepted by the society of which the client is a member (AOTA, 2008). For instance, AD may be viewed as normal aging among Black/African American and Hispanic/Latino culture. Further, Alzheimer’s disease may be attributed to “el mal de ojo” –the evil eye—or “nervios” –nerves. Conversely, AD may be looked at as “punishment” for past sins, bad blood or mental illness in certain Eastern cultures. Some families may not seek out services because they do not wish to bring “shame” upon the family (http://www.alz.org). “The expectations, beliefs, and customs of various cultures can affect a client’s identity and activity choices and need to be considered when determining how and when services may be delivered.” (AOTA, 2008)Personal context.Personal context refers to demographic features of the consumer such as age, gender, education, etc. (AOTA, 2008). AD can be considered an age-related disease due to the fact that the greater majority of people in the early to middle stages of the disease are in late adulthood. Younger onset (before age 65) poses a particular challenge because decisions regarding workforce involvement are emotional and affect self-worth (AOTA, 2010; Thinnes & Padilla, 2011). Individuals also tend to become disoriented to person—becoming confused about their age, marital status, and family composition. There are studies that suggest that women are more susceptible to the disease, but these finding are controversial (Alzheimer's Association, 2012). “The client’s personal context affects service delivery by influencing personal beliefs, perceptions, and expectations” (AOTA, 2008).
  • Temporal context.The temporal context refers to the "experience of time as shaped by engagement in occupations” and “includes stages of life, time of day or year, duration, rhythm of activity, or history” (AOTA, 2008). Circadian rhythms—a daily rhythmic activity cycle, based on 24-hour intervals—are altered due to the prevalence of "sundowner's syndrome" in people with AD. Sundowner’s is a common term used to refer to confusion and agitation that may only appear or become worse in the evening. Altered sleep–wake cycles occur in the middle stages of the disease when daytime becomes confused with nighttime (Alzheimer's Association, 2012).Virtual context.Virtual context refers to interactions in simulated, real-time, or near-time situations absent of physical contact (AOTA, 2008). Behavioral issues related to wandering or exiting safe areas or potentially hazardous activities may require monitoring (AOTA, 2010; Letts, et al., 2011). This external context can provide resources that support or inhibit the consumer’s performance (e.g., access to a computer to communicate with others, or home surveillance system to ensure safety for individuals who are at high risk). The virtual context can keep the consumer safe within his or her own home or in a residential facility.
  • Physical environment.Physical environment refers to the natural and built nonhuman environment and the objects in them (AOTA, 2008). i.e., it is the primary living space and places that the person frequents during daily activities. The consumer may experience difficulty negotiating and navigate his or her physical environment due to increased cognitive impairment. Lighting, visual contrasts, colors may also affect the consumer’s functional level (AOTA, 2010; Letts, et al., 2011). In order for the consumer to remain at home, versus a residential setting, the physical environment may need to be adapted to provide the precautionary supports for safety and independence.Social environment.The social environment is constructed by the presence, relationships, and expectations of persons, groups, and organizations with whom the client has contact. The social environment may provide resources that support or inhibit the client’s performance (AOTA, 2008). For example: the presence or absence of a paid-caregiver; or the willingness (or lack thereof) of family members, friends or neighbors to provide assistance with weekly or daily tasks (AOTA, 2010; Letts, et al., 2011). Relationships with spouse, friends, and caregivers may become strained. Also, relationships with social systems (e.g., political, legal, economic or institutional) that are influential in establishing norms, role expectations, and social routines may dissolve.
  • Due 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 consumer with AD is a unique individual with a distinct set of underlying factors, both physical and motivational (Thinnes & Padilla, 2011). 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 on a case-by-case, phase-by-phase basis. The individual may have visual deficits that impede unsupervised community mobility (Montine, et al., 2012; Bashar, Yan, & Peng, 2012). 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 (Letts, et al., 2011). 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 (AOTA, 2010). The consumer's desire to pursue engagement in spiritual activities should influence recommendations in the intervention planning process.
  • This guideline does not discuss all possible methods of care, and although it does recommend some specific methods of care, the OT practitioner makes the ultimate judgment regarding the appropriateness of a given intervention in light of a specific consumer's circumstances, needs, and available evidence to support intervention.Model of PracticeNo single theoretical model guides occupational therapy intervention with people with Alzheimer's disease. Moreover, the progressive nature of the disease dictates that occupational therapy intervention occurs at intervals (early, middle, and late stages of AD) over time. The goals of stage-based intervention change based on the needs of the client at each stage of the disease, and with it, the models of practice and frames of reference. Generally, 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. Frame of ReferenceWith regard to frames of reference used for individuals 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. Thus, the cognitive disabilities frame of reference would be an apt choice. However, client factors such as the presence of comorbidities coupled with the progression of the disease will affect the overall decision of the practitioner.
  • Table from alz.org

Alzheimer's Dementia vs. Occupational Therapy Alzheimer's Dementia vs. Occupational Therapy Presentation Transcript

  • Chevahlyan Dozier
  • Dementia 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
  • Before 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‖
  • 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 Tangles AD 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.
