Early Stage Alzheimer

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Early Stage Alzheimers disease A Focus on
CommunicationYork Manor, Fredericton, NBSt.
Thomas University, Third Age Centre, Fredericton,
NB
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Presentation Plan Background M M B
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WHAT IS DEMENTIA

• Dementia is NOT a disease
• Dementia a syndrome of intellectual decline
• - Syndrome a collection of symptoms
• - Symptoms in dementia include
• memory loss
• language difficulties
• difficulties in spatial awareness, skilled
  movement
• loss of knowledge understanding of the world
• problems in reasoning, planning, judgement
• changes in personality, behaviour, emotions

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CAUSES OF SYMPTOMS OF DEMENTIA

• Many different challenges to the brain cause the
  symptoms of dementia (difficulties with language
  and understanding, problems with memory...)
• Knowledge of brain and how different areas are
  affected helps to gain a better understanding
• One can then better appreciate the perspective of
  the person with dementia
• This is central to responding to the needs of
  persons with dementia and to promote their
  well-being

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VARIABILITY OF SYMPTOMS

• Recognize Individuality of each person
• Do not assume that dementia is simply a global
  intellectual decline
• Important to constantly recognize preserved
  abilities, not just abilities affected by
  disorder
• Brain damage must be set in a wider context that
  covers the persons past and present
  circumstances
• has the person moved to a new home
• what work has the person been doing

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ALZHEIMERS DISEASE

• Alzheimer s disease most common dementia
• 2/3 of all dementias
• Important determinant of hospitalization
• 65 years 13 of population (2001)
• 22 of
  population (2031)
• Accelerated increase with age
• 5.1
  in 65 years
• 26
  in 85 years
• Long duration 8 to 10 years (and more)
• 50 live in community (usually with family)

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CHANGES IN THE BRAIN

• Cerebral cortex Core symptoms of dementia are
  associated with damage to this part of brain
• FOUR LOBES
• Temporal lobe Memory, language, understanding
• Parietal lobe Body control and space
• Frontal lobe Control of behaviour, planning and
  decision-making
• Occipital lobe Vision

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CHANGES IN THE BRAIN

• Temporal lobe Memory, language, understanding
• Differentiation of smells, sounds
• Sorting new information - believed responsible
  for short-term memory
• Left lobe verbal memory
• Right lobe visual memory

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CHANGES IN THE BRAIN

• Left temporal lobe (verbal memory)
• understanding language (anomia / aphasia)
• understanding recognizing objects (agnosia)
• Right temporal lobe (visual memory)
• understanding recognizing objects (agnosia)
• understanding recognizing people
  (prospoagnosia)

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CHANGES IN THE BRAIN

• Right parietal lobe
• Awareness of left side of space (visual neglect)
• Understanding spatial relations how parts make
  wholes (constructional apraxia)
• Left parietal lobe
• Reading (alexia),
• Writing (agraphia),
• Understanding numbers and calculations
  (acalculia),
• Sequencing body movements in skilled action
  (ideomotor apraxia)
• Lack of understanding (agnosia) with advanced
  dementia

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CHANGES IN THE BRAIN

• Frontal lobe
• Orbitofrontal (upper) region
• Control of emotions, instincts and behaviour
  (??dysexecutive syndrome social - emotional)
• Dorsolateral frontal (lower) region
• Control of thought and planning (dysexecutive
  syndrome cognitive)
• Occipital lobe Vision
• Located at back of brain less vulnerable

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BACKGROUND

• CAREGIVERS OF PERSONS WITH AD
• Older family members (usually spouses)
• Poor health (even in early stage dementia)
• Faced with long caregiving career
• (8 10 years 22 hours / week (early stage)
• (Canadian Study on Health Aging, 1994)
• FEW INTERVENTIONS FOR EARLY PHASE THAT WORK
• COMMUNICATION MAJOR CONCERN

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AFTER DIAGNOSIS

• Six common themes after diagnosis
• (Snyder, 2000)
• Denial
• Ambivalence around disclosure
• Wanting things to stay the same
• Fear of the future
• Day-to-day experiences of Memory Loss
• Changes in self-esteem and self-concept

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AFTER DIAGNOSIS

• Denial
• Normal psychological defence when coping with
  uncomfortable issue situation
• Person with AD may wish to dissociate from
  diagnosis because of stigma
• Next of kin, friends may not accept diagnosis
• Person with AD at times may forget that has AD
• NEED emotional support to accept diagnosis and
  deal with consequences

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AFTER DIAGNOSIS

• 2. Ambivalence about talking about diagnosis
• Myths about AD
• Is it contagious?,
• What will others think?
• Negative attitudes may proliferate if lack of
  education
• NEED person with AD and family members need to
  be better informed

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AFTER DIAGNOSIS

• 3. Wanting things to stay the same
• Characteristics of symptoms of AD
• Variable, fluctuating, sporadic, erratic,
  random, always changing
• Good days, difficult bad days
• Lack of control over ones life is alarming and
  difficult to accept
• Normal and common reaction

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AFTER DIAGNOSIS

• 4. Fear of the future
• Person with AD Fear of loosing part of oneself
• Whats going to happen to me?
• Caregiver Fear of loosing the family member as
  he-she was before
• Whats going to happen to my loved one?

