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Alzheimer's Dementia vs. Occupational Therapy

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 Dementia vs. Occupational Therapy

  1. 1. Chevahlyan Dozier
  2. 2. 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
  3. 3. 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‖
  4. 4. 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
  5. 5. “Neuronal Forest” with healthy neurons unaffected by AD
  6. 6. 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.
  7. 7. 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
  8. 8. 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
  9. 9. 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)
  10. 10. ―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‖—
  11. 11. 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
  12. 12. 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
  13. 13. 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
  14. 14. 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
  15. 15. 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
  16. 16. 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:
  17. 17. 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
  18. 18. 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.‖—
  19. 19. Alzheimer's Association - Alzheimer's Disease Education and Referral Center - Alzheimer's Disease Research - Support groups The following organizations are good resources for information on Alzheimer's disease:
  20. 20. 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
  21. 21. 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
  22. 22. Brain Changes in AD A brain without AD A brain with advanced AD How the two brains compare
  23. 23. 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.
  24. 24. 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‖
  25. 25. 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)
  26. 26. 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
  27. 27. 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
  28. 28. 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
  29. 29.  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
  30. 30. 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.
  31. 31. 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
  32. 32. 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
  33. 33. 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.
  34. 34. 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
  35. 35. 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.
  36. 36. Thank you 
  37. 37.
  38. 38. Alzheimer's Association. (2012, March 1). Facts and Figures:'s Association. Retrieved from Association: 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
  39. 39. 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.
  40. 40. 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