Definition of terms

Neurocognitive disorders, including dementia, arise from acquired changes in the brain, which lead to declines in the cognitive function of an individual. ^, They differ from mental retardation (developmental disability) in which changes arise early in life and baseline cognitive function do not necessarily decline. Though commonly associated with older adults, neurocognitive disorders in the younger population do occur, especially among individuals with human immunodeficiency virus (HIV) infection and traumatic brain injury. ^, In 2013, the American Psychiatric Association published the 5th edition of its Diagnostic and Statistical Manual (DSM-5) and incorporated concepts such as “dementia” and “mild cognitive impairment” into its revised classification system. Major neurocognitive disorder corresponds with dementia, while minor neurocognitive disorder is similar to mild cognitive impairment ( Table 27.1 ).

Major neurocognitive disorders are differentiated from minor neurocognitive disorders in the (a) severity of cognitive decline from a previous level of performance and (b) interference with independence in everyday activities. Cognitive decline in one or more domains could be expressed by the patient or a reliable informant, and/or observed by a clinician. The severity of decline could then be classified as modest or substantial using standardized testing procedures or similar objective clinical evaluation tools.

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  Modest cognitive decline: Test score between 1 and 2 standard deviations below the appropriate norm, or between 3rd and 16th percentile rank.

  
  
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  Substantial cognitive decline: Test score below 2 standard deviations of the appropriate norm, or below 3rd percentile rank.

Cognitive decline in both Major and Minor Neurocognitive disorders could manifest in one or more of these domains: complex attention, executive function, learning and memory, language, perceptual-motor-visual perception praxis, and social cognition. Recognizing early signs of decline (red flags) in any of these domains is paramount in establishing a diagnosis and formulating a timely management plan.

Delirium differs from major and minor neurocognitive disorders in its sudden and rapid onset . ^, A person with delirium shows an acute disturbance in attention, environmental awareness, and cognition from baseline; changes in sleep-wake cycle and emotional states; and worsening of behavioral problems. ^, The patient is often less alert than normal and may be sleepy or obtunded; however, many are hypervigilant and may be extremely agitated and suspicious. Early identification of the symptoms as well as formal medical assessment and treatment are critical to ensure the return of a normal level of alertness and intellectual function and to prevent the development of secondary functional impairments. ^{, ,}

Psychiatric problems may be present before old age or may develop as a result of dementia and need to be assessed and treated along with the dementia. Depression, for example, can mimic dementia and may be hard to recognize given its atypical and subtle nature among older adults. Pain, weakness, headaches, agitation, fatigue, unexpected change in weight/appetite, chronic constipation, insomnia, hypersomnia, and irritability may be observed. Table 27.2 outlines the key characteristics of delirium, depression, and dementia. ^,

Epidemiology

Currently, 50 million people worldwide have dementia, with nearly 10 million new cases every year. ^, In the United States, 5.7 million Americans and one in ten people over the age of 65 years are estimated to have Alzheimer’s disease (AD), the most common cause of dementia. ^{, ,} By 2050, the number of people with AD is estimated to increase to 13.8 million in the United States and 132 million globally, if current trends continue and no cures or effective preventive measures are found. The percentage of adults aged 85 years and older with AD will increase from 2.1 million in 2018 (37% of all older adults) to 7 million (51% of all older adults) in 2050. The prevalence of dementia rises from approximately 3% at ages 65 to 74 years to 17% at ages 75 to 84 years, and to 32% at age 85 years ^, or higher ( Fig. 27.1 ). The increasing number of people older than the age of 85 will be paralleled by an increase in the incidence of dementia. Disorders causing cognitive deficits are expected to continue to be a growing public health problem for at least the next 50 years.

Global age-standardized prevalence of Alzheimer’s disease and other dementias by sex, 2016.

(From GBD 2016 Dementia Collaborators. “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.” The Lancet Neurology, vol. 18, no. 1, 26 Nov. 2018, pp. 88–106.)

More than 70 conditions are known to cause dementia. Secondary behavioral problems in the patient with dementia can be interpreted as a response to somatic, psychological, or existential stress. Because memory impairments, impairments of abstract thinking or judgment, or global cognitive impairments in an older adult may be symptoms of acute physical illness, the patient’s physical, emotional, social, and cognitive status and physical, social, and caregiver environment need to be systematically evaluated.

Gradual or sudden changes in intellectual capacity or memory function are not a normal part of the aging process. Any change, whether it develops slowly over time or happens suddenly, should be diagnosed, and when possible, the underlying cause(s) of the delirium or dementia should be treated. Even if the cause of the dementia is untreatable, teaching the patient and significant others strategies to make the patient’s ADLs and IADLs easier to manage is always possible.