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AFTER DIAGNOSIS

• 5. Day to day experiences of Memory Loss
• Memory loss changes from day to day
  variability, inconsistency...
• Person with AD
• Am I the same person? Can I do this today?
• Caregiver .
• Whats wrong with him-her? Yesterday he-she
  had no problem with this...

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AFTER DIAGNOSIS

• 6. Changes in self-esteem and self-concept
• People live a life where change is constant
• It becomes hard to define oneself
• - An editor may loose ability to recall words
• - A homemaker is less able to prepare meals
• - xxx
• Focus on the person roles in life, qualities,
  relationships, friends, family...

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Communication

• Communication major concern in early AD (refs)
• - Characterized by problems related to
• ? Memory
• long-term (declarative nondeclarative)
• working (short-term) memory
• ? attention
• ? language (comprehension production)
• ? affect

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Communication - Memory

• Memory LONG-term memory
• (declarative nondeclarative)
• 1. DECLARATIVE (explicit memory)
• consciously learned knowledge - facts
  (what-who)
• 1.1 Episodic memory (personal life events)
• EARLY AD OLDER memories intact
• forget RECENT
  personal events
• Recognition memory better preserved than
  recall
• Strategies pictorial/verbal
  recognition,
• work within span
  capacity

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Communication - Memory

• 1.2 Semantic memory
• (knowledge world, facts, schema)
• EARLY AD Impoverished vocabulary
• (naming word-finding problems)
• 1.3 Lexical memory (knowledge words rules)
• EARLY AD Few difficulties

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Communication - Memory

• 2. NONDECLARATIVE (implicit memory)
• (NON fact NON volitional memory)
• automatic acquisition of verbal
  nonverbal
• knowledge and skills
• concerned with the how to perspective
• Examples
• Procedural memory (sports, writing,
  playing piano)
• Habits (evening bath, morning coffee)
• Associations (stopping at a red light)

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Communication - Memory

• WORKING memory (short-term memory)
  
• Three components
• 1. central executive (and two subsystems)
• 2. Visuospatial sketchpad (visual subcomponent)
• 3. Articulatory/phonological loop (verbal
  subcomponent)
• Functions
• Goal directed behaviour problem solving, long
  term planning, making judgements - comparisons

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Communication - Memory

• WORKING memory (short-term memory)
• MAJOR impact on communication in early AD
• COMMUNICATION PROBLEMS result from
• difficulties with ADLs IADLs
• making
  judgements
• finding
  ones way - getting lost

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Communication - Attention

• ATTENTION (concentration)
• (related to executive function since problem-
• solving requires a certain degree of attention)
• 1. Sustained attention focus over longer time
  period (generally well retained in early AD)
• 2. Divided attention focus on more than one
  activity at a time (PROBLEMATIC in early AD)

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Communication - Attention

• ATTENTION
• 3. Selective attention a.) ability to focus
  while ignoring other stimuli (noise) b.) ability
  to switch attention between 2 activities
  (shifting sets)
• (HIGHLY PROBLEMATIC in early AD)
• COMMUNICATION PROBLEMS in regard to following TV
  - radio, conversing with 1 persons

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Communication - Language

• LANGUAGE
• 1. Language COMPREHENSION
• Reading comprehension some difficulties in
  early AD
• Auditory comprehension intact if easy to
  understand
• NB Combined (written oral) better for longer
  message

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Communication - Language

• 2. Language PRODUCTION (written, oral)
• 2.1 WRITTEN skills
• Dysgraphia/agraphia problems
• exception words (cough, yacht)
• phonological errors (tomb-toom),
• perserveration (repetition of letters
  lamppp)
• Graphomotor (mechanics of writing) some
• problems with spontaneous writing
  letters

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Communication - Language

• 2. Language PRODUCTION
• 2.2 ORAL skills
• SYNTAX (sentence structure, word order)
  minimal problems when sentence structure simple
• SEMANTICS
• (lexicon knowledge vocabulary, word
  meaning)
• intact language production when depends on
  nondeclarative memory
• (over learned automatic speech hello,
  thanks)

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Communication - Language

• Continued 2.2 Oral Skills
• Problems in EARLY AD (vary between persons)
• - paucity of speech
• - word-finding difficulties
• - word production
• - naming
• - word-finding
• - broken speech
• - circumlocutions
• - stammering

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Communication - Language

• LANGUAGE
• 2. Language PRODUCTION
• 2.2 ORAL skills
• PRAGMATICS (how language is used
• contextually appropriate language)

