The term dementia refers to a number of syndromes characterized by diverse behavioral, cognitive, and emotional impairments (Launer, 2011). Dementia is not a disease, but a broader set of symptoms that accompanies certain diseases or physical conditions and often occurs in conjunction with other chronic medical diagnoses such as stroke (Alzheimer’s Association, 2013a). Dementia is an effect of a marked loss of neurons in the brain (Sandmire, 2010). Dementia affects memory and cognition to the point of personal, social, or occupational impairment. The symptoms of dementia can be seen in both reversible and irreversible conditions, and may co-occur with other conditions, but dementia is primarily recognized to be an irreversible, progressive condition (Kurz & Lautenschlager, 2010). Alzheimer’s disease (AD) is the most common cause of dementia, accounting for 50% to 60% of cases (Alzheimer’s Association, 2013a). In the brain of a person with Alzheimer’s disease there are key indicators of neuronal loss; neuronal loss seems to result from plaques and tangles, but why this loss occurs is still unknown. Plaques are clumps of beta-amyloid proteins that are found to interfere with cell communication. Tangles are tau proteins that have become twisted together inside nerve cells and inhibit the transport of nutrients and other materials for cell health (Mayo Clinic, 2014a). These changes are seen in the hippocampus and neocortex. Alzheimer’s disease has been characterized using the Global Deterioration Scale (Alzheimer’s Association, 2013b) by stages of cognitive impairment, including: ● No cognitive decline. ● Very mild cognitive decline (age-associated memory impairment). ● Mild cognitive decline (mild cognitive impairment). ● Moderate cognitive decline (mild dementia). ● Moderately severe cognitive decline (moderate dementia). ● Severe cognitive decline (moderately severe dementia). ● Very severe cognitive decline (severe dementia). While the Global Deterioration Scale is internationally known and frequently considered a gold standard in determining impairment, its categories provide no additional information regarding how these levels relate to function. Memory impairment is always an early sign of AD; however, not all memory loss indicates AD. AD usually progresses gradually; it is not uncommon for people to experience symptoms for years before AD is suspected. Friends and family begin to notice deficiencies as the disease progresses. Visuospatial and language problems become increasingly more prevalent, interfering with a person’s ability to manage such IADLs as balancing a checkbook. Many people in the early stages of AD report some awareness of the growing mental deficiencies but react differently. Although some will recognize that things do not seem right, others may deny their experiences and cover up their deficits in memory and other intellectual tasks. As the disease progresses, people experience major gaps in memory and cognitive functioning. At some point, persons with AD will require constant super-vision and help with all daily activities. Eventually persons with AD will lose the ability to speak, control movement, and interact with the environment, often becoming responsive only to basic needs or pain at the final stage of the disease. Vascular dementia is the second most common cause of dementia, comprising roughly 20% of all dementia cases (National Institute of Neurological Disorders and Stroke [NINDS], 2013). Vascular dementia develops when blood flow is reduced to parts of the brain. Symptoms can appear suddenly after a single major stroke blocks blood supply to a significant portion of the brain, or after a series of very small strokes, or infarcts, block small blood vessels; this type of dementia was previously known as multi-infarct dementia. Cumulatively, these “mini-strokes” cause noticeable symptoms over time, which vary depending on the specific brain areas deprived of blood. The course of vascular dementia may differ from AD in that impairment may occur in “steps” compared to the progressive
decline typically seen in AD (Mayo Clinic, 2014b). People likely to experience vascular dementia may have a past history of heart attacks, high blood pressure, high cholesterol, or other cardiovascular conditions. Symptoms of vascular dementia tend to differ from AD. For example, memory problems may or may not be a prominent symptom, depending on which areas of the brain are affected. Confusion may be present and may worsen at night. Other symptoms include difficulty concentrating, planning, communicating, and following instructions, and a reduced ability to carry out daily activities (Alzheimer’s Society, n.d.). There are also physical symptoms, typically associated with strokes, such as sudden weakness, difficulty speaking, or confusion. A magnetic resonance imaging (MRI) scan of the brain may show characteristic abnormalities associated with vascular damage. Because vascular dementia is closely tied to cardiovascular conditions, potential preventative treatment options include monitoring of blood pressure, weight, blood glucose, and cholesterol. Managing risk factors associated with heart disease could play a major role in preventing later cognitive decline for many individuals. Acquiring information from patients about risky behaviors is important. In some cases, active management of these factors in older adults who develop vascular dementia may help prevent symptoms from getting worse. It is important to assess cognitive disorders for several reasons. First, an early diagnosis of dementia increases the chances of successful treatment and management of the disease’s symptoms and progression. The earlier a person with AD and his or her family know the diagnosis, the more time they have to make future living arrangements, handle financial matters, establish a durable power of attorney, deal with other legal issues, create a support network, and seek out resources for behavior management, caregiver respite, and community-based services (Etkin, Bright, & Krajci, 2012). Social workers can aid in finding resources and programs and provide counseling to families and clients with AD to enable successful living in the community, and can also aid in the transition to care facilities. Second, testing assesses cognitive functioning in a systematic way and, under standardized conditions, yields findings that can be compared with normative data (Zarit & Zarit, 2007). However, testing is not performed in all cases because of such factors as time, costs, and the availability of personnel trained to administer the tools. In addition, standardized tests do not constitute the sole measure of cognitive functioning. Common elements of cognitive functioning assessment include orientation, thought process, affect and mood, behavior, personality, and perception. Two of the most common screening tools historically used by the general population of healthcare practitioners to assess mental status among older adults are the Mini-Mental State Exam (MMSE) by Folstein, Folstein, and McHugh (1975) and the Short Portable Mental Status Questionnaire (SPMSQ) by Pfeiffer (1975). Physical therapists may use alternate comprehensive assessment tools or assess cognition through observation of functional activities. Criticisms of the MMSE for lack of sensitivity in detecting cognitive impairment at the early stage of dementia led to the development of the Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005). The MoCA is a cognitive assessment tool that has become increasingly popular in the field of rehabilitation for older adults. Unlike the MMSE, which now requires a fee for use, the MoCA is freely accessible within public domain. The MoCA can be used to assess the following: ● Attention and concentration. ● Executive function. ● Memory. ● Language. ● Visuoconstructional skills. ● Conceptual thinking.
● Calculations. ● Orientation.
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