Physical and occupational therapists are an important part of the comprehensive evaluation, treatment, and caregiver training for patients with delirium or dementia. All treatment planning should occur as a part of a team effort in which the patient, the family or significant others, physician, nurses, social worker, physical therapist, and occupational therapist collaborate so that a consistent treatment plan and orientation are followed. Inclusion of the day-to-day caregivers is crucial for all training because they—more than anyone—need to know and use the adaptations for the patient’s personal style of communication and how to facilitate functional movement for ADLs and IADLs.

The normal brain

The brain of a normal person at age 80 years shows several significant anatomical, physiological, and neurochemical changes when compared with the brain of a younger person. Brain weight decreases with advancing age. Neuropathological changes, such as the deposition of senile plaques and neurofibrillary tangles, and multiple-domain cognitive decline do occur. However, such changes are not associated with significant functional limitations in healthy older people. In contrast, older people with neurodegenerative conditions demonstrate tremendous neuronal loss and substantial declines in cognitive function. Normal age-related changes vary from person to person in degree and severity and can include the following:

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  Disturbance in the ability to register, retain, and recall certain recent experiences ^,

  
  
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  Slowed rate of learning new material

  
  
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  Slowed motor performance on tasks that require speed ^,

  
  
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  Difficulties with fine motor coordination and balance

A motivated, upbeat older adult who is not undergoing emotional stress will show few negative changes in intellectual capacity and may actually demonstrate an increase in intellectual functioning over time. ^, Neuroplastic changes continue through old age and research has shown that specific parts of the brain can increase in volume, functional connectivity in the brain can improve, and cognitive performance can be enhanced if older persons are immersed in optimal experiences and exposed to enriched environments. ^,

Because many of the variables that need to be considered as part of the clinical evaluation of the rehabilitation potential of the person with dementia are affected by both aging and disease, therapists working with the older adult should be aware of these variables. The therapist explores ways to compensate for these changes; as a result, the patient will have a greater possibility of achieving her or his potential for self-care and contentment.

A slowing of the natural pace of movement is commonly noted in older adults. This slowdown is manifested in the brain as a slowing of resting electroencephalogram (EEG) rhythms (e.g., the mean frequency of the occipital rhythm is 10.3 Hz at the age of 60 years versus 8.7 Hz at the age of 80 years). The speed of nerve conduction in older adults can be 10% to 15% slower than in younger persons. Because of these physiological changes, if the process and structure of evaluation and care of the healthy older adult emphasize speed of execution or timed activities, they will appear less capable than they really are. The therapist may need more time when working with persons older than 70 years than is generally required with younger individuals.

The brain is the most physiologically active organ in the body. The brain represents only 2% of the total body weight, yet it consumes up to 20% of the oxygen and 65% of the glucose available in the circulation in the entire body. The minimal cardiovascular output required to deliver this is 0.75 L/min, which is equal to 20% of the total circulation (also dependent on body size). Because of the high level of nutrient use by the brain, it is one of the organs of the body most likely to be affected by any acute change in homeostasis. The homeostasis of the older adult brain is more vulnerable to disruption because of the normal age-related changes already discussed, as well as the increased permeability of the blood-brain barrier and increased sensitivity of neurons to the effects of outside agents such as drugs, food, and allergens.

Arndt-Schulz principle

The Arndt-Schulz principle summarizes the differences between the abilities of the younger brain and the aged brain to discriminate or respond to stimuli. In older adults, a higher level or a longer period of stimulation is required before the threshold for initial physiological response is reached. Their physiological response is rarely as large, as visible, or as consistent as noted in younger individuals. The implication of the Arndt-Schulz principle for clinical problem solving is that the level of a stimulus (e.g., heat, cold, sound, light, or emotional input) needs to be adjusted to compensate for the altered physiology of the older adult patient. Optimal balance of the levels of sensory stimulation and emotional stimulation that is therapeutic for a young person may not be therapeutic for the older adult. The stimulus may be too low so it does not reach the threshold for generating a physiological response, or it may go beyond the safe therapeutic range for the older adult and become harmful. Therefore when an older adult patient does not respond to treatment or presents an unusual physical response, the clinician needs to ascertain whether the strength of the stimulus is too strong or too weak and whether modification of the stimulus is necessary because of factors associated with the aging process or the patient’s cognitive deficits (e.g., he or she may be unable to accurately report the response because of a cognitive deficit). The older person with mild or moderate confusion needs small, slow clinical input and precise monitoring of the general response (heart rate, blood pressure, and respiration) as well as of the local response. This adjustment in approach is especially important for people with hearing impairment. Because the patient may not hear what is being spoken, the therapist may assume that the patient does not have the capability to comprehend what is being said.

