Dementia

1. SPEECH/LANGUAGE/COMPREHENSION

1.1. Other characteristics of speech

1.1.1. Confabulation

1.1.1.1. spontaneous or provoked use of inaccurate information to fill in memory gaps

1.1.1.2. something that occurs when a person does not know the answer to the question but responds by offering an answer to it with no intention to deceive the one asking the question

1.1.2. ambiguous referents

1.1.2.1. overuse of pronouns where it hasn't been established who/what the pronouns refer to

1.1.2.2. also mentions of proper names as if they have meaning to a listener that has no knowledge of who those people are (and no reason to think the listener would know those names)

1.1.3. spontaneous versus nonspontaneous i.e. does vs doesn't initiate much speech

1.1.4. speech latency (pauses between questions and answers)

1.1.5. Verbal Perseveration

1.1.5.1. the inappropriate recurrence or uncontrolled repetition of a previously produced response—phoneme, word, syntactic structure, semantic feature, idea, and the like—in place of the correct target item

1.2. Paraphasias

1.2.1. Neologistic Paraphasia

1.2.1.1. substitution of words with non-words

1.2.1.2. nonsense words (neologisms / jargon)

1.2.2. Verbal Paraphasia

1.2.2.1. confusions of words or the replacement of one word by another real word

1.2.3. Literal/phonological paraphasia

1.2.3.1. where more than half of the spoken word is said correctly; substitution of a word with a nonword that preserves at least half of the segments and/or number of syllables of the intended word

1.2.4. Semantic

1.2.4.1. errors of meaning

1.2.4.1.1. a word with a similar meaning, such as saying “son” instead of “daughter” or “orange” instead of “apple.”

1.3. Aphasia

1.3.1. Fluent

1.3.1.1. Wernicke's (receptive)

1.3.1.1.1. characterized by fluent (spontaneous, grammatically shaped sentences, preserved prosody) language with made up or unnecessary words with little or no meaning to speech … difficulty understanding others speech and are unaware of their own mistakes…when corrected they will repeat their verbal paraphasias and have trouble finding the correct word. Effortless speech output.

1.3.1.2. Empty speech

1.3.1.2.1. Fluent, sometimes even with eloquent articulation, but is meaningless i.e. lacks substance, devoid of meaningful information (aka 'semantic content')

1.3.1.2.2. irrelevant speech

1.3.2. Anomic

1.3.2.1. characterized by fluent speech complicated by word-finding difficulties

1.3.2.2. circumlocutory speech

1.3.2.2.1. talking around a word or type using approximate or imprecise expressions

1.3.2.2.2. Circumlocution is a phrase that circles around a specific idea with multiple words rather than directly evoking it with fewer, more precise words

1.3.3. Nonfluent

1.3.3.1. Broca's (expressive)

1.3.3.1.1. characterized by non-fluent or telegraphic-type speech - where articles, conjunctions, prepositions, auxiliary verbs, pronouns and morphological inflections (plurals, past tense) are omitted. The word substitutions are infrequent and distortion of consonants and simplification of consonant clusters is frequent. Content words such as nouns, verbs and adjectives may be preserved. Typically, unaware of their errors in speech and do not realize their speech lacks meaning. Effortful speech output.

1.4. Apraxia of speech (AOS)

1.4.1. Motor speech disorder. It involves impaired planning or programming of movements that prevents accurate production of sounds and syllables across words or within multisyllabic words.

1.4.2. most often results from left hemisphere stroke

1.4.3. AOS presents as the only or predominant symptom of a neurodegenerative condition, it is termed primary progressive AOS (PPAOS)

1.5. Speech Intelligibility

1.5.1. unintelligible due to...

1.5.1.1. post-stroke dysarthria

1.5.1.2. edentulous orodyskinesia

1.5.1.2.1. Older adult patients can exhibit choreic-like movements of the lips, tongue, and jaw associated with ill-fitting dentures or lack of dentures

1.5.1.3. Parkinson's disease

1.5.1.3.1. dysarthria

1.5.1.3.2. hypophonia

1.5.1.3.3. tachyphemia

1.5.1.4. orofacial dyskinesia

1.5.1.4.1. speech impairment accompanying TD -- deficits common in timing, phonation and articulation

