Dementia

Dementia is a general term that covers a range of specific medical conditions, including Alzheimer’s disease. Dementia is generally characterized by memory loss and difficulty with problem-solving and thinking that may interfere with daily life.¹  Currently, more than 55 million people live with dementia globally and there are ~10 million new cases annually. Dementia is not a byproduct of the biological aging process. Pathologically, there is the physical deterioration of the CNS. Dementia may result in primary and secondary diseases that affect the brain. Alzheimer’s disease is the most common form of dementia. Dementia is the 7th leading cause of death among all diseases and is a major cause of disability and dependency among older people globally. Overall, dementia can have physical, social, psychological, and economic impacts from the client to the larger macro-scale of impact on society.² 

Etiology

The number of people with dementia is projected to increase to 152 million by the year 2050. Low-income and middle-income countries are more likely to have a rise in people with dementia. Global costs due to dementia is estimated to be about $1 trillion annually.³  The rise in dementia may be attributed to a larger population of people living longer.⁴  However, in the US, incidence rates are lower compared to previous decades. This may be due to people being born more recently having access to education, improved healthcare, and lifestyle changes. This may be offset due to obesity, diabetes, and decreased physical activity.^5 5 5 

Prevention

• Minimizing diabetes
• Treating hypertension
• Preventing head injuries
• Smoking cessation
• Reducing exposure to air pollution
• Reducing obesity
• Maintaining exercise
• Managing depression
• Avoiding excessive alcohol
• Maintaining social contact
• Attaining higher education (maximizing cognitive reserve)
• Preventing hearing loss and using hearing aids – hearing loss may cause cognitive decline due to decreased cognitive stimulation⁶ 
• Hearing impairment as measured by audiometry is associated with increased temporal lobe, hippocampus, and entorhinal cortex volume loss.⁷ 

Dementia Types

1. Alzheimer’s (60-80%)
2. Lewy Body Dementia (5-10%)
3. Vascular Dementia (5-10%)
4. Frontotemporal Dementia (5-10%)
5. Others: Parkinson’s Disease, Huntington’s Disease
6. Mixed Dementia: more than one cause¹ 

Pathology

FYI. Likely not tested on the NBCOT Exam.

Alzheimer’s Disease (AD)

• Hallmarks of AD are the accumulation of Aβ peptides, neurofibrillary tangles (NFTs) composed of protein-tau. There is neuronal degeneration, neuroinflammation, microglia activation, blood-brain barrier dysfunction, and cognitive decline.^8 9 
• The pathology of NFT in AD has three stages: transentorhinal, limbic, and isocortical, which correlates with the Braak and Braak staging system of AD.
  • Stages I & II: transentorhinal – asymptomatic
  • Stages III & IV: limbic – mild symptoms
  • Stages V & VI: isocortical – dementia¹⁰ 
• Many theories have been proposed for the cause of AD including (1) exacerbation of aging, (2) degeneration of anatomical pathways, including the cholinergic and cortico-cortical pathways, (3) an environmental factor such as exposure to aluminium, head injury, or malnutrition, (4) genetic factors including mutations of amyloid precursor protein (APP) and presenilin (PSEN) genes and allelic variation in apolipoprotein E (Apo E), (5) mitochondrial dysfunction, (6) a compromised blood-brain barrier, (7) immune system dysfunction, and (8) infectious agents.
• There is a strong genetic component of AD that drives the accumulation of parenchymal Aβ plaques.¹¹ 
• It is most likely that AD is a multifactorial disorder in which genetic and environmental risk factors interact to increase the risk of AD.¹² 

Dementia with Lewy Bodies

“Before Robin Williams was diagnosed with Lewy Body Dementia, it was reported that he had been experiencing paranoia, confusion, insomnia, constipation and lacking the ability to smell. For many, the wide range of early symptoms — not all related to brain function — makes Lewy Body Dementia difficult to diagnose.”¹³ 

• Second most common cause of dementia in the elderly.¹⁴ 
• Characterized by the abnormal aggregation of the synaptic protein α-synuclein as ‘Lewy bodies’ in neurons associated with brain atrophy.¹⁵ 

Vascular Dementia (VaD)

