Transcript Executive Functioning in the Aging Population

Executive Functioning in
the Aging Population
Jennifer Essig, MA, CCC-SLP
Disclosures
I received a speaking fee from ISHA for this presentation.
I have no relevant nonfinancial relationships in the products or
services described, reviewed, evaluated or compared in this
presentation.
Learning Objectives
• Identify assessment tools appropriate for geriatric populations.
• Discuss hearing loss and its role in cognition.
• Develop goals to address executive functioning in the aging
population.
• Identify ways to involve team members in intervention.
Executive Functioning
Management of Activities
Controlling, starting, stopping,
regulating, adjusting, planning when
faced with new situations, forming
ideas, storing information in working
memory and accessing it, controlling
emotions, and thinking abstractly (Doty,
2012)
Executive functioning and Life
Nearly every task involves executive functioning
Grocery shopping: List steps involved in this task. How
many did you come up with???
1. Planning your list
2. Taking inventory
3. Projecting your needs
4. Budgeting time for the task
5. Locating items
6. Deciding on bargains-price shopping
7. Budgeting money
8. Recalling items needed-working memory
Normal aging
Working memory increases in childhood but declines in late adulthood
(Dempster, 1980; Park, Smith, Lautenschlager, et al., 1996; Pickering, 2001).
Why?
• Processing speed (Salthouse, 1994, 1996)
• Neural integrity (Lindenberger and Baltes, 1994)
• Breakdown in inhibitory functions (Hasher and Zacks, 1988)
• Regardless, in the aging, executive functions seem to be dependent on the
efficiency of working memory. So, if working memory declines, there will be
an impact on executive functions.
And with memory comes language…
Working memory is crucial to production and comprehension of
language.
• Older adults tend to have smaller working memory spans than young adults
(Borella, Carretti & De Beni, 2008)
• Grammatical complexity decreases when researchers collected language
sampling (Kemper and Sumner, 2001)
• Decline in text comprehension and recall (Kwong See and Ryan, 1996)
• More prone to distractions (irrelevant thoughts, preoccupations) which
affects language processing (Hasher, Zacks and May, 1999)
• With multitasking or the introduction of noise, the speech output in regards
to grammatical complexity reduces and becomes more like that of an adult
with dementia (Kemper, LaBarge, Ferraro, et al., 1994).
Normal health and cognitive decline
Prevalence of dementia in the US
5% in those ages 71-79
24% in the population age of 80-89.
37% prevelance when individual is over the age of 90.
(Lin, O’Connor, Rossom, et al., 2014).
Mild cognitive impairment is between 3-42% in age 65 and older.
40-50% of adults report memory symptoms
29-76% of patients with dementia in primary care settings are undiagnosed
(Valcour et al., 2000)
In 2011, Medicare added detection of cognitive impairment to the annual
wellness visit.
Normal aging and sensory deficits
• Hearing loss is not associated with decreased performance on
memory and attention tasks.
• People with significant hearing loss actually use their working
memory more efficiently to compensate.
• Cognition must be tested using nonverbal memory tests.
• Hearing loss also did not impact sequential learning. These individuals
had same level of decline as the aged group.
Zekveld et al., (2007)
Humes and Floyd (2005)
When you can’t compensate, though…
• Hearing loss not only affects the ability of older adults to detect and
discriminate speech sounds but also the ability to engage in more
effortful semantic and syntactic processing. The effort older adults
have to expend to overcome hearing loss results in decreased ability
to process incoming information. They encode less into memory.
Wingfield, Tun, and McCoy (2005)
Dementia, Brain Injury, Cognitive decline
Neuropathologies
Heavy Hitters:
• Acute Ischemic Stroke
• Intracerebral hemorrhage
• Subarachnoid hemorrhage
• Subdural hematoma
• Traumatic Brain Injury
Infections:
• Brain Abscesses-rare. Usual risk factors might include poorly controlled diabetes
and resulting fungal infections
• Encephalitis-Herpes Simplex Encephalitis is the most common. Untreated it has a
70% mortality rate and few than 3% of survivors return to normal.