2. SENSORY MISPERCEPTIONS

2.1. AUDITORY MISPERCEPTIONS

2.1.1. AUDITORY HALLUCINATIONS

2.1.1.1. CAUSES

2.1.1.1.1. DELIRIUM

2.1.1.1.2. ALZHEIMER'S

2.1.1.1.3. SCHIZOPHRENIA/SCHIZOAFFECTIVE D/O

2.1.1.2. Subtypes

2.1.1.2.1. hallucination of running commentary

2.1.2. nonpsychotic auditory hallucinations

2.1.2.1. Auditory release hallucinations (Auditory Charles Bonnet syndrome)

2.1.2.1.1. hallucinatory auditory perception stemming from hypacusis

2.1.3. Pseudohallucinations AKA hallucinosis

2.1.3.1. Involuntary sensory experience perceived as a hallucination but also recognized as a hallucination (I.e. reality sense intact)

2.1.3.2. Experienced as unreal; vivid but circumscribed for other accurate perceptions

2.1.4. thought echo

2.1.4.1. patient hears his/her thoughts spoken aloud, sometimes not psychotic, but rather some people vividly experience their own thoughts)

2.1.4.2. Vividly experiencing one’s own thoughts as having sound

2.2. VISUAL MISPERCEPTIONS

2.2.1. VISUAL HALLUCINATIONS

2.2.1.1. CAUSES

2.2.1.1.1. DELIRIUM

2.2.1.1.2. ALZHEIMER'S

2.2.1.1.3. LEWY BODY

2.2.1.1.4. PARKINSON'S

2.2.1.1.5. SCHIZOPHRENIA

2.2.2. nonpsychotic visual hallucinations

2.2.2.1. Visual Release Hallucinations (Charles Bonnet syndrome)

2.2.2.1.1. Podoll's criteria

2.2.2.1.2. Gold and Rabins' criteria

2.2.3. Illusion

2.2.3.1. Dementia-Related Visual Impairment

2.2.3.1.1. Cortical Visual Dysfunction

2.2.3.1.2. Visual agnosia

2.2.3.2. a mistaken sense perception (visual or auditory); the sensory input is there, but it is misinterpreted

2.3. TACTILE DYSPERCEPTIONS

2.3.1. Formication

2.3.1.1. feeling of insects crawling in, on or underneath your skin

2.3.1.1.1. Withdrawal from drug misuse or alcohol use can also cause formication. The most common drugs that can cause this include: Stimulants: Cocaine, methylphenidate and amphetamines, as well as other stimulant drugs, can cause formication.

3. BEHAVIORS

3.1. PHYSICALLY NONAGGRESSIVE S/SX/BX

3.1.1. Verbal - Vocally Disruptive Behavior

3.1.1.1. aka over-vocalizing, verbal agitation, inappropriate vocalizations, disruptive vocalizing

3.1.1.2. abusive/threatening speech

3.1.1.3. perseveration, repetitive and inappropriate requests, persistent screaming/moaning, repetitive speech, repetitious questioning

3.1.1.4. perseverative speech

3.1.1.4.1. continuous chattering, muttering, singing or humming

3.1.1.5. profane/vulgar speech

3.1.1.6. nonverbal emotional vocalizations

3.1.1.6.1. grunting and bizarre noise-making

3.1.2. Motor

3.1.2.1. Behaviors

3.1.2.1.1. Involunatary

3.1.2.1.2. Voluntary

3.1.2.2. Deficits

3.1.2.2.1. Apraxia

3.1.2.2.2. Dysphagia

3.1.2.2.3. Agnosia

3.1.2.2.4. Thought Process

3.2. PHYSICALLY AGGRESSIVE

3.2.1. combativeness

3.2.1.1. combative behavior, seemingly unmotivated/untriggered, i.e. random

3.2.1.1.1. e.g. patient who randomly strikes another patient

3.2.1.2. agnosia related aggression

3.2.1.2.1. Aggression towards familiar people, e.g. family, because patient cannot recognize them

3.3. INAPPROPRIATE SEXUAL BEHAVIOR

3.3.1. sex talk

3.3.1.1. making explicit sexual comments, overt requests for sexual activity

3.3.1.2. making obscene gestures

3.3.2. sexual acts

3.3.2.1. exhibitionism

3.3.2.2. assault - touching body parts of another person

3.3.2.3. masturbating in inappropriate times/settings

3.3.2.3.1. intentionally exposing genitals, breasts (female), or buttocks, to another person - behavior appears premeditated and deliberate (versus non-sexual disrobing)