• Potential causes of VaD include vascular dysfunctions such as large vessel disease, cardioembolic disease, and small-vessel disease.
• VaD is caused by diminished cerebral blood flow which leads to hypoxia and the blood-brain barrier permeability being prolonged and exposed to toxic effects leading to neurodegeneration and amyloid deposition.¹⁶ 
• There are six subcategories of VaD: (1) multi-infarction dementia, (2) strategic infarction dementia, (3) hemorrhagic dementia, (4) mixed dementia, (5) subcortical ischemic vascular dementia (SIVD), and (6) other forms of VaD.¹⁷ 

Frontotemporal Dementia (FTD)

• Sporadic frontotemporal dementia (cases not due to genetic causes) account for 60% of cases; 40% are genetic.¹⁸ 
• The sporadic form develops in the elderly from 60 years onwards¹⁹ 
• Characterized by atrophy of the frontal and temporal lobes instead of the diffuse atrophy seen in AD.²⁰ 

Mixed Dementia

• More common with increasing age, e.g., older than 85.²¹ 
• Studies on mixed dementia are scarce.

Symptoms

Early Stage

• Forgetfulness
• Losing track of time
• Becoming lost in familiar places

Middle Stage

• Becoming forgetful of recent events
• Forgetting people’s names
• Becoming confused at home
• Difficulty with communication
• Needing help with personal care
• Experiencing behavioral changes, e.g., wandering, repeated questioning

Late Stage

• Becoming disoriented and unaware of time and place (A&O)
• Having difficulty recognizing familiar people
• Having an increased need for self-care assistance
• Difficulty with walking
• Increased behavioral changes including aggression² 
• Agitation²² 

Treatment

• Depends on the underlying cause.
• Often no cure for progressive dementias, including Alzheimer’s disease.
• Aduhelm has been a controversial and evolving treatment for AD that works by removing amyloid. – See blog post.
• Many treatments slow or control dementia symptoms and improve quality of life.
• The same types of drugs to treat AD are prescribed for other types of dementias.
• Non-drug therapies may alleviate some symptoms of dementia.¹ 

Outcome Measures

• Allen Cognitive Levels Screen
• Montreal Cognitive Assessment (MoCA)
• Mini-Mental State Examination (MMSE) ^23 24 
• Canadian Occupational Performance Measure (COPM) ²⁵ 
• Occupational Performance History Interview-II (OPHI-II) ²⁶ 
• Geriatric Depression Scale (GDS) ²⁷ 
• Assessment of Motor and Process Skills (AMPS) ²⁸ 
• Disability Assessment in Dementia (DAD) – assesses 10 activities for ADLs and IADLs²⁹ 
• Loewenstein Occupational Therapy Cognitive Assessment-Geriatric (LOTCA-G) ³⁰ 
• Contextual Memory Test (Toglia)
• Rivermead Behavioral Memory Test

Occupational Therapy

Goals

• Prolonging independence
• Health promotion – maximizing performance in preferred activities
• Remediation – not cognitive skills, but incorporating exercise to improve performance
• Maintenance – supporting habits and routines
• Modification – most frequently used approach
• Promoting social participation
• Safety³¹ 

Evaluation

• Strengths
• Impairments
• Performance areas needing intervention³² 

Specific Recommendations

• Provide ADL and leisure training to improve or maintain participation.
• Modify activities for ADL and leisure participation.
• Use exercise-based interventions to improve or maintain ADLs, functional mobility, and sleep.
• Use of errorless learning and prompting strategies for therapy.
• Provide cognitive stimulation to enhance social participation.
• Use of Montessori and spaced retrieval for self-feeding.
• Provide individualized social activities to enhance sleep.
• Use multicomponent interventions to improve and maintain quality of life.
• Use client-centered and individually tailored environment-based interventions.
• Designate rooms for their intended purpose with privacy and personalization of familiar rooms (e.g., bedrooms, living rooms, dining rooms).
• Implement monitoring devices for fall prevention.
• Provide environmental interventions to compensate for perceptual changes.
• Use ambient music to improve behavior outside of mealtimes.
• Use multisensory interventions for short-term behavior interventions.
• Conceal objects and the environment to reduce elopement and manage wandering.
• Regulate the ambient noise level to improve behavior.
• Use multicomponent psychoeducational interventions to improve quality of life and mental health.
• Provide communication skills training for caregivers.
• Use cognitive reframing therapy, CBT, mindfulness, and stress reduction interventions to reduce caregiver stress, anxiety, and depression.
• Delay nursing home placement using psychoeducational interventions.
• Use physical activity and exercise programs to reduce caregiver stress.^33 34 
• Prescribe assistive technology to promote function, participation and prevent falls.³⁵ 

