Symptomatology in Practice in the Case of Dementia




(1)
Neurorehabilitation Centre at CNA, Breda, Noord-Brabant, The Netherlands

 




3.1 Introduction


Dementia is a pathology with which the physiotherapist will increasingly come into contact. In the Netherlands, the predicted total of elderly patients with dementia lies at about 240,000 for 2015. In the same year, 28 patients per family doctor’s practice will have been diagnosed with dementia. Of these, 18 patients will still be living at home. According to the forecasts, the number of dementia patients will have almost doubled by 2050.

Previously dementia patients were generally admitted to a nursing home, but the current generation of elderly people prefers to continue to live in their own surroundings for as long as possible, and the Dutch government is aiming to allow these people to live for as long as possible in their own homes. The criteria for admission to a care or nursing home have thus also become stricter. This, in combination with the increase in the number of dementia patients, means that in the future both first-line physiotherapists and those in rehabilitation centers will be dealing with elderly dementia patients. Insight into this pathology is necessary, on the one hand, in order to conduct good interventions and, on the other hand, to be able to fulfill an identifying function when a patient is suspected of developing dementia.

Dementia is a pathology that is progressive, where in the first stage, depending on which form of dementia is involved, but with Alzheimer’s in particular, the cognitive function declines. To allow dementia patients to preserve the contact with their family and friends as much as possible, specific approach strategies have been developed for the different stages of the disease. This is the reason why this chapter is structured in a different manner to the previous two. Firstly, we state when the diagnosis of dementia can be determined. This is followed by a description of the different dementias and the course thereof. In ► Sect. 3.3 ◘ Table 3.1 shows a schematic overview of how you can recognize the different forms of dementia. Also the importance of insight in these different forms is stated. At the end of this section, specific approach strategies are described that can be used in the several stages of the dementia, and the term paratonia is explained.


Table 3.1
Schematic overview of the symptomatology of the various dementias



























































Symptoms

Alzheimer’s dementia

Vascular dementia

Lewy body dementia

Memory

Memory impairments (mild) that increase

In the beginning not an obvious symptom in the foreground

Slowed retrieval of information

Speech

Intact, but sometimes disoriented

Slowed, word finding problems

Monotonous and hypophonia

Orientation

Becomes distorted

Not necessarily

Good

Motor skills

Seems intact, but praxis ↓

Praxis and planning of actions ↓

Motor skills resembling those of Parkinson’s patient

Taking initiative

Diminished on the basis of loss of interest

Diminished on the basis of depression

Not disrupted at the initial stage

Depression

Normal, sometimes even euphoric

Present because of good awareness of disease

Unknown

Awareness of disease

Diminished presence

In the initial stage good

In the initial stage good

Muscle tone

Initially normal muscle tone

Muscle-tone dysregulation

Rigidity

Course

Gradual

Erratic course with ups and downs

Rapidly progressive


3.2 Diagnosis of Dementia


Dementia is a clinical syndrome in which the diagnosis can be determined when a number of symptoms occur simultaneously. The symptoms may not be a consequence of psychiatric impairments; they must occur when the person is fully conscious and should have an inhibitive influence on the social participation of the patient (APA 2004).

The symptoms that appear are:



  • Memory problems


  • Disturbed orientation


  • Impairments in the higher cortical functions, such as speech and perception


  • Actions and disturbances in executive functions (e.g., planning and organization)


3.3 Various Forms of Dementia


There are several forms of dementia:


  1. 1.


    Alzheimer’s dementia (70%)

     

  2. 2.


    Vascular dementia (20%)

     

  3. 3.


    Lewy body dementia (10%)

     


3.3.1 Alzheimer’s Dementia


Alzheimer’s dementia is the commonest form. The accumulation of amyloid plaques between the nerve cells in the brain is characteristic of this disease. Amyloid is a protein fragment that is created by the body and which is normally broken down in the brain. The breakdown of this protein fragment is disrupted in Alzheimer’s patients, and in fact an aggregation of these fragments occurs. This aggregation of protein fragments takes place between the nerve cells. One consequence is that there is a disruption in the information processing between the nerve cells in the brain.

Tau proteins stabilize the microtubules that form part of the cytoskeleton of the neuron. When tau proteins become defective and insoluble, they can form neurofibrillary tangles. These tangles contribute to the pathology of Alzheimer’s disease by interrupting the transfer of information along the nerve fibers. Tangles destroy a vital cell transport system made of proteins.