Law of initial values

The law of initial values is both a physiological and a psychological principle stating that with a given intensity of stimulation, the degree of change produced tends to be greater when the initial value of that variable is low at the onset of stimulation. Therefore the higher the initial level of functioning, the smaller the change that can be produced. ^, The law of initial values, when defined and applied to younger individuals, presumes that homeostasis is a stable and consistent process. When the law is used to describe physiological and psychological responses in older adults, it cannot be presumed that homeostasis for any variable is predictable or consistent from one person to the next, or even within a 24-hour period for the same individual. For example, an older person with mild dementia may eat only sweets if left without companionship at a meal. As a result, after the meal, the individual may feel unsteady and afraid to walk back to the room.

Biorhythms

The brain has a biological clock that controls all physiological functions in a precise temporal course, whether daily (e.g., secretion of some hormones), monthly (e.g., menstruation), or during a certain period of the life cycle (e.g., ability to become pregnant) . Before evaluating an older adult patient with dementia or a disturbance of intellectual functioning, assessment of the patient’s premorbid biorhythm is helpful. What was his or her daily schedule of activities before the medical crisis? An assessment or time study can map such things as rest periods, activities and level of exertion, sleep or rest periods, mental stimulation, emotional stimulation, eating, and elimination cycles across a 24-hour period. The patient assessment must allow for and assess the current and past variability of individual biorhythms. These biorhythms should be clearly documented, and their stability should be evaluated and maintained as much as possible (critical if the patient will be going back to the family). Defining the peak times of day for awareness and intellectual capacity for each individual is necessary. For example, some patients are best able to participate in learning a new skill in the early morning, and some only in the late afternoon. If a woman has worked for 40 years as a night nurse, being primarily active from 11 p.m. to 7 a.m., she will most likely be alert and best able to participate in a rehabilitation program during those hours. In most cases the patient should be allowed to choose the best time for treatment. For patients whose dementia is too severe for them to make this determination, the staff can monitor the patient’s behavior and choose a time for treatment when the person is most alert. For older adults with dementia, the time of assessment and treatment must be documented to maximize the person’s rehabilitation potential. ^,

Cognitive changes in normal aging

The idea that cognitive decline is a necessary part of aging is a myth. This belief has been debunked by research on crystallized and fluid intelligence. ^, Crystallized and fluid intelligence are components of general intelligence. Crystallized intelligence involves the ability to perceive relationships, engage in formal reasoning, and understand intellectual and cultural heritage. Crystallized intelligence can be affected by the environment and the attitude of the individual. Crystallized intelligence can increase with self-directed learning and education as long as a person is alive. The measurement of crystallized intelligence is usually in the form of culture-specific items such as number facility, verbal comprehension, and general information.

Fluid intelligence, what has been called “native mental ability,” is the product of the brain’s information processing system. It includes attention and memory capacity and the speed of information processing used in thinking and acting. It is not closely associated with acculturation. It is generally considered to be independent of instruction or environment and depends more on the genetic endowment of the individual. The items used to test fluid intelligence include memory span, inductive reasoning, and figural relationships, all of which are presumed to be unresponsive to training. Because fluid intelligence involves those intellectual functions most affected by changes in neurophysiological status, it has been generally assumed to decline with age. Several studies have shown this to be untrue; one study noted that during middle age, scores on tests for fluid intelligence are similar to scores in midadolescence. ^, These changes, however, are primarily associated with processing speed, working memory, and executive function. ^,

Studies on the effects of cognitive changes in activities have shown that older people perform activities at a slower rate and use different areas of the brain in the process compared with younger people. Those additional areas of the brain used have mostly to do with monitoring and processing the ongoing activity. ^, Activities are therefore performed more in a feedback rather than a feedforward manner, which also requires more time. So, if older adults are given time to complete tasks, they usually do well.

