_____ UNIT 4: ASSESSMENT AND INTERVENTION IN DEMENTIA _____

1. Epidemiological data
Number of people with dementia is rising. Nearly 9.9 million people develop dementia each year. Young onset
dementia accounting for up to 9% of cases (genético) 45-50 años 1 de cada 10 es Joven. Aumenta el coste de tartar la
demencia.
2. Mild Cognitive Impairment
Neurocognitive disorders DSM-V:
a. Mild neurocognitive disorder (cognitive impairment): transitional state between the cognitive
changes of normal aging and dementia. Some individuals with MCI will remain stable over the time,
most of them will progress to dementia and others (minority) will revert to normal cognition.
Memory deficits higher than expected for the subject's age and educational level. No dementia.
Activities of daily living intact or minimally altered. Lack of vitamin b12 = symptoms of MCI.
i. DSM-5:
- Evidence of modest cognitive decline from a previous level of performance in one or more cognitive
domains (complex attention, executive function, learning and memory, language, perceptual motor or
social cognition) based on:
- Concern of the individual a knowledgeable informant, or clinician that there has been a mild
decline in cognitive function, and
- A modest impairment in cognitive performance, preferably documented by standardized
neuropsychological testing.
- The cognitive deficits do not interfere with the capacity for independence in everyday activities (complex
instrumental activities like managing the medication)
- The cognitive deficits do not occur exclusively in the context of a delirium.
b. Major neurocognitive disorder (dementia):
Difference between minor neurocognitive disorder (MCI) and major neurocognitive disorder (dementia) symptom
intensity and level of impairment of ADL [actividades de la vida diaria: Básica (comer, vestrise) instrumental
(medicación, coger el autobús…)] Cognitive continuum showing the overlap in the boundary between normal ageing
and MCI and Alzheimer's disease

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MCI subtypes:
• Amnestic MCI single-domain: the most frequent subtype and with higher risk of conversion to dementia of
the Alzheimer’s type (DAT)
• Amnestic MCI multiple-domain: can progress to DAT and vascular dementia
• Non-amnestic MCI single domain: Lewy body dementia, vascular dementia or Parkinson's disease
Annual rate of conversion to dementia à between 7.5% and 16.5% in clinical studies and between 5.4% and 11.5% in
epidemiological studies.

3. Dementia types
• Dementia: common aspects:
o It is acquired and progressive
o Alteration of several cognitive domains
o It has an organic cause
o The level of consciousness is normal (until more advanced stages of the condition)
o Impaired subject's ability to perform ADL independently
Según el DSM-5:
A. Evidence of significant cognitive decline from a previous level of performance in one or more cognitive domains
(complex attention, executive function, learning and memory, language, perceptual-motor, or social
cognition) based on:
a. Concern of the individual, a knowledgeable informant, or the clinician that there has been a
significant decline in cognitive function; and
b. A substantial impairment in cognitive performance, preferably documented by standardized
neuropsychological testing or, in its absence, another quantified clinical assessment.
B. The cognitive deficits interfere with independence in everyday activities (i.e., at a minimum, requiring
assistance with complex instrumental activities of daily living such as paying bills or managing medications).
C. The cognitive deficits do not occur exclusively in the context of a delirium.
Según ICD-10
G1. Evidence of each of the following:
- (1) A decline in memory, which is most evident in the learning of new information, although in more severe
cases, the recall of previously learned information may be also affected. The impairment applies to both
verbal and non-verbal material. The decline should be objectively verified by obtaining a reliable history from
an informant, supplemented, if possible, by neuropsychological tests or quantified cognitive assessments.
- (2) A decline in other cognitive abilities characterized by deterioration in judgement and thinking, such as
planning and organizing, and in the general processing of information. Evidence for this should be obtained
when possible, from interviewing an informant, supplemented, if possible, by neuropsychological tests or
quantified objective assessments. Deterioration from a previously higher level of performance should be
established.
G2. Preserved awarenenss of the environment (i.e. absence of clouding of consciousness) during a period of time long
enough to enable the unequivocal demonstration of G1. When there are superimposed episodes of delirium the
diagnosis of dementia should be deferred.
G3. A decline in emotional control or motivation, or a change in social behaviour, manifest as at least one of the
following:

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 - (1) emotional lability;
- (2) irritability;
- (3) apathy;
- (4) coarsening of social behaviour.
G4. For a confident clinical diagnosis, G1 should have been present for at least six months; if the period since the
manifest onset is shorter, the diagnosis can only be tentative.
Dementia due to Alzheimer’s disease:

Alzheimer’s disease: the most common form of dementia (60-70% off all cases of dementia). A progressive, irreversible
brain disorder that causes a gradual deterioration of memory, reasoning, executive function, language and eventually
physical function
• Impairment in episodic memory
• Involves a deficiency in the neurotransmitter acetylcholine
• No known cure, treatment is symptomatic
• Brain pathology: amyloid plaques (abnormal accumulations of fragments of the protein beta amyloid between
nerve cells) and neurofibrillary tangles (insoluble twisted fibers that build up inside the neurons and consist
of a protein called tau)

o Neurofibrillary tangles: abnormally phosphorylated tau proteins, which, in their normal state, bind
to microtubules and stabilize them to form a functioning cytoskeleton in neurons. Excessive Tau
phosphorilation and aggregation are the key processes in the formation of neurofibrillary tangles finally leads
to neuronal death.
o Amyloid plaques: contain accumulations of amyloid-β protein together with glial and neurotic debris.
The gliosis (reaction of the CNS to injury of the brain or spinal cord) and neuroinflammation resulting from
accumulation of the amyloid-β protein is itself neurotoxic.

• Amyloid cascade hypothesis: mutations in the amyloid precursor protein (APP) à formation of amyloidogenic
peptides that first aggregate into oligomers, which can interfere with synaptic neurotransmission à amyloid
plaques, which are thought to cause intracellular metabolic alterations that lead to
the hyperphosphorilation of tau proteins à hyperphosphorylated tau proteins aggregate to form
neurofibrillary tangles à alter intracellular metabolism to a sufficient degree to cause neuronal death.

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 • Markers for AD
- Neuropathological: Abnormal levels of concentration of β-amyloid (Aβ42) and tau protein in CSF.
- Genetic: the most studied gene as a risk factor for AD.
- Structural neuroimaging.
- Grey matter atrophy: bigger in patients with early-onset AD; mainly neocortical áreas (especially the occipital
lobe) in the early-onset AD and the hippocampus in the late-onset AD.
- White matter atrophy: parahippocampal atrophy in the late-onset AD and a more diffuse pattern of posterior
atrophy (In splenium of the corpus callosum) and in dorsal temporoparietal regions in the early-onset AD
Functional Neuroimaging (PET): Hypometabolism of the posterior cingulate, the posterior temporoparietal cortex and
the anterior region of the medial temporal lobes.
- Episodic memory: marked difficulty in remembering recent information, but also problems with the acquisition
and coding of information. Low performance in delayed recall. Attenuation of the primacy effect. Intrusion
errors.
- Deficit in semantic memory. Alteration of executive functions. Deficits in visoconstructive capacity.
- IADL and AADL alteration. Anosognosia: alteration of metacognition. The impossibility for updating personal
information due to memory impairment as a possible explanatory hypothesis.

Pharmachological treatment of AD
• First generation of therapies specific for AD
- Cholinergic neurons are the first to be lost. Acetylcholine transferase markers are absent, and
choline up-take and acetylcholine release are reduced in AD. Correcting the reduction of
cholinergic neurotransmission through cholinesterase inhibitors (Rivastigmine, Doenepezil)
• Anti-amyloid strategies:
- Secretase inhibition or stimulation (γ-secretase,β-secretase,α-secretase) and reduction of Aβ42
synthesis (Semagacestat, trials interrupted)
- Prevention of amyloid aggregation: therapeutic agents that bind Aβ42, blocking its aggregation and
producing an anti-inflammatory effect (Tramiprosate).
- Anti-amyloid immunotherapy: anti-Aβ42 vaccine; administration of anti-Aβ42 Anti bodies
(Gantenerumab, Solanezumab, Crenezumab, etc.)
• Anti-tau strategies:
- Tau phosphorylation and aggregation inhibition: reducing Tau hyperphosphorylation by inhibiting
glycogen synthase kinase 3.

Dementia with Lewy bodies (DLB)

The second most common diagnosis of dementia. A type of synucleinopathy. High concentrations and accumulations
of α-synuclein combined with ubiquitin.
Inhibition. Lewy bodies: intracellular inclusions with an eosinophilic core and marked by a peripheral halo. Found in the
substantia nigra, brainstem nuclei, the limbic system, parahippocampal cortices, amygdala, and cortex. Loss of
cholinergic neurons in the nucleus basalis.