The American Alzheimer’s Association offers an explanation for the consequences:

In healthy areas:

The transport system is organized in orderly parallel strands somewhat like railroad tracks. Food molecules, cell parts and other key materials travel along the “tracks.” A protein called tau helps (…) keep the tracks stay straight.

In areas where tangles are forming:

Tau collapses into twisted strands called tangles. The tracks can no longer stay straight. They fall apart and disintegrate. Nutrients and other essential supplies can no longer move through the cells, which eventually die.


Initially with Alzheimer’s disease, cognitive problems predominate, such as memory and orientation problems. However, problems with motor skills occur earlier than is generally assumed. These motor problems are expressed especially at the skill level as a result of problems with planning activities or a mild form of apraxia. The physiotherapist must be aware of this, because a combination of motor impairments and memory and orientation problems can be an indicator of emerging Alzheimer’s dementia. This is, namely, not only attributable to normal biological aging processes.


Interlude

I want to ask her something, but she has already left the room. Ten minutes. The big hand is pointing to seven. When it gets to nine, that will be 10 min. But what then? What needs to happen? I close the book and push it away from me. I stare at the black hands on the gold-colored wall clock. There is no second hand on it. It seems as if the clock is standing still. It is a modern one; it doesn’t tick.

I go to the kitchen, sit down at the kitchen table, and look at the bright red kitchen clock on the wall, an electric one with a gold-colored second hand that ticks its way around the dial with slight twitches. I do not let my eyes stray from it for a moment. I have always been a man of the clock. Punctual. You cannot say that about others.

One more time and the big hand will be on nine. Then the 10 min will be up. It is there. I stand up and walk into the living room.

«Vera,» I call, «time’s up.» I walk through the room into the hall. «Vera, Vera, the 10 min are up, » I call as calmly as possible. Then I hear her answer coming from the bedroom. «Turn the oven off then, will you.»

I do not know how fast to get back, to carry out her instructions. When I hear the rushing sound of the gas cease, I sit down at the kitchen table with a sigh of relief. It’s only thanks to her that I’ve been able to carry out this task. Otherwise I wouldn’t have known what I had to do. That you can suddenly be so alienated from the most everyday actions worries me. I have no explanation for it.

From: Hersenschimmen [Out of Mind]


Course

Before memory impairments become clear with Alzheimer’s dementia, both the patient and those immediately involved with the patient indicate that there is a decrease in interests. The suspicion is that there is an underlying depression. The patient himself is unable to properly indicate what is actually happening. As long as the patient in daily life continues to function normally or his functioning is at most somewhat odd, the diagnosis of dementia cannot be made (APA 2004).

Forgetfulness that deviates from biological aging and a slight euphoric feeling can be indications of an emerging dementia. Normally we can store about seven things in our short-term memory and then reproduce them. In dementia patients, that is limited to two or three. In such a case, there is a mild cognitive impairment (MCI) (World

Health Organization). People with MCI are not demented, but do have a five to six times increased risk of developing dementia (Chertkow 2002).

When someone with MCI is removed from his or her own direct environment, for example, when there is a sudden admission to hospital, you see that the functioning deteriorates. This is also known as «cascade breakdown.» The memory problems can suddenly become much more prominent and have a restrictive influence on daily functioning. Apparently there seems to be an acute dementia. In reality the memory problems already existed, but had not yet been recognized as such. If the person concerned is removed from his trusted environment, the limitations in ADL then come to light. This proves that a safe trusted environment contributes to better functioning.

As the disease progresses, language will give rise to problems, not only in terms of comprehension, but language processing will also require extra time. The patient does not notice an incorrect answer on a question, and he tries out with all kinds of evasions and excuses to avoid answering the question. This is called «façade behavior.» This occurs frequently with Alzheimer’s dementia.

With increasing disease progression, the patient loses the control over his life. The family or home care must increasingly often lend a hand, and activities such as cooking, dressing, and washing become ever more difficult. The next stage is disorientation in time, place, and person. This disorientation can lead to straying or restlessness, and in some cases this lead to dangerous situations. Continuing to live in the trusted environment will cost those directly involved a lot of energy.