Botwinick described the classic pattern of changes in intelligence with aging. In the adult portion of the life-span, verbal abilities decline little, if at all, whereas psychomotor abilities decline earlier and to a greater extent (greater decline if the individual is not engaged in regular physical activity). The period between ages 55 and 70 years is a transition time, and some decreases in performance are noted on many cognitive tests. A substantial decline on laboratory tests of cognitive function is generally limited to those older than 75 years. In these latter years, however, the decline in fluid intelligence is offset by the growth in crystallized intelligence for most people unless dementia is present ( Fig. 27.2 ). Although changes may be demonstrated in the laboratory, they may not be significant in the “real world,” and the older adult may be as capable as the young of participating in rehabilitation training. For older adults to benefit maximally, however, they must control the pace of training because the tasks that are the most difficult for older adults are those that are fast paced, unusual, and complex. All physical and occupational therapy treatments with older patients need to be structured to encourage the patient to set his or her own pace. The goal is to have a pace that allows ease of breathing and a comfortable, functional upright posture so that the person can enjoy the experience. Interventions should be predictable and progress by adding one new concept at a time.

Gains in crystallized intelligence throughout adulthood compensate for potential declines in fluid intelligence.

(From Avers D, Williams A. “Cognition in the Aging Adult.” Geriatric Physical Therapy, Elsevier Mosby, 2012, pp. 132–134.)

Stress and intellectual capacity

Selye defined stress as the nonspecific response of the body to any demand made on it. All human beings require a certain amount of stress to live and function effectively. When a stressor (stimulus) is applied, the body predictably goes through the three stages of response called the general adaptation syndrome (GAS). The first response is a general alarm reaction, a “fight-or-flight” response that mobilizes all senses in an effort to make a judgment about the response needed. The older person is at a disadvantage because collecting and processing accurate sensory data are decreased with normal aging owing to short-term memory loss. The sensory memory in an older person lasts less than 1 second. The next stage involves judgment and the selective adaptation to the stressor. A decision is made regarding which action is needed, and all other bodily activities return to homeostasis. If the stimulus continues and goes beyond the therapeutic or functional level, then the body system or part will gradually experience physiological exhaustion. A person in physiological exhaustion is likely to manifest abnormal responses to any new stimulus.

When a person is under perceived stress (whether real or imagined), a predictable set of cognitive changes can occur such as preoccupation; forgetfulness; disorientation; confusion; low tolerance to ambiguity; errors in judgment in relation to work, distance, grammar, or mathematics; misidentification of people; inability to concentrate, solve problems, or plan; inattention to details or instructions; reduced creativity, fantasy, and perceptual field size; decreased initiative; decreased interest in usual activities, the future, or people; and irritability, impatience, anger, withdrawal, suspicion, depression, and crying. Differentiating whether the patient is having a stress reaction or has dementia is critical. If the changes occur with a sudden onset, they are probably related to a medical or pharmaceutical problem, which may be indicative of delirium and amenable to intervention.

With aging, the brain undergoes physiological changes that make the older people less physiologically efficient in her or his response to stressors. The general alarm reaction is poorly mobilized and takes longer to become activated (Arndt-Schulz principle). The stage of resistance should yield a series of responses that allows the body to economize in its response to stress. In persons of all ages who receive too many different stimuli and in older adults who experience normal levels of stimuli, the body becomes less efficient at turning off the general alarm response and replacing it with more appropriate and limited responses. When a person is overwhelmed by this type or level of stress, the individual may demonstrate mild global or specific cognitive impairments, especially mild short-term memory loss.

The assessment of an older adult, with or without dementia, must include a determination of the type, number, and severity of the patient’s current stressors. Positive life events (e.g., marriage or the birth of a grandchild) are also stressful life events. Scores that rate stressful life events can identify patients who are at greatest risk of physiological and emotional exhaustion. Developed in the 1970s, the Holmes-Rahe Social Readjustment Rating Scale is still a commonly used life stress evaluation tool (see www.stresstips.com ). Older adults, with their numerous psychosocial problems and chronic and acute illnesses, are likely candidates for physiological and emotional exhaustion and the development of psychopathology. Thus the environment and process of rehabilitation need to be modified to counteract the effect of stress on the intellectual capacity of the older adult patient. Any action that modifies stress so that a deterioration of intellectual function is stopped or reversed is an efficient and cost-effective part of the total rehabilitation effort.

