Continuum of Cognitive Impairment
Cognition refers to the ability to execute complex mental processes such as learning, perceiving, making decisions, and remembering. Cognitive impairment exists on a continuum, from mild cognitive impairment to dementia. Differentiation is based on the number, type, and severity of deficits in mental capacity that a person exhibits. Mild cognitive impairment causes significant and persistent memory deficits, yet people remain functional and independent in most ways, without other clinical signs of dementia. Each year, however, the cognitive deficit progresses to AD in as many as 12 to 15% of the people with mild cognitive impairment.[1]
Dementia refers to a global loss of cognitive and intellectual functioning caused by damage to the brain severe enough to interfere with social and occupational performance. Dementia is a general clinical term that refers to a group of disorders with common symptoms but different causes. The etiology of dementia varies and may be related to conditions such as Parkinson's disease, Huntington's disease, acquired immune deficiency syndrome, or one or more of the neurodegenerative disorders discussed elsewhere in this issue.
Delirium, depression, and adverse effects of medication also can trigger dementia-like syndromes, which can overlap with existing dementia or appear independently. Behavioral symptoms caused by these and other health conditions may be reversed or arrested. Comprehensive assessment of all possible causes of symptoms of cognitive impairment is therefore essential.
Declines in cognition, activities of daily living, and behavior, considered the three symptomatic domains of AD, create challenges for caregivers. Subtle common cognitive symptoms usually appear first. The functional losses that follow are likewise subtle but eventually lead to complete dependence. Multiple behavioral symptoms, which are often the most distressing for caregivers, become more prominent as the disease progresses. These three domains do not exist separately; instead, they overlap and influence one another. Cognitive deficits facilitate functional disability. In turn, both contribute to the development of behavioral symptoms. Nonpharmacologic interventions must address the following three issues: cognitive impairment, challenging behaviors, and activities of daily living.
Cognitive Deficits
Cognitive deficits associated with dementia affect several higher cerebral functions, including memory impairment, aphasia, apraxia, and agnosia. Short-term memory loss is a common presentation in the practitioner's office. The patient, family, or both describe difficulty recalling recent events as well as difficulty learning new material. Attention deficits are present early in the dementing process.
Strategies include minimization of stimuli, which helps increase patients' attention span by decreasing their distractibility. Early in the disease process, the use of central information areas is helpful. These areas consist of calendars, notes, or message boards placed on a refrigerator or on a wall near the phone. The use of visual cues can be effective. For example, if a patient uses a basket to hold keys and glasses, affixing a picture of glasses and keys to the side serves as a cue to the contents of the basket. Caregivers are encouraged to give patients simple directions. Breaking complex tasks into smaller steps allows patients to complete a task with minimal redirection. In all stages of the dementing process, maintaining a consistent structured routine is helpful and is encouraged.
Aphasia is the inability to use symbols to communicate. Expressive aphasia is the decreased ability to form words to express oneself clearly orally or in writing. Receptive aphasia is the decreased ability to understand spoken or written language. Common in AD is word-finding difficulty; that is, difficulty in the ability to retrieve and express a thought, particularly nouns. Frequently noted is the use of circumlocution, which is the description of a noun in the absence of the word itself.
Patients find difficulty with language to be one of their most challenging problems. They tend to isolate themselves and to minimize social contact because of their expressive aphasia. Coping strategies for patients include using circumlocution to communicate a thought and speaking slowly. Asking people to repeat themselves and avoiding fatigue, alcohol, and activities outside of the routine are helpful. Caregivers are encouraged to provide opportunities for meaningful communication. The use of a validating approach via verbal and nonverbal cues is helpful. Visitors are encouraged to visit early in the day or after rest periods. Visitors should be limited to a few at a time.
Apraxia is the inability to initiate complex learned motor movements. This symptom can manifest as an ability to perform an activity spontaneously but an inability to perform the same activity on command. Patients with apraxia may be experiencing sequencing problems. They may not know what to do first or next. Unfortunately, apraxia is often attributed to a lack of motivation or to being obstinate. Coping strategies for caregivers include education to help them understand that apraxia is a motor-planning problem. Visual cues can be effective in these situations, as can the use of imitation. As the disease progresses, apraxia can become more pronounced. Imitating a behavior, such as buttoning a shirt or combing hair, can be useful and promotes independence.
Agnosia is the inability to recognize familiar objects by sight, touch, taste, smell, or sound. This symptom can precipitate anxiety and agitation. Caregivers should be educated on the use of a soothing tone of voice and on therapeutic touch. Agnosia typically develops during the mid- to late stages of dementia.
Activities of Daily Living
Activities of daily living most often identified as problematic in dementia include dressing, toileting and continence, eating, and bathing. The ability to complete these activities can determine the need for a patient to be placed in a skilled nursing facility.
The types of cognitive problems that affect the ability to dress are deficits in perception, attention, initiation, memory, judgment, and apraxia. For example, a person with ideational apraxia may have difficulty in sequencing actions, whereas a person with ideomotor apraxia may know what to do but is unable to perform the motor movements. Dressing is the most studied activity of daily living. Strategies for caregivers include placing clothing to be worn for the day in a place that the patient can access such as on a chair or bed. Clear directions must be given, one at a time, such as "please put your socks on." Patients should be allowed to dress themselves until they are unable to do so.
