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Any redistribution or duplication, in whole or in part, is strictly prohibited,
without the expressed written consent of Teepa Snow and
Positive Approach, LLC

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 Brain Changes in
Dementia

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PET and Aging:

PET Scan of 20-Year-Old Brain PET Scan of 80-Year-Old Brain

ADEAR, 2003
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.

As we age, we do not lose

function in our brains,
unless…
Something Goes Wrong with
Our Brains

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 Normal vs. Not Normal
Normal Aging: Not Normal Aging:
Slower to think Can’t think the same
Slower to do Can’t do like before
Hesitates more Can’t get started
More likely to ‘look before Can’t seem to move on
leaping’
Doesn’t think it out at all
Know the person but not Can’t place the person
the name
Words won’t come – even later
Pause to find words
Confused about past versus
Reminded of the past now
Harder Very different
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Ten Early Warning Signs:

1. Memory loss for recent or new
information, repeats self
frequently
2. Difficulty doing familiar but
difficult tasks: managing money,
medications, driving
3. Problems with word finding,
mis-naming, or misunderstanding
4. Getting confused about time or
place, getting lost while driving,
missing several appointments
5. Worsening judgment, not
thinking thing through like before
© Teepa Snow, Positive Approach, LLC – to be reused only with permission.
6. Difficulty problem-
solving or reasoning
7. Misplacing things or
putting them in ‘odd’ places
8. Changes in mood or
behavior
9. Changes in typical
personality
10. Loss of initiation:
withdraws from normal
patterns of activities and
interests

What Could It Be?

- Another medical condition symptom
- Medication side effect
- Hearing loss or vision loss
- Depression/anxiety
- Acute illness, delirium
- Pain or medication for pain
- Other things

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 Drugs That Can Affect
Cognition in Elders:
Anti-arrhythmic agents Histamine receptor
blockers
Antibiotics
Antihistamines - Immunosuppressant
agents
decongestants
Tricyclic Muscle relaxants
antidepressants Narcotic analgesics
Anti-hypertensives Sedative hypnotics
Anti-cholinergic agents Anti-Parkinsonian
Anti-convulsants agents

Anti-emetics
Washington Manual Geriatrics Subspecialty Consults edited by Kyle C. Moylan (pg 15) – published
by Lippencott, Wilkins & Williams , 2003
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Screening Options:
Old:
- MMSE
New:
- SLUMS – 7 minute screen
- Animal fluency – 1 minute # of animals
- Clock Drawing – 2 step
- Full Neuropsychological testing panel

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What Should the Doctor Do?

- A thorough physical and medical history
- Blood work
- A neurological exam
- A good history from the person and the family
- A complete medication review
- A CAT scan or MRI or PET scan
- Neuropsychological testing: screening for
cognitive changes
- Follow-up and counseling, or at least a
referral
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 So, What is Dementia?
It is not part of normal aging! It is a disease!

It is more than just forgetfulness - which is

part of normal aging

It makes independent life impossible,

eventually

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13

Cognitive Changes with Aging:

- Normal changes: more forgetful and slower to learn

- MCI: Mild Cognitive Impairment: Immediate recall, word

finding, or complex problem-solving problems
-Half these folks will develop dementia in 5 years

- Dementia: Chronic thinking problems in > 2 areas

- Delirium: Rapid changes in thinking and alertness, seek

medical help immediately

- Depression/anxiety: Chronic unless treated, poor

quality of life, “I don’t know” or “I just can’t”
responses, no pleasure, can look like agitation and
confusion
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 © Teepa Snow, Positive Approach, LLC – to be reused only with permission.

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Alzheimers:
- New information lost
- Recent memory worse
- Problems finding words
- Misspeaks
- More impulsive or indecisive
- Gets lost
- Notice changes over 6 months – 1 year

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Positron Emission Tomography (PET)

Alzheimers Disease Progression vs. Normal Brains
Early Late
Normal Child
Alzheimers Alzheimers

G. Small, UCLA School of Medicine. © Teepa Snow, Positive Approach, LLC – to be reused only with permission.

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 Vascular Dementia:
- Sudden changes
- Picture varies by person
- Can have good and bad days
- Judgment and behavior ‘not the same’
- Spotty losses
- Emotional and energy shifts
- 3-30 year duration