Screening tests for cognitive impairment

The Mini-Mental State Examination (MMSE) provides a screening test for identifying unrecognized cognitive disorders in older adults. The MMSE assesses only cognition and can identify whether the patient is oriented; remembers (short term); and can read, write, calculate, and see and reproduce in drawing the relation of one object or figure to another. The MMSE may also be used in a serial fashion to quantify changes in a patient’s cognitive status over time. All caregivers must be part of the team effort to get a real 24-hour picture of the cognitive capacities of the patient. This examination can be used as a springboard for planning how to carry out the traditional rehabilitation evaluation of a patient who has some intellectual dysfunction. ^,

The MMSE has been standardized for older adults living in the community, with scores correlating significantly with the Wechsler Adult Intelligence Scale and the Wechsler Memory Test. It has been found that when a cutoff score of 24 is used for the detection of dementia, the MMSE had a sensitivity of 87.6% and a specificity of 81.6%. Several studies have noted that interviews with informants are highly consistent with older adults’ scores on the MMSE.

The entire examination grades cognitive performance on a scale from 0 to 30. A score of 24 or less usually indicates some degree of cognitive dysfunction, but some patients with dementia may score above 24 and some with depression or delirium may score significantly below 24. A low score on this examination can mean that the patient probably has dementia, delirium, mental retardation, amnestic syndrome, or aphasia. A low score on the MMSE can indicate the areas of specific cognitive impairment and gives the rehabilitation team data about how to best communicate with the patient. MMSE scores are also correlated with educational level, with scores dropping 10% to 20% for people with an eighth-grade education or less if older than 70 years. A shortened version of the MMSE has been developed that uses only 12 of the 20 original variables.

The MMSE was freely available when it was first released in 1975, but its developers have since enforced copyright use restrictions ^, (USD 81 for 50 test forms, as of 2018). Fortunately, a growing number of screening tools have been developed and could be used as possible alternatives to the MMSE. ^, Free educational versions of the MMSE are widely available on the Internet, including sites such as those maintained by Oxford Medical Education. In 2013, the Alzheimer’s Association formed a workgroup to develop recommendations that would operationalize cognitive assessment in the primary care setting. As mandated in the Patient Protection and Affordable Care Act of 2010, Medicare beneficiaries can avail an Annual Wellness Visit (AWV), which includes the detection of any cognitive impairment by assessing an individual’s cognitive function. The assessment should be done using direct observation while taking into account information obtained subjectively from the patient, the patient’s care providers, family, friends, and others concerned. The workgroup identified the Memory Impairment Screen (MIS), General Practitioner Assessment of Cognition (GPCOG), and Mini-Cog as suitable brief cognitive assessment tools in primary care. All three tools require less than 5 minutes to administer, have been validated in a primary care setting, have good-to-excellent psychometric properties, and do not require permission or payment for copyrights when used in the clinical setting. Clinicians may also select from a number of alternate tools in Box 27.1 and supplement the information with those obtained from a patient informant using the Ascertain Dementia 8-item Informant Questionnaire (AD8), GPCOG informant score, and short Informant Questionnaire on Cognitive Decline in the Elderly (Short IQCODE). Patients who present with any indication/s of cognitive impairment would need to be referred for further evaluation, as shown in Fig. 27.3 .

Alzheimer’s Association Medicare Annual Wellness Visit Algorithm for Assessment of Cognition.

(From Avers D, Williams A. “Cognition in the Aging Adult.” Geriatric Physical Therapy, Elsevier Mosby, 2012, pp. 132–134. In the book this is Figure 8.2 .)

The recent American Academy of Neurology guideline on mild cognitive impairment (MCI) recommends the assessment for MCI in cases wherein a patient and/or a close contact voices concern about memory or impaired cognition. The guideline further emphasizes that clinicians not assume such concerns as a part of normal aging. Validated assessment tools should be used in the screening process, and if positive, more formal clinical assessment should follow. The guideline cautions against a premature diagnosis of dementia in the absence of functional impairments and detailed testing. Lastly, clinicians lacking experience and training in assessing cognitive impairments should refer patients suspected of having MCI to the appropriate specialist. A summary of the practice recommendations is outlined in Table 27.3 .

Sensory and perceptual changes with dementia

Patients with dementia may have specific problems that inhibit the integration of sensory input. Aphasias and disruption of association pathways may inhibit the patient’s ability to integrate accurately perceived sensory information in a meaningful way. Patients with AD, multiinfarct dementia, and alcoholic dementia may demonstrate disturbances in visual acuity, depth perception, color differentiation, and differentiation of figure from ground when compared with normal age-matched control adults and normal younger adults.