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 • Neuropsychological profile of DBL
- Fluctuating cognition
- Early symptoms (parkinsonism, delusions, hallucinations and axiety)
- Anomia, aphasia, apraxia
- Pattern similar to Parkinson’s disease: slow movements, muscle stiffness, limb rigidity…
- Memory loss, episodic and recognition memory
- Visual hallucinations
- Sleep disturbances are common

Parkinson’s disease dementia (pdd)

Movement disorder characterized by bradykinesia, rigidity, rest tremor, and postural instability.
- Typical prodromal symptoms of PD: constipation, anosmia, depression, excessive daytime sleepiness, and REM
sleep behavior disorder. An essential feature differentiating PDD and DLB: the time of onset of dementia in
relation to onset of motor signs:
o DLB: neurobehavioral symptoms precede or occur within the first 12 months of the motor signs.
o PDD: cognitive symptoms have their onset more than 12 months after the onset of parkinsonism.

Frontotemporal dementia
Progressive, relatively selective atrophy of the frontal and temporal lobes. Third most common. Early onset (often in
middle age)
• Causes: abnormal protein aggregation referred to collectively as frontotemporal lobar degeneration (FTLD).
begins with changes in personality and behavior. Disinhibition, euphoria, and poor judgment. Apathy and
eating disturbance.
• Behavioral variant frontotemporal ldementia (Pick’sdisease). The other two: subtypes of the Primary
Progressive Aphasia (PPA) syndromes. The semantic variant is associated with the loss of word knowledge
(e.g., semantic structure of language), while the nonfluent variant is characterized by early disturbances in
motor speech output and loss of syntax (e.g., grammatical structure of language).
• Neuropsychological profile of FTD:
- Memory
Relative preservation of episodic memory in FTD; FTD patients tend to retain information over delays, while AD patients
exhibit rapid forgetting. notable declines in speech and language ability. Reductions in spontaneous speech and
decreased verbal output. Echolalia, verbal stereotypies.

Vascular dementia
• Risk factors for CVD: reduced vascular plasticity, atherosclerosis, hypertension, diabetes mellitus,
hiperlipidemia, history of stroke or transient ischemic attack, coronary heart disease
• Lifestyle variables: smoking, obesity, lack of exercise, and poor nutrition, correlate with cardiovascular risk
factors. They are modifiable risks and represent prime therapeutic targets.
• Subtypes of VaD:
- Strategic infarct dementia: usually one infarct in specific cortical or subcortical area; sudden onset
and stepwise progression.

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 - Multi-infarct dementia: Often viewed as the prototypical vascular dementia syndrome. Multiple
cortical or subcortical infarcts that can be visualized by neuroimaging. Sudden onset of symptoms
with stepwise progressive deterioration and focal neurologic signs.
- Subcortical vascular dementia (also known as small vessel dementia or subcortical ischemic
vascular dementia): cognitive and behavioral changes are more homogeneous than those in multi-
infarct dementia (disruption of prefrontal- subcortical circuits).
The most common site of vascular damage: the middle cerebral artery.

ASSESSMENT AND INTERVENTION IN DEMENTIA

• The Alzheimer’s Disease Assessment Scale-Cognitive Subscale (ADAS-Cog)
• Mattis Dementia Rating Scale-2 (MDRS-2): multidimensional neuropsychological battery for assessing and
grading cognitive impairment in older adults.
• Clinical dementia rating (CDR): a global rating device for grading the severity of dementia.
• CDR judgement and problem solving.

4. Risk and protective factors for dementia

• Protective factors:
o Cognitive reserve
o Diet
o Physical Activity
• Risk factors:
o Hypertension o Tabacco
o Type II diabetes o Traumatic brain Injury
5. Assessment and (non-pharmacological) intervention in dementia
(1) Cognitive Interventions
- Neuro/psychological interventions
- Cognitive stimulation: participation in a range of activities aimed at improving cognitive and social
functioning.
- Cognitive training: guided practice of specific standardized tasks designed to enhance particular
cognitive functions
- Neurorehabilitation: in acquired brain injury; main aim: rapid establishment of independence in
activities of daily living through compensatory strategies
- Cognitive reserve: the brain’s ability to cope with or compensate for neuropathology or damage.
- Systematic reviews:
- Cognitive stimulation in healthy older adults targeting intellectual wellbeing (e.g. brain exercises,
learning a musicale instrument, etc.) improves cognitive outcomes in at least one cognitive domain
(executive function, attention, memory, language and/or processing speed)
- Cognitive based training for improving cognition in older adults with normal cognition: significant
and moderate positive effect on overall cognitive functioning.
- Cognitive training for MCI patients: significant, moderate positive effect on cognition and a
significant and small positive effect on ADLs but not for QoL. Both cognitive stimulation and