• Sepsis
Neuropathologies
Neurodegenerative:
• Multiple Sclerosis
• Lupus
• Alzheimer’s Disease
• Parkinson Disease
• Primary Progressive Aphasia
• Frontotemporal Dementia
• Progressive Supranuclear Palsy
Episodic:
• Seizures
• TIAs
• Migraines
Role of Collaborators
• Referral sources
• Therapy team
• Social work/Discharge planners
• Nursing staff
Hallmarks of Executive Dysfunction
from Geffner 2007
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Easily distracted
Perseverative on response set
Difficulty initiating activity
Difficulty maintaining effort
Difficulty with recognizing and or using feedback
Difficulty modulating actions without cues.
Poor self awareness of deficits.
Decreased social interactions.
Difficulty with organizing demands of discourse.
Insufficient memory and retrieval
Impaired strategic thinking
Executive Dysfunction in Dementia
• Abilities waver. Some days better and some worse, but with disease progression comes
decline in executive functioning.
• Difficulty of the body to do the right steps to perform an action (i.e. putting down a
glass)
• Needing to be reminded to take another bite.
• Difficulty being appropriate and honoring limits (i.e. “Don’t touch” sign)
• Difficulty holding back rude actions or comments. Accusing another “You should have
gotten out of the way.”
• Difficulty keeping emotions stable.
• Difficulty keeping up the pace of an activity or conversation.
• Difficulty thinking about consequences before acting.
• Getting stuck in a rut.
• Difficulty monitoring self to realize a mistake.
Early warning signs
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Notice mild problems at first with finishing a task.
Lack of interest in visiting friends.
Inappropriate behavior at a family function.
Driving Issues: A decline in judgment, decision making, predicting consequences and
handling multiple details at the same time.
• Household Issues: Vulnerable to scams, spend large amounts of money on unused goods,
difficulty paying bills, handling the mail, using machinery. (ex: family tax returns)
Deficits in executive functioning are often seen in early stages of Alzheimer’s disease.
Mild cognitive impairment is considered a risk factor for AD.
Identification Tools
Does the patient live alone?
Does family report changes in social skills, increased isolation?
Does the patient have difficulty learning how to use a new tool?
Does the patient have difficulty remembering appointments?
Does the patient have difficulty with complex problem solving, like cooking, checkbook, etc?
Does the patient have difficulty naming a list of items, such as vegetables? Or while in engaged in that task,
does he/she repeat the same 3 words over again?
In normal aging, there may be a slowing of ability to name items or recall words, but the ability is present. With
cognitive dysfunction, there would be deficits in those areas.
AD8 Dementia screen:
http://knightadrc.wustl.edu/About_Us/PDFs/AD8form2005.pdf
MMSE: Mini-Mental Status Examination
Common patient case presentation
• Patient lives alone. History of falls. Femur fracture. Demonstrating
symptoms of mild cognitive impairment while working with PT/OT.
• TBI s/p burr hole evacuation following a fall at home.
• Uncontrolled diabetes with resultant encephalopathy.
• Early stage Alzheimer’s patient with recurrent UTIs and cognitive
changes.
Panic referral
New evaluation on a patient admitted to ____.
History indicates possible mild cognitive deficits, but patient was
functioning independently at home. H&P indicates that there likely was
the presence of dementia but nothing formally diagnosed.
The person you have in front of your team appears fairly advanced in
the level of cognitive deficits, much more than just “Mild”.
Acute Care Admission
Assessment Tools:
Need a quick and easy tool.