An assessment of specific sensory systems is necessary when a person demonstrates cognitive losses. The challenge in rehabilitation is to design a process and environment of care so that compensation and modification maximize the ability of the older adult with sensory deficits to adapt to most life situations. The example of visual deficits is a case in point. One of every two blind persons in the United States is older than 65 years (see www.afb.org/ and click on AFB senior site). Techniques of environmental adaptation and special measures to organize care to help blind older adults have allowed many of them to live independently in the community. However, many older adults with visual impairments are not blind. Some of the structural changes that result in mild to moderate deficits of vision include yellowing; uneven growth, striation, and thickening of the lens; increasing weakness of the muscles controlling the eye; alteration in the perception of color (especially fine distinctions in tone and brightness); and slower adaptation to light. Modifications of the environment can include adequate effective lighting (including adequate intensity and controlling of reflection), dark and clear large-print, low-vision aids (e.g., magnifying glass), verbal orientation and escort by persons accompanying patients in a new environment, consistent furniture placement, explanation when changes occur, clear hallways, a systematic storage system for clothes and toilet articles, and the use of consistent contrasting colors to identify doors, windows, baseboards, and corners.

Older adult learning styles and communication

Learning occurs throughout life. In physical and occupational therapy, habilitation occurs when the patient learns new skills, and rehabilitation occurs when the person relearns old adaptive skills. As with intelligence, the learning process does not change abruptly when an individual reaches old age, but differences in performance have been reported. One challenge for rehabilitation therapy is to find ways to improve the efficiency of learning by the older person ( Box 27.2 ).

Learning and performance are not the same. Poor performance on a learning task may mean that insufficient learning has occurred, that learning has not transferred to a new environment or task, or that the performance does not accurately reflect the extent of learning achieved. The key variables that affect a person’s ability to participate in a learning task can include intelligence, learning skills acquired over the years, and flexibility of learning style. Noncognitive factors can also have a strong bearing on an individual’s performance. The noncognitive factors include visual and auditory acuity, health status, motivation to learn, level of anxiety, the speed at which stimuli and learning is paced, and the meaningfulness to the individual of the items or tasks to be learned. Research has shown that learning styles change over the life-span and that people learn better when instructional approaches are matched to their learning style. Therefore a rehabilitation assessment needs to include a review of the preferred learning style of the patient. This strategy is particularly important before discharging a patient from a rehabilitation program. The rationale is that a lack of progress may not reflect the patient’s lack of capacity for rehabilitation but rather may reflect a dissonance between the patient’s learning style and skills with the presentation of materials in the treatment program (e.g., verbal input has not been adapted to match the level or pace of comprehension of a person who may have a strong preference for visual learning and slower pace).

Interference

Interference can make the learning process less efficient in two major ways. First, interference can result from a conflict between present knowledge and the new knowledge to be learned. Second, if the task to be learned has two or more components, secondary components may interfere with the learning of primary components. This situation is particularly true if secondary components overlap in time or use the same sensory modality. Older adults have special difficulties if they must concentrate on intake, attention, and retrieval processes at the same time. Therefore the process and therapeutic environment of rehabilitation for the older adult patient must not be disturbed by background noise, other stimuli in the environment, or anxiety. When learning a new task, the older adult patient may require a quiet room with no stimuli other than that offered by the therapist. The need to rid the environment of distractions is particularly important when working with an older adult patient with dementia because this patient will have greater difficulty filtering out irrelevant sensory input compared with other patients without dementia.

Pacing

The pacing of therapeutic intervention is a significant variable in helping an older adult learn. Older adults (with or without dementia) perform best if they are given as much time as they need and when learning is self-paced. The major drawback of a fast pace (as perceived by the patient) is that an older adult generally chooses not to participate rather than risk making a mistake. A lack of response by the patient is often interpreted as apathy, poor motivation, or “confusion.” Patient participation is increased when extra time to complete a rehabilitation task is offered. After the individual assessment, group work (where concepts can be presented, reviewed, and examined at leisure) also can be used to reduce the psychological pressure of faster paced one-on-one learning. The details of therapy must be planned carefully, including how questions are asked (this involves asking clear and precise questions in nonmedical language) and, most importantly, setting aside enough treatment time so the patient can respond at a manageable pace.

Organization

If data are organized in the brain as part of the learning process, the retrieval of these data becomes easier. Older persons are less likely than members of other age groups to organize data spontaneously to facilitate learning and later retrieval (memory) of that learning. Older adults who are highly verbal show fewer weaknesses in the ability to organize stimuli. Older adults with poor verbal skills show significant improvement in data retrieval when strategies for data organization are provided by others (e.g., the therapist). In addition, organizing therapy by beginning with an overview of the entire lesson may be helpful as this presents a conceptual map of the learning experience. Older learners have difficulty following content because they cannot anticipate what will be taught and do not see the “whole picture” of what is being presented. The use of purposeful organizing can help bridge the gap between what the older person knows and the new information or task to be learned. This is an example of how organization may influence the learning process.