3.3.3. implied sexual acts

3.3.3.1. openly reading pornographic material

3.3.3.2. requesting unnecessary genital care

3.4. Feeding

3.4.1. refusal to eat

3.4.2. inability to self-feed

3.4.2.1. often 2/2 apraxia

3.5. Hygiene

3.5.1. refusal to bathe/shower

3.5.2. toileting behaviors

3.5.2.1. urinating or defecating in places other than the bathroom

3.6. “Sundowning” AKA nocturnal delirium, various definitions include:

3.6.1. temporal pattern of agitation, temporally associated agitation

3.6.2. recurring pattern of psychomotor agitation, confusion, and wandering in the evening

3.6.3. temporally specific pattern of recurring disruptive behaviors

3.6.4. disrupted sleep-wake cycle

4. physical resistance

4.1. physical resistance to care

4.1.1. combative with hands-on attempts to prevent falling

4.1.1.1. some patients with dementia and poor safety awareness will become combative with any touching by caregivers, including caregivers who attempt to grab or hold patient who appears to be falling or at risk of falling

4.1.2. combative with care

4.1.2.1. i.e. striking, kicking, biting, etc. caregivers in response to hands-on care

4.1.2.2. sometimes specific to type of care, e.g. combative in response to peri-care or showering; sometimes non-specific, i.e. will become combative with any hands-on care

4.1.3. i.e. physical resistance to care, but without attempting to harm caregiver(s)

4.1.4. sometimes specific to a certain type of care; sometimes non-specific, i.e. will resist any hands-on care

4.2. physical resistance to redirection, e.g. physically resisting redirection from entering others rooms or personal space

5. DELUSIONS

5.1. Feeling of Presence (FP)

5.1.1. Common in patients with Parkinson's disease

5.1.2. a.k.a. "extracampine hallucination"

5.1.3. the vivid sensation that somebody (distinct from oneself) is present nearby; presence of a silent, emotionally neutral human, perceived not as a visual hallucination but as a vague feeling of somebody being near

5.2. misidentification syndromes

5.2.1. Definition

5.2.1.1. Delusional Misidentification is a delusional interpretation that an acquaintance or familiar object has changed into a different person or object,

5.2.1.1.1. deficit of recognition overlap with dementia-related visual impairment?

5.2.2. types

5.2.2.1. Mirrored-Self Misidentification

5.2.2.1.1. personal images in a mirror is a different person

5.2.2.1.2. aka 'Mirror sign"

5.2.2.2. Capgras (“imposter”) syndrome

5.2.2.2.1. belief that someone they know has been replaced by an impostor

5.2.2.3. Fregoli syndrome

5.2.2.3.1. Unfamiliar people or places misidentified as familiar

5.2.2.4. Nurturing syndrome

5.2.2.4.1. Deceased family members believed as still living

5.2.2.5. phantom boarder syndrome

5.2.2.5.1. a type of delusional misidentification syndrome in which the patient believes that someone uninvited is residing in his or her home despite evidence to the contrary

5.2.2.5.2. There is some debate over whether PBS is a delusion or hallucination, it is sometimes difficult to distinguish between the two in dementia, and accurate classification based on common criteria is difficult.

5.2.2.6. Reduplicative paramnesia

5.2.2.6.1. Belief that oneself has been replaced into an identical or near identical duplicated person

5.3. persecutory/paranoid

5.3.1. 73% of delusions in AD

5.3.2. common --> someone is stealing things/money

5.4. delusions of infidelity

5.4.1. 9.5% of delusions in AD

5.5. hypochondriasis/somatic

5.5.1. 1.4% of delusions in AD

5.6. Temporal Disorientation

5.6.1. misremember remote events as recent OR revert to themselves in a previous time (of note temporal disorientation can masquerade as AVH to caregivers, as patients describe remote events as recent, caregivers often misinterpret that as patient having recently heard or seen someone, when in fact the patient was simply recalling a remote memory)

5.6.1.1. dead relatives being still alive

5.6.1.1.1. consider d/t temporal disorientation vs. primary psychosis

5.6.1.2. fluctuating temporal disorientation is considered as the hallmark of delirium

5.7. Delusional Perception

5.7.1. linking a normal sensory perception to a bizarre conclusion, e.g. seeing an airplane means the patient is the president