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Communication - Language

• LANGUAGE production
• Problems in EARLY AD
• - repetitiveness
• - poverty of vocabulary and range of
  expression
• - increased response time
• - pausing more frequently
• - vague speech irrelevant comments
• - self-centred conversation
• - circuitous speech
• ?Problems with?complexity of discourse context

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Communication Affect, Beahviours

• AFFECT and BEHAVIOURAL ASPECT
• 1. Emotive-affective changes (variability)
• e.g., anger, insensitivity, anxiety,
  sadness, frustration, self-centredness,
  irritabilityUNDERSTANDABLE!
• 2. Passive behaviours (infrequent - early
  stage)
• e.g., apathy, withdrawl, blunted
  emptions, lack of responsiveness, ? spontaneity,
  disinterest, ? enthusiasm, reclusiveness
• 3. Psychomotor slowing (infrequent - early
  stage)
• e.g., reduction in physical activity,?in
  bed - rest, ?gait - especially noticeable

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Communication - Perception

• PERCEPTION
• Sensitivity to sound
• Major problem for large proportion of persons
  with
• early AD due to ?ability to filter out extraneous
  noise
• This problem is magnified when combined with
• - attention related problems (present in early
  AD)
• - hearing deficits of many elderly persons

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Communication and Caregivers

• Communication important concern for family
  caregivers because person with AD - problems
• - memory (short-term, ?vocabualry wordfinding,
  ?recall - ?recognition)
• - attention (selective - divided, noise)
• - language production (verbal - wordfinding, )
• - language comprehension (too fast - slow)
• - conversational abilities (discourse)
• - behaviours
• - emotions - affect (? lability)
• Needs of caregivers KNOWLEDGE and SKILLS to
  better communicate with their family member

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Conception of Communication Study

• In response to this problem
• Development of an individualized
  psycho-educational intervention centred on
  communication conceived for family caregivers of
  persons with cognitive problems associated with
  the early stage of Alzheimers disease
• Focus of Program Knowledge and Skills in
  regard to communication

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Communication-focused Program

• Five themes, five modules, five meetings (2 hr.)
• Memories are important
• What do we talk about today?
• 2 . Remembering and forgetting
• Where did I put my keys?
• Why doesnt he/she listen?
• How can I get his/her attention?
• 4. Caring for my family member.
• 5. Emotions How can I better communicate with my
  family member?

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Module 1

• Communication MAXIMIZE STRENGTHS
• Memory aids
• ONE subjet at a time, changing subjets
• Reading writing
• Word-finding - naming
• Short simple sentences
• Normal moderate rate of speech
• ? nouns specific words
• ? pronouns non specific words
• Common and familiar words
• Questions YES-NO 2-choice answers
• ?????Help - encourage conversations

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Module 2 MEMORY

• Communication FORGETTING - REMEMBERING
• Forgetting to FINISH a task
• Forgetting WHERE one placed something
• Forgetting TO DO something
• WRITTEN reminders
• ONE place for important items - information
• Putting things in the WRONG place
• Remembering the past, forgetting the present
• Forgetting MEDICATIONS
• Forgetting to turn ON - OFF household appliances
• REPEATING the same stories questions

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Module 3 ATTENTION

• CommunicationATTENTION - ENVIRONMENT influences
• Talking face to face
• Crowded places, many people
• Noise
• Volume and tone of voice
• Getting the attention of the person
• More time to reply
• Talking and doing something (at the same time)
• Several persons talking (at the same time)
• Staying on topic
• The first message, the second message

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Module 4 Daily life activities

• Communication ACTIVITIES OF DAILY LIVING.
• Using the telephone - computer
• Getting dressed, eating
• Activities which require several steps
• Personal grooming
• Restless behaviour, unable to sit still
• Needing more time to do something
• Getting lost (cannot find the way)
• Needing more sleep rest
• Waking up at night (cannot sleep)
• Knowing the date time, counting things
  (money)

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Module 5 Emotions

• Communication EMOTIONS
• The family member who
• IGNORES others
• Feels SAD
• Gets UPSET when furniture moved about
• Gets UPSET when in an unfamiliar place
• Gets UPSET when he/she cant express him-herself
  
• Gets UPSET when he/she doesnt understand
• Gets UPSET when cant do hobbies - sports
• Gets UPSET when cant find something
• Gets UPSET when he/she cant find the way

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STUDY PARTICIPANTS (n 50)

• GROUPS Experimental (program) Control
  (flier)
• (n25)
  (n25)
• Gender 20 (f) 5 (m) 21
  (f) 4(m)
• Age (mean) 59.1 yr
  64.8 yr
• Education (all completed elementary school)
• university 14
  7
• Cohabitation 10
  11
• Relationship - children 15
  - children 11
• - partner 7
  - partner 11
• - other 3
  - other 3
• Significant differences between the 2 groups

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RESULTS

• Significant effects of program
• - knowledge (T2 et T3)
• - degré de dérangement (T2 maintenu au T3)
• - efficacité personnelle (T3)