Consider the following case study: Clara is an 82-year-old woman with mild-moderate dementia admitted 3 days ago to your subacute rehab unit; her status is post open reduction internal fixation for a right femoral shaft fracture. The fracture was the result of a fall in her home where she reportedly tripped over the cat. She has always been fit and active. She lives with her husband in a one-level home. Her two adult children live nearby and are very supportive. They regularly visit and take Clara for outings in the community. Past medical history includes: Alzheimer’s disease diagnosed 4 years ago, hypertension, hyperlipidemia. Medications : ● Donepezil/Aricept 5 mg. ● Simvastatin/Zocor 10 mg. ● Carvedilol/Coreg 3.125 mg. ● Paracetamol/Tylenol 500 mg prn. Weight bearing status: Weight bearing as tolerated right lower extremity. Pain : Appears to be well-managed. Upon PT examination on the day of admission, Clara presented with a baseline state of mild confusion, but she was pleasant and cooperative and expressed she was anxious to return home with her family. She was motivated and participatory with therapy and able to follow one-step commands. Transferring sit-to-stand and stand-to-sit required minimal assistance and she successfully trained with a rolling walker with contact guard and cues to walk 20 feet, weight bearing as tolerated on the right lower extremity. Initial impressions suggested she would be in the subacute setting for no longer than a week and would be ready for discharge to home with home care follow-up. Over the past 2 days, the therapist notices she is more confused and withdrawn than her baseline. She appears somewhat lethargic and disorganized in her thought expression. She is now requiring minimal to moderate assistance for transfers and has not improved in her ambulation status; she doesn’t seem less stable, just doesn’t seem to making progress. Nursing and support staff have not been consistent, so there is no other individual providing the continuity of care who can compare Clara’s current status to her admission status. Clara’s The normal brain A comprehensive neuroanatomical review is beyond the scope of this course, but a brief refresher on the primary regions and accompanying functions of the brain may facilitate understanding of the pathology of AD. The brain stem (made up of the midbrain, pons, and medulla) is most notable for regulation of vital life functions, such as respiration, cardiac function, some reflex activities (e.g., coughing, vomiting, swallowing), and autonomic functions (e.g., vasomotor tone). The cerebellum plays a large role in motor function via its influence on muscle tone, coordination of movements, and control of posture and balance. The cerebellum does not initiate motor commands, but modulates and adapts movement to situational needs. The left and right cerebral hemispheres communicate via the corpus callosum, a thick bundle of heavily myelinated nerve fibers, allowing for rapid transmission and communication between hemispheres. The cerebral hemispheres are anatomically divided into frontal, temporal, parietal, and occipital lobes. The frontal lobes, the most anterior part of the brain, house our unique personalities and intellects and control executive functions such as thinking, planning, memory, attention, and problem solving. The motor cortex is located at the most posterior aspect of the frontal lobe, and, upon the integration of sensory, cognitive, and memory data, is responsible for goal-directed movement. The lower portion of the left frontal lobe (in the majority of left-brain dominant individuals) contains Broca’s speech area, which is responsible
husband visits and remarks that he is worried her Alzheimer’s is progressing because last night she reported seeing forest animals in her room. Questions 1. What are possible causes of Clara’s declining status? Given the specifics of the case, what is the most likely culprit? 2. What is the role of the therapist in facilitating optimal care? What is the next step? Responses 1. Clara’s declining status could be caused by the following: a. Progression of dementia : This is an unlikely cause, as the rapid change in her status over the course of a few days is contrary to the typical slow, steady course of Alzheimer’s dementia. b. Depressive episode : This is possible, but unlikely, given the specific characteristics of Clara’s behavior. While depression can lead to social withdrawal and could be perceived by others as lethargy, the disorganized thought and hallucinations are not typical of depression. c. Normal pressure hydrocephalus : This is possible, but the clinical picture does not match the classic 3 Ws of NPH: wet (incontinence), wild (uncharacteristic behavior), wobbly (unsteady gait). Clara is showing none of these signs. d. Delirium : This is the most likely of causes, given the rapid onset, the lethargy, the disorganized thinking, and the hallucinations. 2. Suspecting delirium, the therapist approaches the medical team to suggest/discuss appropriate workup to reveal what might be causing the episode. Medications are often implicated in delirium, so an immediate review of Clara’s medication list is in order. The only medication that is new to her is the Tylenol, which is unlikely to interact with her other medications to cause these cognitive side effects. Infection/ sepsis is another common cause of delirium, with urinary tract infections being a common source. Urinalysis and blood work reveals this to be the case and Clara is treated with a course of IV antibiotics. Within 24 hours of treatment, she is back to her pleasant, motivated self and ready to participate in physical therapy.
BRAIN NEUROANATOMY AND NEUROPATHOLOGY
for speech and language production. Positioned posterior to the frontal lobes, the parietal lobes house the somatosensory cortex and interpret sensory information (e.g., pain, touch, taste, and visuospatial cues). The temporal lobes, located along the inferior lateral aspect of the brain, house the primary auditory cortex and Wernicke’s speech area (left side), which allows the individual to interpret sounds and language. Taste and smell capabilities are also located in the temporal lobe. The temporal lobe is home to the hippocampus, a structure that is vital to new learning and the formation, storage, and retrieval of short-term memories, as well as the conversion of short-term memories into long-term memories; it is implicated early in the course of AD. The predictable pattern of AD pathology and the close proximity of the hippocampus to areas responsible for taste and smell help to explain the degradation of these senses in many individuals with AD. The occipital lobes, on the posterior aspect of the brain, are responsible for interpretation of visual information. The term limbic system describes a functional and anatomical interconnectedness among several brain structures, including the hypothalamus, amygdala, and hippocampus. The hypothalamus monitors bodily activities, such as temperature and appetite, and influences the body’s endocrine functions, including the release of key hormones. The amygdala has a role in the fight-or-flight response and plays a major role in emotional responses and emotional memory. The thalamus, superior to the brain stem in the center of the brain, is a relay station for sensory and limbic
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