  • An 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
  • Approximately 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
  • Including 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 system Neurological 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 conditions Brain 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)
  • ―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
  • 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
  • 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
  • Memory 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
  • 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
  • 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
  • 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:
  • 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
  • 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
  • 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:
  • Stage IV: Mild or early-stage AD Moderate cognitive decline Stage III: early-stage AD Mild cognitive decline; AD may be diagnosed in some, individuals Stage II: earliest signs of AD may 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 AD Very severe cognitive decline Stage VI: Moderately severe or mid-stage AD Severe cognitive decline Stage V: Moderate or mid-stage AD Moderately severe cognitive decline
  • Emotional regulation part of brain Decreased control over moods and feelings Logical thought part of the brain Declining ability to problem solve, grasp concepts, and make plans Language processing part of the brain Diminished capacity to use words correctly Memory forming part of the brain Decreased 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 brain Loss of oldest memories Sensory processing part of brain Wreaks havoc on senses; sparks hallucinations
  • Brain Changes in AD A brain without AD A brain with advanced AD How the two brains compare
  • 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.
  • 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‖
  • 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)
  • 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
  • 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
  • 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 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
  • 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.
  • 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
  • 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
  • Due 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.
  • 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
  • The 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 
  • 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
  • Alzheimer's Association. (2012, March 1). Facts and Figures: alz.org/Alzheimer's Association. Retrieved from alz.org/Alzheimers Association: http://www.alz.org/ American Occupational Therapy Association. (2008). Occupational Therapy Practice Framework: Domain & Process 2nd Edition. American Journal of Occupational Therapy, 62, 625-683. American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC. Bashar, M. R., Yan, L., & Peng, W. (2012). Study of EEGs from Somatosensory Cortex and Alzheimer's Disease Sources. International Journal Of Biological & Life Sciences, 8(2), 62-66. Berrios, G. E. (2004, October 13). Alzheimer's disease: A conceptual history. International Journal of Geriatric Psychiatry, 5(6), 355-365. doi:10.1002/gps.930050603
  • Dhikav, V. &. (2011). Potential Predictors of Hippocampal Atrophy in Alzheimer's Disease. Drugs & Aging, 28(1), 1-11. Letts, L., Edwards, M., Berenyi, J., Moros, K., O’Neill, C., O’Toole, C., & McGrath, C. (2011, September/October). Using Occupations to Improve Quality of Life, Health and Wellness, and Client and Caregiver Satisfaction for People With Alzheimer’s Disease and Related Dementias. American Journal of Occupational Therapy, 65(5), 497-504. doi:10.5014/ajot.2011.002584 Letts, L., Minezes, J., Edwards, M., Berenyi, J., Moros, K., O’Neill, C., & O’Toole, C. (2011, September/October). Effectiveness of Interventions Designed to Modify and Maintain Perceptual Abilities in People With Alzheimer’s Disease and Related Dementias. American Journal of Occupational Therapy, 65(5), 505-513. doi:10.5014/ajot.2011.002592 Montine, T., Phelps, C., Beach, T., Bigio, E., Cairns, N., Dickson, D., & Hyman, B. (2012). National Institute on Aging-Alzheimer's Association guidelines for the neuropathologic assessment of Alzheimer's disease: a practical approach. Acta Neuropathologica, 123(1), 1-11. doi:10.1007/s00401-011-0910-3 Özkay, Ü., Öztürk, Y., & Can, Ö. (2011). Yaşlanan dünyanın hastalığı: Alzheimer hastalığı. Medical Journal Of Suleyman Demirel University, 18(1), 35-42.
  • Özkay, Ü., Öztürk, Y., & Can, Ö. (2011). Yaşlanan dünyanın hastalığı: Alzheimer hastalığı. Medical Journal Of Suleyman Demirel University, 18(1), 35-42. Padilla, R. (2011, September/October). Effectiveness of Environment-Based Interventions for People With Alzheimer’s Disease and Related Dementias. American Journal of Occupational Therapy, 65(5), 514-522. doi:10.5014/ajot.2011.002600 Padilla, R. (2011, September/October). Effectiveness of Interventions Designed to Modify the Activity Demands of the Occupations of Self-Care and Leisure for People With Alzheimer’s Disease and Related Dementias. American Journal of Occupational Therapy, 65(5), 523-531. doi:10.5014/ajot.2011.002618 Padilla, R., & Jensen, L. E. (2011, September/October). Effectiveness of Interventions to Prevent Falls in People With Alzheimer’s Disease and Related Dementias. American Journal of Occupational Therapy, 65(5), 532-540. doi:10.5014/ajot.2011.002626 Thinnes, A., & Padilla, R. (2011, September/October). Effect of Educational and Supportive Strategies on the Ability of Caregivers of People With Dementia to Maintain Participation in That Role. American Journal of Occupational Therapy, 65(5), 541- 549. doi:10.5014/ajot.2011.002634