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 cognitive training are crucial for reducing the risk of cognitive decline and/or dementia in older
adults with MCI
- Reality orientation: presentation of orientation information (time, place and person-related)
improved sense of control and self-esteem
- Reminiscence therapy (life review therapy) à uses all the senses - sight, touch, taste, smell and
sound - to help individuals with dementia remember events, people and places from their past.
- Use of external memory aids
- Computer-based interventions

(2) Behavioral interventions

- Balancing arousal controls excesses controls the daily activity schedule so that there is a balance between
the time a person is in a high-arousal and a low-arousal state.
- Light therapy - Behavioral modification techniques.
- Establishment and maintenance of routines
(3) Interventions in mood and affect: Music therapy and Animal-assisted therapy

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 _____ UNIT 5: DEPRESSION AND ANXIETY _____

Etiological causes of depression in the elderly:

¡ Retirement
¡ Partner’s death
¡ Physical illness and functional disability
¡ Economic difficulties
¡ Lack of social support
¡ Early cognitive impairment

The public health burden of depression in older adults:

§ Suffering and disability
§ Increased caregiving burden for family members
§ Greater utilization of healthcare resources
§ Increased risk of mortality and of suicide
§ Increased risk of CI and dementia

Prevalence of MDD in older adulthood remains lower than in younger and middle adulthood. Depression in older
adulthood à worse trajectory that is moderated by depression severity, number of previous episodes, and medical
comorbidity.

The differential diagnosis of depression in older adults encompasses major depressive disorder (MDD), bipolar
disorder, bereavement (including prolonged or complicated grief), mood disorders related to a general medical
condition, substance-induced mood disorder and dementia with depressed mood.

Major depressive disorder (MDD): Depressed mood and/or loss of interest or pleasure (anhedonia). Most of the day,
nearly every day for at least 2 weeks. At least 4 additional symptoms:
- Significant weight loss when not dieting, weight gain, or significant decrease or increase in appetite
- Insomnia or hypersomnia
- Noticeable psychomotor agitation or retardation
- Fatigue or loss of energy
- Feelings of worthlessness or excessive guilt
- Diminished ability to think, concentrate, or make decisions
- Recurrent thoughts of death, recurrent suicidal ideation, or a suicide attempt
Clinically significant distress or impairment in social, occupational, or other areas. Symptoms are not due to the effects
of a substance (e.g., drug abuse) or another medical condition.

Clinical features
Ø One or more major depressive episodes separated by periods of remission
Ø Single episode – highly unusual
Ø Recurrent episodes – more common

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From grief to depression
Ø Previously could not be diagnosed during periods of mourning (until 2 months after the loss)
Ø Now recognized that major depression may occur as part of the grieving process

Main manifestations à fatigue, loss of concentration, somatic complaints, crying, insomnia, recurring thoughts of
death.

Multidimensional assessment:
- Biomedical factors: medications, medical conditions co-occuring with depressive symptoms, dementia, past
history of major depressive or bipolar disorder episodes
- Psychological factors: mental state, self-control, self-esteem, personality traits, sleep, etc.
- Social and environmental factors: death of a loved one (or other recent stressors), retirement, recent entry
into a residence, etc.

Compared to younger people, OLDER ADULTS:

¡ Less likely: Endorse cognitive-affective symptoms of depression: dysphoria and feelings of
worthlessness/guilt
¡ More likely:
¡ Sleep disturbance, fatigue, psychomotor retardation, loss of interest in living, and hopelessness
about the future
¡ Subjective complaints of poor memory and concentration.
¡ Slower cognitive processing speed and executive dysfunction are frequent findings from
objective testing
¡ Suicide rate in older population: 14%, suicide rate in general population: 5%
¡ Elderly people: higher suicide rate and lower parasuicide rate
¡ Risk factors: male sex, living alone, recent widowhood, social isolation, chronic illness, alcoholism, economic
difficulties

MDD in the elderly is accompanied by structural and functional abnormalities in the frontal lobes and their connections
with limbic and striatal systems.