• Bedside screeners: department generated tool
• Standardized: MoCA, MMSE, SLUMS, RIPA-G
• MoCA Blind http://www.mocatest.org/wpcontent/uploads/2015/tests-instructions/MoCA-Test-BLIND.pdf
• MoCA http://www.mocatest.org/wp-content/uploads/2015/testsinstructions/MoCA-Test-English_7_1.pdf
• SLUMS
http://www.drarmandohernandez.com/uploads/1/9/7/4/1974701/sl
ums_with_instructions.pdf
Skilled Nursing Facility
• SNF Assessment Tools:
• Cognitive Linguistic Quick Test: 15-30 min administration. Normed for ages 18-89 on
individuals with acquired neurological dysfunction
• Ross Information Processing Assessment-Geriatric: 55 years or older. Assesses
memory, orientation, vocabulary, listening comprehension. Time: 25-35 min
• Global Deterioration Scale (GDS): assessment of primary degenerative dementia
• ABCD-Arizona Battery for Communicative Disorders: assesses ability to read, name,
describe, define, repeat, answer questions, follow commands, retell a story, recall
and recognize words, copy figures and draw. Standardized on Alzheimer’s population.
Best for early and middle stages. Takes 45-90 min.
• Functional Linguistic Communication Inventory: Mod-severe dementia. If they get a
or 1 on Mental Status subtest of ABCD, administer this. Takes 30 min. Good for
establishing baseline and tracking changes in LTC.
• FROMAJE-Function, Reason, Orientation, Memory, Arithmetic, Judgment, and
Emotional Status.
• FAST-Functional Assessment Staging Test: Coincides with the FLCI.
Examples of Assessment tools
Assessment tools for home health/outpatient
• Home Health or Outpatient:
• Wisconsin Card Sorting: Assesses perseveration and abstract thinking and
executive functioning. For ages 7-89. Takes about 20-30 min.
• Test of Everyday Attention: ages 18-80. Assesses selective and sustained
attention and ability to switch attention sets. 45 min administration time.
Need good visual skills (map reading, telephone directory)
• Behavioural Assessment of Dysexecutive Syndrome: Ages 16-64, individuals
with closed head injury. Rule shifts, zoo map, awareness questionnaire.
• Arizona Battery for Communication Disorders of Dementia (ABCD)
• Comprehensive Trail Making Test: detects frontal lobe deficits, problems with
psychomotor speed, visual search, sequencing, and attention. Ages 8-74. 10
min or less.
Intervention
Move beyond orientation. Start thinking
function!
Acute Care
Goals will focus on patient and family education, proper discharge
planning, and safety/problem solving to ensure a safe discharge.
• Gather information from family members when they are available to
determine prior level of functioning.
• Keep in mind that acute illness/hospital stay is likely impacting cognitive
changes.
• Work with Social Worker/Discharge planners to identify cognitive deficits to
start referral process pre-discharge.
SNF Intervention
Rehab to Home
It’s all about function!
• Medicare and ACO’s are really pushing quick turn around. They don’t
want long term stay as it affects reimbursement.
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Address supports needed in the home.
Work on problem solving with transfers, safety, ADLs.
Train memory with spaced retrieval for steps involved in transfers.
Work on medication management.
Identify key caregivers and address education and training.
Long term stay patient
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Work with team to generate referrals.
Have social work look closely at BIMS scores that are completed monthly.
During quarterly screens, also look at BIMS and ADL scores. Look for declines in function.
Talk to Activities. They often spend the most time with patients.
PT/OT are your friends. Look to them for referrals.
Provide brief inservicing to nursing and therapy staff about normal vs. nonnormal declines in
aging. Discuss the role of speech therapy. Too often do we hear, “They don’t have any
difficulty talking.” Have them put on their cognitive goggles.
• Social work and discharge planning: Got people who might not need to be there…have made
progress physically over the last year and could just use a mental jump to get them into
assisted living. Some people just take longer to heal…doesn’t mean it’s the end of the road.
• CNAs: First line of defense but if they aren’t in your court, you won’t get their help. They can
cue you in to changes in word finding, self care, sleeping patterns, behavior escalation. They
don’t have the level of education, though, to speak SLP.
Documentation
Must have documentation of functional change in the chart.
Nursing staff can document:
• Increasingly confused, disoriented, negative behaviors.
• Change in memory
• Change in safety and judgment
• Change in ability to communicate
Documentation continued
Events can cause functional change
• Depression
• Pneumonia
• TIAs
• UTI
• URI
Exacerbation of chronic conditions
• COPD
• Pain
• Parkinson’s Disease
• Multiple Sclerosis
Other
• Change in lab values
• Weight loss
• Has there been a fall?