Sundowning

• Characterized by neuropsychiatric symptoms in the late afternoon to evening.
• Symptoms may include confusion, disorientation, anxiety, agitation, aggression, pacing, wandering, resistance to redirection, screaming, and yelling.
• Associated with sensory deprivation, circadian rhythm disorders, sleep disorders and distrubances, maladaptive response to environmental factors, temporal changes in body temperature, medications, other medical and psychiatric conditions.
• Individuals with AD are not able to react to stimuli and physical discomfort in “normal ways” and may use aggression and other behaviors to express such discomfort.
• Management: treat underlying causes and risk factors.
• S.M.A.R.T. or P.I.E.C.E.S. Approach: safety, medical work-up, assessment of competency, rest/review, trial medications; physical problems, capabilities, environment, social/cultural issues.
• Environmental and behavioral medications may help.
• Also trial music therapy, aromatherapy, caregiver education, multisensory stimulation³⁶ , reduction of background noise, visitors, and loudness of speech.
• Offer simple instructions and adhere to a consistent routine.
• Meet physical needs (basic human).
• Address pain and other discomforts.
• Redirect, reassure, and distract if necessary.
• Monitor content, e.g., TV for frightening or violent events.
• Provide a client-centered program for activities and modifying the environment.³⁷ 

Memory

• Calendars
• Schedules
• Notes
• Labels
• Bulletin boards
• Decorations
• Familiarity
• Photographs
• Music and Videos
• Current events
• Reminiscing³⁸ 

Allen Cognitive Levels

• Level 6 (Planned Activity): symbolic cues
• Level 5 (Independent learning): related cues
• Level 4 (Goal-directed activity): visual cues
• Level 3 (Manual actions): tactile cues
• Level 2 (Postural actions): proprioceptive cues
• Level 1 (Autonomic actions): subliminal cues³⁹ 

  -> See lesson and podcast on ACL Disney Mnemonic.

Reality Orientation

• “Evidence indicates that RO has benefits on both cognition and behavior for dementia sufferers.
• However, a continued program may be needed to sustain potential benefits.”⁴⁰ 
• “Health professionals and caregivers can be further educated and trained to regularly perform reality orientation therapy to improve the cognition of older people with dementia.”⁴¹ 

Principles of Dignity in Care

1. Zero tolerance of all forms of abuse.
2. Support people with the same respect you would want for yourself or a member of your family.
3. Treat each person as an individual by offering a personalised service.
4. Enable people to maintain the maximum possible level of independence, choice and control.
5. Listen and support people to express their needs and wants.
6. Respect people’s privacy.
7. Ensure people feel able to complain without fear of retribution.
8. Engage with family members and carers as care partners.
9. Assist people to maintain confidence and positive self-esteem.
10. Act to alleviate people’s loneliness and isolation.⁴² 

Coping Strategies for Caregivers

• Recognizing the person as not being “mean”.
• Changing the environment.
• Monitoring personal comfort – pain, hunger, thirst, constipation, fatigue, infection, skin irritation, temperature.
• Avoiding confrontation.
• Redirecting attention.
• Creating a calm environment.
• Allowing adequate rest.
• Acknowledging requests and responding to them.
• Look for reasons behind behavior.
• Not taking behaviors personally.⁴³ 

Additional Learning

• Occupational therapy practice in Australia with people with dementia: A profile in need of change – see Table 3 for interventions
• Effectiveness of environment-based interventions for people with Alzheimer’s disease and related dementias
• Novel occupational therapy interventions may improve quality of life in older adults with dementia