Inefficient learning and, at times, an inability to learn occur in the older adult if material is presented in one way and the older person is expected to apply it in some other way. Instructions need to be provided in the format and context in which they are to be used. If possible, pieces of new data should be presented one at a time. A conscious transition needs to be made by the therapist from the patient’s current frame of reference to the understanding of the new data, and the pace needs to be set by the patient.

Several other strategies exist for maximizing the efficiency of older adult learners based on awareness of normal age-related changes. Some of the more frequently used techniques are summarized in Box 27.2 .

Communication

Therapists can begin by inquiring into what the reality of the patient looks like. The first goal should be to communicate with words, gestures, positioning, and so on, so that stimuli bring out functional responses in the patient.

The therapist needs to be sensitive to the entire communication—what is said and what is withheld. The patient with cognitive problems may not understand the content, but many patients still have the ability to sense and respond to the therapist’s affective state at the moment. When beginning communication, be clear of all previous concerns and bring no extraneous emotions into the interaction. Caregivers and therapists bring into the conversation the power of intention to create a therapeutic interaction and the choice to stay on task. Patients bring their own set of concerns at any particular moment. Knowing something about the patient’s concerns helps the process.

Therapists and caregivers need to be self-aware. What is the therapist’s favorite strategy for communication? What is the therapist’s favorite sentence structure? Our habitual forms of presentation need to be assessed with regard to whether they are effective, because the patient needs to be the focus of attention. Honoring the communication habits of the patient is necessary if effective communication is to occur with a person with cognitive deficits. If the therapist chooses to speak to the patient as if there were no cognitive deficits, consistent results will not occur, and the patient may be upset or agitated. The patient could be approached as if he or she were a person from another culture that has its unique customs, norms, and ways of communication. The patient-therapist interaction becomes an inquiry in which success is measured by the achievement of functional outcomes that are needed and wanted (e.g., the patient transferring into bed and feeling safe).

Now the question becomes what is the specific process of interaction with which the patient appears to be most comfortable and feels safe? Every patient is different, and it may depend on the time of day or whether the patient is feeling tired or threatened. Persons commonly respond best to one particular style of communication and are predictably upset or agitated by another style. If a patient wants to joke around and be playful, this should be a cue to staff that this is a workable style of communication. Another patient smiles whenever the tone of the conversation is soft, nurturing, and tender, and if staff is willing, this is where ease of relating can occur. Other patients relate best to rules and need predictable structures and boundaries. They love to know what is coming next. Still another category is people who can relate and communicate when definite admiration and respect are built into the conversation or when patient and therapist can agree to disagree. Each patient with cognitive problems needs to have caregivers develop a chart of what works to create a sense of relatedness and ease in communication. A challenge here for caregivers is that the patient’s abilities can change; guidelines for communication when new caregivers are introduced to the patient can also be helpful. Someone who is familiar and enjoys interacting with the patient should introduce new staff to the patient.

For people with cognitive disturbances, familiarity and rituals are keys to the ease of adaptability. The basis for rituals is well-organized documentation to which all caregivers have access and contribute on an ongoing basis. This information needs to be filtered and organized so that each shift can see what is working for the patient today. Even a nonverbal patient can relate effectively to bathing if a ritual exists regarding dressing and undressing (e.g., the socks always come off first). Another detail that requires staff or caregiver attention, evaluation, and adaptation in daily care is ideational apraxia. LeClerc and Wells described this as “a condition in which an individual is unable to plan movement related to an object because he or she has lost the perception of the object’s purpose.” Consideration is especially important in relation to feeding, dressing, toileting, and bathing. The authors described a tool that can help caregivers assess ideational apraxia and problem-solving compensations to prevent unnecessary agitation or disability and take actions to preserve existing abilities. Savelkoul and colleagues emphasized the importance of effective communication between staff and patients and the importance of routines for patient care to maximize functional behaviors for institutionalized older adults living in residential homes.