Evaluation and goal writing
Document that services are reasonable and necessary. There must be
medical necessity.
Document that you staged the patient and used a standardized
evaluation.
Document how the patients’ status is affecting their ability to function
safely in their living environment or the need to maintain the patient’s
current condition to prevent or slow further deterioration of their
condition.
Terminology to avoid
Avoid unskilled terminology
• Help, monitor, check, review, practice, repeat, exercise, teach, feeling
better, doing well.
Use these words instead:
Modify, assess, establish, implement, individualize, strategy, technique,
skilled, demonstrate, complete, perform, utilize, initiate, self-correct,
achieve, increase, respond, functional outcomes.
Documentation
Prior level of functioning:
“Patient was living at home independently” not enough.
Instead, use
“Patient was living in SNF for 1 year, current nursing notes indicate patient
was independent for ADL’s, ambulation and transfers.”
Or “Patient was living in own home with spouse, required min assistance
with self care, upper and lower body dressing.”
Reason for referral:
Need as much functional data as possible.
“Nursing notes patient with increasing confusion re: finding room and
requesting help with negative outbursts over past 1 month.”
“Nursing notes patient experiencing falling episodes 2 in one week,
increased confusion, decreased use of call light over past 2 weeks.”
Clinical Impressions
This is a 72 year old female presenting with stage 5.5 dementia per
standardized FLCI evaluation and GDS, a change from stage 4 six
months ago. She is demonstrating decreased cognition and orientation,
increased agitation and catastrophic outbursts impacting safety and
quality of life per nursing notes. The change in negative behaviors have
been advancing significantly over past month.
Developing goals for therapy
The goals need to be functional for the patient within his/her living environment and skilled, measurable, attainable, reasonable and
medically necessary.
Sample goals:
Pt will identify 3 basic items for functional grooming and dressing with 50% accuracy.
Pt will provide adequate verbal descriptions of 2 target ADL activities related to self care with ___% acc, 3 of 5 sessions.
Pt will communicate 5 targeted functional needs with 70% accuracy over 5 consecutive sessions with min verbal/visual cues to
increase communication of basic needs.
Pt will attend to 2 social activities in a quiet environment for 15 min with min redirection, 3 of 5 sessions to decrease anxiety.
Pt will utilize visual schedule to attend 2 activities each day 3 of 5 days with min verbal cues for environmental predictability to
decrease anxiety.
Pt will locate their room, 8/10x’s, 3 of 5 days to decrease confusion/anxiety.
Pt will demonstrate appropriate behavior within living environment by staff providing 2 choices during pt’s periods of anxiety over 5
sessions.
Pt will initiate sit to stand sequence, mod verbal cues 8/10 trials over 5 consecutive sessions for transfer safety.
Pt will demonstrate ability to complete home money management tasks with min verbal cues in 8 out 10 trials.
Pt will initiate and correctly sequence functional tasks involving more than 3 steps, such as planning grocery list, without verbal cues
in 4 out of 5 trials.
Intervention for home health/outpatient
Focus will be on function and successful reintegration into the home
environment.
-skills related to medication management
-sequencing required for cooking, cleaning, self-care
-safety in the home: how to use the telephone, call light, kitchen safety,
managing fatigue
-return to driving
-problem solving in and around the home
Goal writing
Sample goals:
Pt will demonstrate ability to correctly set up and execute meal
planning and preparation task with cues less than 10% of the time by
her caregiver/spouse.
Pt will utilize visual schedule system without cues to manage
appointments and medications in 8 out of 10 opportunities
Pt will demonstrate retention and carryover of learned information
following spaced retrieval tasks with 80% accuracy in 4 out of 5
opportunities.
Pt will change response to problem solving task when met with conflict
with 80% accuracy in 4 out of 5 opportunities.
Role of collaborators in
Carryover/Generalization
Establishing functional maintenance plan.
Involving family/caregivers
“Checking in” during quarterly screens
How to rally your team