Bookmark

1. Alzheimer’s Association. (n.d.). What is Dementia? Retrieved from https://www.alz.org/alzheimers-dementia/what-is-dementia[↩][↩][↩]
2. World Health Organization. (2021). Dementia: Key Facts. Retrieved from https://www.who.int/news-room/fact-sheets/detail/dementia[↩][↩]
3. Patterson, C. (2018). World alzheimer report 2018.[↩]
4. Collaborators GBDD Global, regional, and national burden of Alzheimer’s disease and other dementias, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol. 2019; 18: 88-106[↩]
5. Wu Y-T Beiser AS Breteler MMB et al. The changing prevalence and incidence of dementia over time – current evidence. Nat Rev Neurol. 2017; 13: 327-339[↩][↩][↩]
6. Livingston, G., Huntley, J., Sommerlad, A., Ames, D., Ballard, C., Banerjee, S., … & Mukadam, N. (2020). Dementia prevention, intervention, and care: 2020 report of the Lancet Commission. The Lancet, 396(10248), 413-446.[↩]
7. Armstrong NM An Y Doshi J et al. Association of midlife hearing impairment with late-life temporal lobe volume loss. JAMA Otolaryngol Head Neck Surg. 2019; 145: 794[↩]
8. Regulation of tau pathology by the microglial fractalkine receptor. Bhaskar K, Konerth M, Kokiko-Cochran ON, Cardona A, Ransohoff RM, Lamb BT Neuron. 2010 Oct 6; 68(1):19-31.[↩]
9. The pathobiology of vascular dementia. Iadecola C Neuron. 2013 Nov 20; 80(4):844-66.[↩]
10. Neuropathological stageing of Alzheimer-related changes. Braak H, Braak E Acta Neuropathol. 1991; 82(4):239-59.[↩]
11. Gene dose of apolipoprotein E type 4 allele and the risk of Alzheimer’s disease in late onset families. Corder EH, Saunders AM, Strittmatter WJ, Schmechel DE, Gaskell PC, Small GW, Roses AD, Haines JL, Pericak-Vance MA
    Science. 1993 Aug 13; 261(5123):921-3.[↩]
12. Armstrong RA. What causes Alzheimer’s disease? Folia Neuropathol. 2013;51(3):169-88. doi: 10.5114/fn.2013.37702. PMID: 24114635.[↩]
13. Parkinson’s Foundation. (2021). Robin Williams Would Have Been 70 This Year, Here’s What We Know About Lewy Body Dementia, Suicide and Parkinson’s. Retrieved from https://www.parkinson.org/blog/awareness/robin-williams-lewy-body-dementia-suicide-pd[↩]
14. Relative frequencies of Alzheimer’s disease, Lewy body, vascular and frontotemporal dementia, and hippocampal sclerosis in the State of Florida Brain Bank. Barker WW, Luis CA, Kashuba A, Luis M, Harwood DG, Loewenstein D, Waters C, Jimison P, Shepherd E, Sevush S, Graff-Radford N, Newland D, Todd M, Miller B, Gold M, Heilman K, Doty L, Goodman I, Robinson B, Pearl G, Dickson D, Duara R Alzheimer Dis Assoc Disord. 2002 Oct-Dec; 16(4):203-12.[↩]
15. Alpha-synuclein in Lewy bodies. Spillantini MG, Schmidt ML, Lee VM, Trojanowski JQ, Jakes R, Goedert M
    Nature. 1997 Aug 28; 388(6645):839-40.[↩]
16. Pericytes control key neurovascular functions and neuronal phenotype in the adult brain and during brain aging. Bell RD, Winkler EA, Sagare AP, Singh I, LaRue B, Deane R, Zlokovic BV Neuron. 2010 Nov 4; 68(3):409-27.[↩]
17. Prevalence, incidence, and factors associated with pre-stroke and post-stroke dementia: a systematic review and meta-analysis. Pendlebury ST, Rothwell PM
    Lancet Neurol. 2009 Nov; 8(11):1006-18.[↩]
18. The epidemiology of frontotemporal dementia.
    Onyike CU, Diehl-Schmid J Int Rev Psychiatry. 2013 Apr; 25(2):130-7.[↩]
19. Frontotemporal lobar degeneration: epidemiology, pathophysiology, diagnosis and management.
    Rabinovici GD, Miller BL CNS Drugs. 2010 May; 24(5):375-98.[↩]
20. Clinic, neuropathology and molecular genetics of frontotemporal dementia: a mini-review. Pan XD, Chen XC Transl Neurodegener. 2013 Apr 19; 2(1):8.[↩]
21. Mixed dementia: emerging concepts and therapeutic implications. Langa KM, Foster NL, Larson EB
    JAMA. 2004 Dec 15; 292(23):2901-8.[↩]
22. Panca M Livingston G Barber J et al. Healthcare resource utilisation and costs of agitation in people with dementia living in care homes in England – the managing agitation and raising quality of life in dementia (MARQUE) study.
    PLoS One. 2019; 14e0211953[↩]