Toileting and continence are issues that many patients and family members have difficulty discussing. Consequently, the health care provider may need to broach the topic. Behavioral interventions such as habit training and prompted voiding are effective. Doing so requires that a caregiver direct the patient to void every 2 or 3 hours while awake. Verbal prompting and reminders are needed during the early stages of dementia. During the later stages of dementia, toileting is scheduled during normal voiding. Clothing modifications such as pull-on pants with an elastic waistband and shoes with Velcro closures in lieu of shoelaces help promote independence.
The ability to plan and prepare meals is affected in the early stages of dementia. As dementia progresses, nutritional intake may decrease. The nutritional status of older adults is critical, and weight is considered the fifth vital sign by geriatricians.[7] Strategies to improve nutritional intake include establishing meal and snack times. The bulk of the diet is given earlier in the day. Caloric density is maximized. Foods that are easily handled, chewed, and swallowed should be used. The amount and type of food and beverage choices should be limited. The caregiver is encouraged to sit at the table with the patient during mealtimes. Avoiding overstimulation and interruptions diminishes the patient’s distractibility.
Bathing is the most complex activity of daily living.[5] Therefore, it is the first for which the patient may require assistance. During the early stages of dementia, it is preferable to establish a routine that incorporates the patient's bathing habits. As the disease progresses, the patient's needs and preferences may vary. The primary strategy for caregivers is to be flexible and creative. For example, showers and tub baths are not the only options for bathing. Towel baths can be effective in reducing agitation and aggression. For patients who are fearful of falling, a shower chair may be necessary.
Behavioral Impairment
Successful management of challenging behaviors in dementia is critical to the well-being of older adults with dementia and to their caregivers. Challenging behaviors, discussed within the scope of this article, consist of the inability to initiate activities, spatial disorientation, anxiety, agitation, delusions, and hallucinations.
Although easy to overlook, the inability to initiate meaningful activities affects both patients and their caregivers. Lack of meaningful activity may result in apathy or agitation for people with dementia and in frustration and burden for caregivers. When planning activities, caregivers should be encouraged to focus on enjoyment of an activity rather than on achievement. Incorporating activities as part of the daily routine is advised. Planning activities that employ previously learned motor patterns is preferred. Fostering a failure-free environment is the primary goal.
Early in the dementing process cognitive activities such as jigsaw puzzles, card games, word games such as crossword puzzles and trivia, and reading are encouraged. As the dementia progresses, functional household activities are promoted, for example, folding laundry, raking leaves, sweeping, dusting, clearing and setting tables, and making beds. Diversional activities such as watching a previously enjoyed sport or going for a ride in the car may assist with apathy associated with an inability to initiate activities.
Spatial disorientation is misperception of the immediate surroundings or not knowing where one is in relation to the environment. During the early stages of dementia, patients may become confused when in an unfamiliar place. During later stages, patients can become confused when in previously familiar places. Spatial disorientation may cause misperception of the environment and lead to fear, anxiety, suspicions, illusions, and delusions.
Strategies to address spatial disorientation
include the use of 'pop-up cues' or the use of color
contrasts. For example, if a green chair is placed in front
of a green wall, the person with visual spatial difficulty may not
be able to discern a difference between the two objects.
Environmental landmarks play an important role. Caregivers
are advised to minimize the movement or addition of furniture in a
room. Decorations should be maintained and changed only to
simplify and remove clutter. Lighting is of key importance.
Shadows are often misperceived and can cause
anxiety.
Anxiety is defined as a vague, uneasy feeling, the source of which
often is nonspecific or unknown to the individual who is
experiencing it. Anxiety is both a normal and pathological
emotional response.[2] Strategies to address anxiety include
maintaining rituals and consistency. Caregivers are
instructed to approach patients calmly and from the front. It
is imperative for people with dementia to see and hear who is
speaking to them. If touch and proximity cause stress, they
should be avoided. A low-stimuli environment is helpful as is
using distraction to manage behavior. As with all
interventions with persons with a dementing process, all unmet
needs, such as hunger, pain, or the need to void, should be
addressed.[4]
Agitation is likely to occur as dementia progresses. It may manifest as motor movement, irritability, anger, pacing, or all of these behaviors. Strategies to mediate agitation begin with caregiver education. Caregivers are instructed not to expect patients with dementia to adapt. Caregivers should remain calm and establish eye contact with patients. They should be aware of their nonverbal communication. If possible, problematic behavior should be ignored unless safety is a concern. The use of distraction and redirection can also be helpful. Choices for persons with dementia should be limited. For example, asking if a person wants 'tomato or chicken soup' is preferable to asking "what would you like for lunch." When possible, patients should be asked questions that can be answered yes or no.
Delusions and hallucinations occur during all stages of dementia. In about 50% of individuals with hallucinations, they are temporary.[5] In others, they may persist until death. Delusions are defined as a fixed false belief. Hallucinations are sensory perceptions that occur without appropriate stimulation. Sensory interventions for people with dementia include insuring that hearing aides are functional and in place. Eye glasses should be cleaned and worn properly. Environmentally, lighting should be adequate and auditory stimuli should be minimized. Spaces for ambulation should be free of clutter. Caregivers are advised to recognize that these behaviors cannot be changed by words. The word no should be avoided, and reality testing should be avoided to decrease agitation.
Conclusions
Over the long and unpredictable course of most dementias, care may be provided in a variety of settings that range from home to hospice. Behavioral interventions are recommended as first-line treatment for the behavioral symptoms of dementia.[6] Staff and family caregiver training programs are not readily available in many areas. Therefore, it falls on health care providers to educate caregivers on interventions that can be used to manage dementia.