As a patient goes through gradual deterioration of cognitive status, as is common in AD, staff, family, and caregivers must be trained in nonverbal, positional, and manual cues and emotional communication techniques. Many patients come to a place in their lives with dementia when words are a source of confusion. Other strategies to communicate should then be used. Sign language is initially a possible tool until the associative functions begin to disappear. Accurate assessment needs to create adaptations in communication. It may be necessary to use hand-guided communication, in which the patient is led through a task or parts of a task to get his or her cooperation. At this stage of communication, ease and trust are the most important goals. It may take 5 minutes of tenderly holding a patient’s hand before the patient is ready to walk to the dining room or bathroom. This strategy requires much patience on the part of caregivers. Positional communication can be used as well as simple touch. As patients begin to feel safe with their state of being, they will relax and choose to participate. At times, patients have unique needs, such as only wanting to be cared for by a female caregiver or a male caregiver. Honoring patient needs is critical because the cognitively impaired may not be able to learn or adapt to the demands of the staff member because of previous trauma (assault or incest, real or imagined).

As a way to summarize the considerations regarding communication with a person with cognitive impairment, therapists may find it useful to examine their own intentions from moment to moment. “What is my goal in this interaction?” “Who am I being at this moment?” The task may be important, and the “doing” of it may be critical. For the patient with cognitive disturbance, therapists must provide life-enhancing stimuli on the basis of the patient’s perceptions. If in the zeal to “do,” the patient is accidentally scared, intimidated, or bullied, the damage may not be able to be undone. The patient with cognitive impairment presents a unique challenge if a threat has been created, because reestablishing their trust is often difficult. Often, the patient may be afraid of the therapist and simply needs the therapist to leave the room for some time. The saving grace for many patients is that their short-term memory is poor so they may not remember the incident tomorrow. The problem with agitation occurs when other patients who are cognitively impaired in the area also get upset.

The solution to the crisis moment, when a breakdown in communication has occurred, is to redirect communication and the focus of the present moment effectively. For example, a staff member could purposely bump into a chair and knock it over, drop a cup of water or a book, start to sing, whistle loudly, or clap his or her hands. At that moment, a distraction is created. If the distraction works, then the patient’s attention is pulled away from his or her old thought and focused to a new topic. At that moment, the staff needs to be intentional. The new focus needs to offer comfort or nurturing or a predictable sense of well-being (e.g., helping to clean up, eating some food, looking at a picture of a favorite thing, holding a favorite item, touching a favorite comfort object, hugging).

Hypothermia

The temperature of the living environment must be carefully controlled because older adult patients may not perceive that the environment is cold and may not experience shivering. Accidental hypothermia can develop in an older person even at temperatures of 60°F (15.5°C) to 65°F (18.3°C). Accidental hypothermia is a drop in the core body temperature to less than 95°F (35°C). Patients at risk for hypothermia are presented in Box 27.3 .

The symptoms of hypothermia may include a bloated face, pale and waxy or pinkish skin color, trembling on one side of the body without shivering, irregular and slowed heartbeat, slurred speech, shallow and slow breathing, low blood pressure, drowsiness, and symptoms of delirium. The two principles of treatment of hypothermia are that the person will stay chilled unless the body temperature is slowly increased and that he or she should be evaluated by a physician, regardless of the apparent severity of the hypothermia. ^,

If a person continues to be at risk for hypothermia, specific measures can be taken to prevent subsequent distortions of cognitive status. First, the room temperature should be set to at least 70°F (21°C). Second, the person should wear adequate clothing; this may include long underwear and an undershirt. Adequate nutrition also may be a factor in preventing hypothermia.

Patients and their caregivers may attempt to save money by lowering room temperatures and thus inadvertently cause hypothermia. To prevent accidental hypothermia in institutions with central air conditioning, special accommodations for older adults, such as a special wing of the building or individual temperature controls in the rooms, are required.

Transplantation shock

Some older adults seem to function well in a familiar environment but become severely disoriented and unable to perform ADLs if taken out of their own homes. As a general rule, these persons have mild symptoms of dementia that are not readily apparent when they remain in a structured, familiar, stable environment and maintain a consistent daily routine. When faced with the need to adapt to a new environment bombarded with multiple unfamiliar sensory stimuli, however, their limited brain capacity is unable to make sense of the large volume of new stimuli. If a patient was oriented before admission to an institution and then becomes disoriented, the patient’s cognitive functioning will likely return to its baseline level of functioning on return to the familiar environment. Therefore all moves by a patient from one hospital room to another or from one institution to another, and all changes in a treatment regimen, need to be carefully planned. If a change is anticipated, the patient should be involved in the decision making. If the change is a permanent move, the patient needs to have a chance for one or two trial visits before the actual move. The patient needs to be informed of all changes well in advance, and this information needs to be given repeatedly to the patient with dementia. The precautions mentioned can help the patient relocate without creating transplantation shock and any related negative cognitive and emotional changes.