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Vascular Dementia:

CT Scan:
The white spots indicate dead cell areas
caused by mini-strokes

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 Latest Thinking About
Vascular Dementia?
- Lots of similarity with Alzheimer’s
- Manage blood flow issues carefully!
- Watch for and manage depression

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Lewy Body Dementia:

- Movement problems, falls
- Visual hallucinations
- Fine motor problems: hands, swallowing
- Episodes of rigidity and syncopy
- Nightmares or insomnia
- Fluctuations in abilities
- Drug responses can be extreme and strange

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Latest Thinking about

Lewy Body Treatment:
- Use AChIs
- Add Namenda early
- Be very careful about anti-psychotic meds
- Parkinson’s meds may help movement but may
make hallucinations and delusions worse
- Anti-depressants and anti-convulsants may be
used to help anxiety, sleep, and depression
but can increase confusion, movement, and
drowsing

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 Fronto-Temporal Dementias:
- Many types
- Frontal: impulse and behavior control loss
- Says unexpected, rude, mean, odd things to
others
- Disinhibited about food, drink, sex, emotions,
actions
- Becomes ‘stuck’ or obsessed about ‘things’
-Temporal: language loss
- Can’t speak or get words out
- Can’t understand what is said, uses nonsense
words

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Pick’s Disease:

PET Scan

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 Latest Thinking About
FTD Treatments:
- Consider Namenda earlier
- Look at SSRI medications
- May use medications used to treat OCD
- May not use AChI Medications

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The person’s brain is dying

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Normal Brain Alzheimers Brain

Used with permission from Alzheimers:The Broken Brain, 1999 University of Alabama
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10
 Learning and
Memory
Center:
Hippocampus
Big Change

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31

Understanding Language – Big Change

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32

Hearing Sound – Not Changed

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 Sensory Strip
Motor Strip
White Matter
Connections:
Big Changes
Automatic
Speech
Rhythm – Music
Expletives:
Preserved
Formal Speech
and Language
Center:
Huge Changes

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Executive
Control
Center:
Emotions
Behavior
Judgment
Reasoning

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Vision Center – Big Changes

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 What is Dementia?
It is both
a chemical change in the brain
and
a structural change in the brain

So…
Sometimes they can and sometimes they can’t

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37

Brain Atrophy:
-The brain actually shrinks
-Cells wither, then die
-Abilities are lost
-With Alzheimer’s, area of
loss are fairly predictable,
as is the progression, but
the experience is
individual

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38

Memory Loss:
Losses:
• Immediate recall
• Attention to selected info
• Recent events
• Relationships
Preserved Abilities:
• Long ago memories
• Confabulation
• Emotional memories
• Motor memories

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13
 Understanding:
Losses:
• Can’t interpret words
• Misses some words
• Gets off target
Preserved Abilities:
• Can get facial expression
• Hears tone of voice
• Can get some non-verbals
• Learns how to cover

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Sensory Changes:
Losses:
- Awareness of body and position
- Ability to locate and express pain
- Awareness of feeling in most of body
Preserved Abilities:
- 4 areas can be sensitive
- Any of these areas can be
hypersensitive
- Need for sensation can become
extreme

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Self-Care Changes:
Losses:
- Initiation and termination
- Tool manipulation
- Sequencing
Preserved Abilities:
- Motions and actions
- The doing part
- Cued activity

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 Language:
Losses:
• Can’t find the right
words/vague language
• Word salad
• Single phrases
• Sounds and vocalizing
• Can’t make needs known
Preserved Abilities:
• Singing
• Automatic speech
• Swearing/sex words/forbidden
words
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Impulse and Emotional Control:

Losses:
• Becomes labile and extreme
• Think it - say it
• Want it - do it
• See it - use it
Preserved:
• Desire to be respected
• Desire to be in control
• Regret after action

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Sensory Processing and

Dementia:
With dementia or brain
change, it matters

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 Five Ways Humans Get
Information:
What we:
- See
- Hear
- Feel
- Smell
- Taste
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46

Two Major Categories of

Sensory Information:

- Protective
- Discriminatory

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Two Categories:
Protective: Discriminatory:
Fast Slower
Reflexive Brain driven
Try to keep you safe Exploring and figuring out
Autonomic – reflexive Details and differences
Big! Focused
Strong Emotions!!! Ignore big world to
experience immediate
Spinal and primitive
Want more or want less
Flight-Fight-Flight