Disruption of the “cognitive control network” à dorsolateral prefrontal cortex, dorsal and rostral regions of the
anterior cingulate, and parietal association regions
Symptoms of executive dysfunction: a tendency to attend to irrelevant information, impaired concentration,
disorganization, difficulty shifting attention, perseveration

Pseudodementia à depression with reversible dementia

- a cognitive impairment reaching the severity of dementia but subsides upon remission of depression
- a large percentage of patients with depression with pseudodementia progress into irreversible dementia
within 2–3 years
- patients with pseudodementia often have impairment of both recent and remote memory, in contrast to
Alzheimer's dementia, which is characterized initially by impairment of recent memory
- patients with AD often try to confabulate and try to minimize their deficits, whereas those with
pseudodementia tend to highlight their deficits.

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Depression is 56% less likely to be diagnosed in older patients à
- Older adults deny or do not report depressed mood, rather may focus on somatic symptoms
- The healthcare profesional may choose to focus on seemingly more urgent physical problems that compete
for attention
- The clinician may discount depressive symptoms because they make sense in the psychosocial context of the
patient’ s life

Clues in an ambulatory patient (in order to enhance recognition):

- help-seeking, with persistent complaints of pain, fatigue, and insomnia as well as multiple diffuse symptoms;
- frequent calls and visits to the physician (high utilization of services).

Challenges in interpreting diagnostic features of depression in older adults

- Loss of pleasure (anhedonia) à should be distinguished from the apathy of dementia or other neurologic
conditions
- Loss of appetite or weight à also present in other concurrent illness or dementia
- Sleep disturbances à also occur with chronic pain and many physical illnesses
- Psychomotor retardation à characteristic of neurologic illnesses, similar to the inability to think,
concentrate, or to make decisions

Different approaches to diagnosing depression in the context of concurrent medical and neurologic disease
- Exclusive approach à does not consider neurovegetative symptoms in the diagnosis
- Substitutive approach à replaces neurovegetative symptoms with other or additional cognitive symptoms
(e.g. both feelings of guilt and worthlessness can be counted towards the five symptoms)
- Etiologic approach à evaluates each symptom separately as to pathogenesis (the clinician makes a clinical
judgment on whether a specific neurovegetative symptom can be attributed to a depressive disorder or is
caused by a concurrent physical illness)
- Inclusive approach à counts all depressive symptoms as present, regardless of their potential causes

Depression may be:

- Underdiagnosed: Overattributing these symptoms to the physical illness
- Overdiagnosed: Failing to take the physical illness into account

Psychological intervention
– CBT, Behavioral activation, Acceptance and commitment therapy, Problem-solving therapy AND
Physical exercise (aerobic and weight training)
Problem-solving therapy (PST) à behavioral deficits of patients with late-life depression and executive dysfunction
- Patients are instructed to identify problems, brainstorm different ways to solve them, create action plans,
perform a cost-benefit analysis, and evaluate the effectiveness of potential solutions.

Assessment
- GDS Geriatric Depression Scale
- BDI Beck
- SSI Scale for Suicide Ideation

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 • Lower prevalence than in younger populations
• Prevalence rates of anxiety disorders among older adults à 1.2%–15% in community samples and 1%–28%
in clinical samples
• Phobias and generalized anxiety disorder (GAD) à the most frequent
• High comorbidity with depression (about 40% in the elderly)
• Older adults with panic disorder and social anxiety disorder (SAD) are more likely to present suicidal ideation
compared with younger adults with these disorders. Older adults with SAD present higher rates of suicidal
ideation compared with older adults with other anxiety disorders.
Risk factors:
• Female • Dysfunctional coping strategies
• Hypertension • Retirement
• Cognitive impairment • Bereavement
• Presence of chronic diseases • Institutionalization
• Personality (neuroticism) • Lack of social support
• External locus of control

Differential symptom presentation

• Older adults present more concerns about health compared to younger adults, whose worries are more
focused on finances and family
• Report less of almost every negative affective factor (e.g., depression, guilt, shyness, hostility…) than younger
adults
• Are more likely to experience anxiety directly (e.g., fearful, scared, afraid) compared to younger adults,
whose anxiety is more characterized by shame or guilt
• Report particular fear situations or objects typically not included on existing fear surveys (e.g. fear of being a
burden on their families)

High medical comorbidities: Somatic ítems à make the differentiation between medical and psychological causes of
anxiety complicated in the elderly
High comorbidity with other mental disorders
• With age, anxiety and depression comorbidity seems to increase
• Coexistence of anxiety and dementia: presence of agitation; anxiety symptoms are not always detected,
because of their inability to report their own subjective experiences in an accurate manner