In a further stage, the patient encounters difficulties caused by aphasic problems. He can no longer come up with the names of acquaintances or objects. The vocabulary declines and sentence structure is weak. Reassurance is no longer understood and the restlessness increases. When the nocturnal restlessness increases, this leads to intolerable situations, and admission to care is indicated.

A whole process precedes the decision to admit to care, but then it is still a very serious decision. Admission to a protective environment, such as small-scale living projects, or in the nursing home represents a definite farewell to daily living. It is a difficult decision that has to be taken by those most closely involved for another person.

The progression of the dementia continues, and eventually the cerebellum falls prey to the disease process and substantial motor problems arise. The patient becomes increasingly stiffer, dependent on a wheelchair or bedridden, and adopts a fetal position. Often he is unable to lift his head anymore and dependent on the care staff to feed him and give drinks. The patient becomes incontinent for both urine and feces and in the end is so weakened that he dies.


3.3.2 Vascular Dementia


A number of processes lie behind the occurrence of vascular dementia. It can arise on the basis of an arteriosclerotic process, through multiple small infarctions or because of a leak in one of the small blood vessels. As these processes progress, brains become dysfunctional and memory impairments become clearly visible. This happens in combination with other higher cortical functions that become disrupted, such as speech, perception, action, and problems in the executive functions.

Apart from disruptions in the brain cells, the connections between the brain cells are also disrupted. These connections consist of long nerve endings that are insulated with myelin. As a result of biological aging, the quality of this insulation declines (Eulderink 2004). This process is called demyelination. Biological aging is a gradual process. If the demyelination is occurring at a noticeably faster pace, that can be a sign of an emerging vascular dementia.

Vascular dementia occurs more frequently in people with high blood pressure, with increased cholesterol levels in the blood, with smoke, and with hyperhomocysteinemia. The last one is a metabolic disease in which deficiencies of vitamins B12 and B6 and folic acid lead to elevated levels of homocysteine. This is one of the reasons why a blood test must be done in patients with dementia. If it appears that there is a deficiency in vitamins B12 and B6 and folic acid, that can be remedied medicinally.


Course

The impairments seen in vascular dementia depend on the nature, the extensiveness, and the localization in the brain where the damage occurred. In the initial stage, memory problems are not the predominant symptom of this type of dementia.

Inertia in actions and speech are clearly present in the initial phase. Problems with finding words or difficulty switching from one topic to another are regularly reported in practice.

The patient is personally much more aware of the failures at the cognitive and motor level than people who suffer from Alzheimer’s. Frequently in part because of this disease awareness, behavioral impairments with changeable moods do arise, which can lead to depression. At a later stage, memory problems arise, a symptom that has to be present if the diagnosis of dementia is to be made.

On an MRI or CT scan of the brain, lesions can be seen in the brain such as infarctions and white matter abnormalities. These abnormalities increase over the course of the disease. The course of vascular dementia is not as gradual as that of Alzheimer’s dementia. It is frequently irregular, step by step, with moments of deterioration and afterward partial improvement.

On physical examination, abnormalities can be found in reflexes and muscle strength. The general condition is poorer in comparison with that of the Alzheimer’s patient. In part as a result of this poor general condition, a patient with vascular dementia will in general be admitted earlier to a nursing home. The average length of such an admission is several years less for these patients than for Alzheimer’s patients.

When there is further progression of the vascular dementia, the difference in symptoms when compared with those of Alzheimer’s dementia decreases. It becomes more difficult to distinguish between the different dementias. Eventually the vascular dementia patient will die because of very poor general homeostasis.


3.3.3 Lewy Body Dementia


In patients with Lewy body dementia, abnormal protein aggregates are found throughout the brain. The doctor who first described this form was Friedrich Lewy. Lewy bodies are also seen in Parkinson’s patients, but they are then located solely in the basal ganglia. Lewy body dementia has been recognized as a separate syndrome since 1961. This form is distinguished by the presence of the following symptoms: variable degree of confusion, hallucinations, and walking impairments which also appear with Parkinson’s disease (see ► Chap. 2).


Course

In Lewy body dementia, just as with Alzheimer’s dementia, the first symptoms of confusion are characterized by memories and orientation impairments. The variable sustained attention, the restlessness, and the «pulling» at bedclothes or clothing are noticeable symptoms. Other symptoms include fainting, depression, sleep impairments, and auditory hallucinations. Recently research has shown that patients with Lewy body dementia respond well to medicines that are registered to slow the progress of Alzheimer’s (rivastigmine, galantamine, and donepezil). Patients become more lucid, attention improves, and they are less confused. How long the effect of this medication lasts and what it implies for the progression of the disease are still not yet known.