23. Freitas, S., Simões, M. R., Alves, L., Duro, D., & Santana, I. (2012). Montreal Cognitive Assessment (MoCA): validation study for frontotemporal dementia. Journal of Geriatric Psychiatry an[↩]
24. Morgan-Brown, M., Ormerod, M., Newton, R., & Manley, D. (2011). An exploration of occupation in nursing home residents with dementia. British Journal of Occupational Therapy, 74(5), 217-225.[↩]
25. Law M, Baptiste S, Carswell A, McColl MA, Palataijko H, Pollock N. Canadian Occupational Performance Measurement (COPM), 3rd Ed. Ontario, Canada: CAOT Publications ACE; 1998.[↩]
26. Riopel-Smith R, Kielhofner G. Occupational Performance History Interview II. Chicago: University of Illinois; 1998.[↩]
27. Brink TL, Yesavage JA, et al. Screening tests for geriatric depression. Clin Gerontol.1982;1:37-43.[↩]
28. Graff, M. J., Vernooij-Dassen, M. J., Thijssen, M., Dekker, J., Hoefnagels, W. H., & Rikkert, M. G. O. (2006). Community based occupational therapy for patients with dementia and their care givers: randomised controlled trial. Bmj, 333(7580), 1196.[↩]
29. Gelinas I, Gauthier L, McIntyre M, Gauthier S. Development of a functional measure for persons with Alzheimer’s disease: the disability assessment for dementia. Am J Occup Ther. 1999;53:471–81.[↩]
30. Li, K. Y., & Lin, L. J. (2020). Minimal clinically important difference of the loewenstein occupational therapy cognitive assessment–geriatric (LOTCA–G) in people with dementia. American Journal of Occupational Therapy, 74(6), 7406205020p1-7406205020p7.[↩]
31. American Occupational Therapy Association. (n.d.). Dementia and the role of occupational therapy. Retrieved from https://www.aota.org/about-occupational-therapy/professionals/pa/facts/dementia.aspx[↩]
32. Schaber, P., & Lieberman, D. (2010). Occupational therapy practice guidelines for adults with Alzheimer’s disease and related disorders. Bethesda, MD: AOTA Press.[↩]
33. American Occupational Therapy Association. (2017). Occupational therapy practice guidelines for adults with Alzheimer’s disease and related major neurocognitive disorders. Retrieved from https://www.guidelinecentral.com/summaries/occupational-therapy-practice-guidelines-for-adults-with-alzheimers-disease-and-related-major-neurocognitive-disorders#section-420[↩]
34. Piersol, C. V., Jensen, L., Lieberman, D., & Arbesman, M. (2018). Occupational therapy interventions for people with Alzheimer’s disease. American Journal of Occupational Therapy, 72(1), 7201390010p1-7201390010p6.[↩]
35. Brims, L., & Oliver, K. (2019). Effectiveness of assistive technology in improving the safety of people with dementia: a systematic review and meta-analysis. Aging & mental health, 23(8), 942-951.[↩]
36. Kim, Se-Yun et al. ‘A Systematic Review of the Effects of Occupational Therapy for Persons with Dementia: A Meta-analysis of Randomized Controlled Trials’. 1 Jan. 2012 : 107 – 115.[↩]
37. Khachiyants, N., Trinkle, D., Son, S. J., & Kim, K. Y. (2011). Sundown syndrome in persons with dementia: an update. Psychiatry investigation, 8(4), 275–287. https://doi.org/10.4306/pi.2011.8.4.275[↩]
38. Camp, C. J., Foss, J. W., O’Hanlon, A. M., & Stevens, A. B. (1996). Memory interventions for persons with dementia. Applied Cognitive Psychology, 10(3), 193-210.[↩]
39. Clancy, W., Chapman, R. (n.d.). Dementia Education and Training for Carers (DETC). [PowerPoint] Retrieved from https://www.dementia.org.au/sites/default/files/Final-DETC.pdf[↩]
40. Spector, A., Davies, S., Woods, B., & Orrell, M. (2000). Reality orientation for dementia: a systematic review of the evidence of effectiveness from randomized controlled trials. The Gerontologist, 40(2), 206-212.[↩]
41. Chiu, H. Y., Chen, P. Y., Chen, Y. T., & Huang, H. C. (2018). Reality orientation therapy benefits cognition in older people with dementia: A meta-analysis. International journal of nursing studies, 86, 20-28.[↩]
42. Dignity in Care. Dignity in Care. 2015. http://www.dignityincare.org.uk/.[↩]
43. Alzheimer’s Association. (n.d.). Treatments for Behavior. Retrieved from https://www.alz.org/alzheimers-dementia/treatments/treatments-for-behavior#non-drug[↩]