A home care physical therapist evaluates a 78-year-old woman with Alzheimer’s disease, who lives with her loving husband. Prior to a recent hospital admission, she was independently ambulatory. She had a recent bout with pneumonia but she is bouncing back, and her husband is motivated to oversee a home exercise program that will help her regain her prior level of functioning or perhaps even exceed it. How should the therapist proceed? Implicit bias in healthcare Implicit bias significantly affects how healthcare professionals perceive and make treatment decisions, ultimately resulting in disparities in health outcomes. These biases, often unconscious and unintentional, can shape behavior and produce differences in medical care along various lines, including race, ethnicity, gender identity, sexual orientation, age, and socioeconomic status. Healthcare disparities stemming from implicit bias can manifest in several ways. For example, a healthcare provider might unconsciously give less attention to a patient or make assumptions about their medical needs based on race, gender, or age. The unconscious assumptions can lead to delayed or inadequate care, misdiagnoses, or inappropriate treatments, all of which can adversely impact health outcomes. Addressing
A home care occupational therapist evaluates an 80-year-old man with Alzheimer’s disease who was recently discharged from the hospital after a brief stay for lower extremity cellulitis. His medical status is stable, but his wife notes that he is struggling with self-care and activities of daily living that he was able to do independently prior to admission. How should the therapist proceed? implicit bias in healthcare is crucial for achieving equity in medical treatment. Strategies to combat these biases involve education and awareness programs for healthcare professionals. These programs help individuals recognize and acknowledge their biases, fostering a more empathetic and unbiased approach to patient care. Additionally, implementing policies and procedures prioritizing equitable treatment for all patients can play a pivotal role in reducing healthcare disparities. Ultimately, confronting implicit bias in healthcare is essential to creating a more just and equitable healthcare system where everyone receives fair and equal treatment regardless of their background or characteristics.
DEFINING DEMENTIAS AND RELATED NEUROCOGNITIVE DISORDERS
Dementia is an umbrella term that refers to a variety of diseases and conditions that impact cognition and behavior to the extent of interfering with daily functioning. All dementias result from nerve cell damage and death in the central nervous system. To varying degrees, they alter memory and cognition to the point of negatively affecting personal, social, occupational, and functional status. Although true dementia is chronic and irreversible, dementia- like symptoms can also be seen in conditions that are reversible or treatable. Clinical observation and neuropsychological testing provide the basis for a diagnosis of dementia. Careful observation and synthesis of information about specific symptomatology, the characteristics of onset, and the progression of symptoms can contribute to an accurate diagnosis of dementia type. Increasingly, certain dementias can Alzheimer’s disease Alzheimer’s disease is the sixth leading cause of death in the United States and the fifth leading cause of death among persons aged 65 and older (Alzheimer’s Association, 2018a). While other top causes of death (such as cancer and cardiovascular-related deaths) are decreasing, deaths related to AD are on the rise; and after age 74, AD death rates rise steeply. Death from AD is admittedly difficult to accurately measure. The sequelae of AD include problems with mobility that can lead to pneumonia, falls, and problems with swallowing that can lead to malnutrition. A cascade of events, initiated because of dementia, can lead to death, however documenting the cause of death is not always clear: Is AD the cause of death when an individual dies from sepsis due to pneumonia that results from immobility due to dementia? Or is AD incidental to the cause of death? The clarity of whether someone dies with or from AD continues to be hazy. Nevertheless, deaths from AD are on the rise, and this cannot be entirely explained by the increasing age of the population. It is likely that decreasing death rates from other causes (e.g., heart disease, stroke), increased and earlier diagnosis of AD, and better reporting of AD on death certificates are combined contributors to this rise. Death by age 80 is twice as likely in those who have AD compared to the general population (Alzheimer’s Association, 2018a).
be more definitively diagnosed using biochemical and genetic markers. Mounting evidence from long-term observational and autopsy studies suggests that many people have brain abnormalities associated with dementias of more than one type (Alzheimer’s Association, 2018a; National Institute on Aging [NIA], 2018). Data from 2014 Medicare claims suggests that one-third of Medicare beneficiaries who die in a given year have been diagnosed with Alzheimer’s disease (AD) or another dementia (Alzheimer’s Association, 2018a). The following information on various types of dementia is compiled from multiple sources (Alzheimer’s Association, 2018a; NIA, 2018). Although the focus of this course is AD, practitioners will benefit from a basic understanding of other types of dementia. Alzheimer’s disease progresses gradually. Most noticeable in the early stages is memory impairment. Friends and family begin to notice deficiencies as the disease progresses. Visuospatial and language problems, along with problems with abstract thinking, become increasingly prevalent, interfering with the ability to manage such instrumental activities of daily living (IADLs) as planning a meal or balancing a checkbook. Many people in the early stages of AD demonstrate some awareness of their growing mental deficiencies, but as the disease progresses, insight into one’s own disability diminishes, and major gaps in memory and cognition become apparent. Functional declines in activities of daily living (ADLs) and self-care skills follow and, eventually, individuals with AD require constant supervision and help with all ADLs. As the disease enters the late stages, individuals with AD lose the ability to communicate, control movement, and interact with their environment. The hallmark neuropathology of AD includes (a) plaques made up of beta-amyloid proteins that impact neuron-to-neuron transmission and communication and (b) neurofibrillary tangles made up of abnormal tau protein that negatively impact the cell microtubule transport system, preventing the import of essential nutrients into the cell. An inflammatory response in the midst of neuron damage and decreased neuron connectivity also contribute to AD pathology. Because AD is the focus of this course, more specific information about the etiology, pathology, risk factors, and diagnosis of AD will follow the discussion of the types of dementia.
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