The fact that this type of dementia has not been recognized for very long means that the course can less clearly be described. Just like the Parkinson’s patient, the motor problems arise first (shuffling gait and an increased chance of falling), followed by the cognitive impairments. It seems that once the psychiatric symptoms such as the hallucinations and the changeable attention become more noticeable, the dementia often progresses quickly in severity. This means that patients can change within a period of a few months up to a year from being relatively healthy people into someone who is wheelchair bound and severely demented. When the ability to walk is lost and the patient becomes bedridden, the end is rapidly in view.


3.3.4 Mixed Dementias


There are also mixed dementias. In some patients with vascular dementia, amyloid plaques are found in the brain. This is then called «mixed dementia.» When Alzheimer’s dementia has been proven, the diagnosis of a mixed dementia becomes more likely if the patient has an anamnesis of high blood pressure, cardiac arrhythmias, excessively high cholesterol level, insulin-dependent diabetes, and TIAs. With further progression, the difference in symptoms between the various dementias declines, and it is difficult to distinguish between the different syndromes.


3.4 Recognition of the Various Dementias


◘ Table 3.1 gives a schematic overview of the early symptomatology of the various forms of dementia. From this, the physiotherapist should probably be able to recognize the various forms of dementia in the initial phase. Being able to do so is important because there are differences in the prognosis and speed at which the dementia syndrome develops.


3.5 Insight into the Different Stages of Dementia


The course of dementia runs in stages, and there is a gradual decline in both cognitive and motor functions. In all these stages, the physiotherapist can be of added value in the care of this patient population. He must however be familiar with the various approach strategies. On the one hand, he must know which approach strategies there are and on the other side when he can use them. This means that he will also be regarded as being able to recognize the various stages in dementia. On the basis of the course of the syndrome as what occurs in many Alzheimer’s patients, a classification has been made into seven stages. Insight into these stages gives the multidisciplinary team the ability to match the approach strategies to the stage.

◘ Table 3.2 shows the Global Deterioration Scale (GDS) according to and, added to that, which approach strategy is appropriate at which stage


Table 3.2
Global Deterioration Scale according to Reisberg







































Stage

Loss of skills

Approach strategy

Stage 1

No cognitive decline and normal functioning

Not applicable

Stimulation of an active lifestyle

Stage 2

Very mild cognitive decline

The patient himself experiences decline, and surroundings do not

Forgetfulness with regard to names, appointments, or where belongings have been put away

Subjectively experienced word finding problems

No objective proof for problems in complex activities, such as work

Stimulation of an active lifestyle

Training of muscle strength and stamina

Stage 3

Mild cognitive decline or the beginning of dementia

«The threatened me»

Perceptible problems in activities

Orientation problems in unknown surroundings

Routine actions are intact (e.g., cooking)

Stimulation of an active lifestyle

Training of muscle strength and stamina

ROA (reality orientation approach)

Stage 4

Moderate cognitive decline and emerging Alzheimer’s dementia

Observable problems in ADL, such as grocery shopping, cooking, and organizing something

Self-care is intact

Training of muscle strength and stamina

ROA

Validation

Gentle care

Stage 5

Moderate to severe cognitive declines and further progressed Alzheimer’s dementia

«The lost me»

Difficulty with simple elements of self-care

With stimulation and incidental help, self-care is adequate

Movement activation program (MAP)

Validation

Gentle care

Stage 6

Severe cognitive decline and advanced Alzheimer’s dementia

«The sunken me»

Self-care declines in phases (see below)

Problems with dressing (praxis)

Help needed to get in and out of the bath

Inability to visit the toilet independently

Double incontinence

Validation

Gentle care

Passivities of daily living (PDL)

Stage 7

Very severe cognitive decline and end-stage dementia

Speech and simple motor skills decline

Fetal posture generally arises in the following order

Vocabulary <6 words

Understandable vocabulary at the most one word

Loss of walking function

Is no longer able to sit up straight

The ability for (spontaneous) expression disappears

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Jun 9, 2018 | Posted by in NEUROLOGY | Comments Off on Symptomatology in Practice in the Case of Dementia

Full access? Get Clinical Tree

Get Clinical Tree app for offline access