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 With Dementia:
Protective:
-Less able to pick up on
‘danger’ signals/cues
-More likely to over-react to
‘normal’ range
-To non-demented seems
‘unpredictable’
-But, it’s the new
predictable set point
-May move toward
‘dangerous’ versus away
from it
Discriminatory:
-Either hyper-focused or un-
observant
-From multi-modal
awareness to single
characteristic attention
-Shortened task attention
span
-Variable sensory attention
-Atypical focus on a
characteristic: edges of the
frame versus the picture
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With Dementia All Senses

Are Affected:
- Miss information
- Misunderstand information
- Over-react to information
- Under-react to information
- Get stuck on a sensation
- Can’t stand a sensation
- Variable abilities
- Can’t adjust or adapt to sensation
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With Dementia,
It’s All About Finding the
Balance!!!!
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 Balance:
Like Good for you
Want Tolerate
Pleasant Unpleasant
Comforting Annoying
Stimulating Frightening
Calming Boring
Nothing Too much
Familiar New

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Sensation:

A common stimulus
that causes an
individual experience

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The Stimulus:
- Single mode versus multi-modal
- Constant versus intermittent
- Subtle versus extreme
- Still versus moving
- Gradual versus sudden
- Sought out versus given
- Controlled by me versus by you
- Expected versus unexpected

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 Vision Changes:
Protective: Discriminatory:
Peripheral awareness Organized scanning
Visual field Saccadic eye
Depth perception movements
Light-dark Color discrimination
accommodation Figure ground perception
Tracking Near-far accommodation
Blink Near acuity
Night vision
Object recognition
Facial recognition
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Hearing-Comprehension
Changes:
Protective: Discriminatory:
Direction Localization
Emergency signals Comprehension
Alerting communication Sound recognition
Voice recognition
Foreground-background
Tracking
Following a conversation
Interpreting meaning
Multi-step information
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Touch and Movement Changes:

- This one is both complicated and important!
- Sensation, Processing, Reactions and
Responses happen fast! Almost automatic
due to habits and procedural memories:
looping once started
- Active versus passive: different

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 Touch:
Movement: Sensations:
Balance Pressure
Coordination Temperature
Speed Moving touch
Accuracy Texture
Strength Shapes
Bilateral and unilateral
Gross motor
Fine motor
Reflexes

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Touch:
Protective: Discriminatory:
Extreme Temperature Variation in temperature
Sharp, cutting Variable textures
High velocity impact Massage
Sustained pressure Wet/dry
Friction Manipulation
Grasp

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Movement:
Protective: Discriminatory:

Balance against gravity Voluntary movements to

meet goals
Block incoming
Tool use
Avoid contact
Catch balance Object manipulation

Maintain upright Construction

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 Olfactory-Smell Changes:
Protective (becomes Discriminatory:
limited):
Emotional memories
Smoke
Emotional reaction
Chemicals or gas
Pleasant-unpleasant
Spoiled food
Smell identification
Body odor
Stimulate hunger or thirst
Urine or feces
Stimulate nausea
Localization and tracking

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Gustatory-Taste Changes:
- Less able to pick up on sweet and salty,
so they want more!
- Still keep bitter and sour, so they may not
like things they used to
- Things may ‘taste’ wrong, so may order
something then refuse to eat it

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Truths About Dementia?

- It changes everything over time
- It is not something the person can control
- It is not always the same for every person
- It is not a mental illness
- It is real
- It is hard at times

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 Believe:

People with dementia

are doing
the best they can!

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Dementia is not curable,

but it can be treated:
- With knowledge
- With skill building
- With commitment
- With flexibility
- With practice
- With support
- With compassion

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The content contained in this presentation is strictly for informational purposes. Therefore, if you wish to apply concepts or ideas
contained from this presentation you are taking full responsibility for your actions. Neither the creators, nor the copyright holder
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This presentation is copyrighted by Positive Approach to Care and is protected under the US Copyright Act of 1976 and all other
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format, sold, or used in any way other than what is outlined within this under any circumstances without express permission
from Positive Approach to Care.

Copyright 2017, All Rights Reserved

Teepa Snow and Positive Approach to Care

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