Assessment
• Interview
• Assessment tools:
• Beck Anxiety Inventory
• State Trait Anxiety Inventory
• Hamilton Anxiety Rating Scale
• Geriatric Anxiety Inventory
• Geriatric Anxiety Scale

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 • Adult Manifest Anxiety Scale: 44-item self-report scale composed of a general anxiety factor (Total
Anxiety Scale), three anxiety subscales (fear of aging, physiological anxiety, and
worry/oversensitivity), and a Lie scale.
• Worry Scale: 35 items that assess financial, health, and social worries commonly associated with
aging; 5-point Likert scale (from 0-never to 4- much of the time).

Psychological treatment: Psychoeducation, Self Registers, Progressive muscle relaxation, In vivo exposure therapy,
Systematic desensitization and Cognitive restructuring

Which of the following is a major protective factor for depression in older adults?
• Higher educational level
• Higher socio-economic level
• Close social network
Which of the following affirmations is incorrect related to depression in older adults?
• Depressed older adults present more somatic complaints than younger adults
• Depressed older adults are more likely to present feelings of worthlessness/guilt compared to younger adults
• Suicide rate in the older population is higher than the one in the general population
Which of the following anxiety disorders is less common among older adults?
• Agoraphobia
• SAD
• Panic disorder
What is pseudodementia and what are some of the signs that help clinicians to differentiate It from a real dementia?

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 _____ UNIT 6: ASSESSMENT AND INTERVENTION IN DEPENDENCE_____

Concept of dependence
- Dependent person is someone limited in their ability to function independently daily over an extended period
of time, due to mental and/or physical disability.
- Dependency law (Spain): “the permanent state in which people who, for reasons derived from age, illness or
disability, and linked to the lack or loss of physical, mental, intellectual or sensory autonomy, need the
attention of another or other persons or important aids to carry out basic activities of daily living or, in the
case of people with intellectual disabilities or mental illness, other support for their personal autonomy.”

Benefits linked to services and financial benefits.

Requirements:
• Be a Spanish citizen and reside in Spain. Moreover, residents should have lived in the country for at least five
years, of which the last two should be immediately prior to the application for support; or be a Spanish
returnee.
• Have one of the 3 degrees of dependency:
• Benefits linked to services: include different ways of assisting dependent persons in their own house or in a
residential home, depending on their needs. They can be assisted by both professional careers and their own
family. Beneficiaries must pay part of the costs, depending on their financial circumstances and the service
available
• Financial benefits: Financial benefits vary according to the person's degree of dependency, but these are only
available if the beneficiary does not receive other similar benefits and it is impossible to offer support through
specific services
Distinguishes three different degrees of dependency:
• GRADE I. Moderate: to people who need the support of someone else at least once a day to carry out their
daily basic activities, or who need intermittent or limited support.
• Help for several ADLs
• At least once a day
• Needs of intermittent or limited support for personal autonomy
• GRADE II. Severe: People at this level need support several times a day to carry out their daily basic activities.
• Help for several ADLs
• Two or three times a day
• Does NOT require the permanent presence of a caregiver
• Need for EXTENSIVE SUPPORT for personal autonomy
• GRADE III. Great: People at this level need continuous support from another person.
• Help for several ADLs
• Several times a day
• Indispensable and continuous support from another person because:
• Loss of physical, mental, intellectual or sensorial autonomy
• Need of generalized support for personal autonomy

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Two decision levels:
• Ability to perform ADL
• Need for support and supervision to carry them out

Difference between functional capacity and Independence in ADL?

- Functional capacity à reflects the ability to execute a task in a test situation related to a daily physical
activity.

- Degree of dependency in ADLs à a measure of disability based on the assistance a person receives with
these activities and may be more influenced by factors such as cognition, environmental demands, use of
assistive devices, and the caregiver’s estimation of the need for assistance

Lower functional capacity and dependency in transfer and dressing (Barthel scale) associated with depressive
symptoms. Overall, ADL performance did not have an independent association with depressive symptoms. A person’s
physical ability to perform a task, rather than whether he or she receives help while performing it, may be more
important for self-esteem or self-efficacy.

Related Factors:
• Physicals conditions:
- Limited health and physical dependence
- Reduced mobility + decreased muscle strength à falls and accidents
- Presence of chronic diseases: arthritis, osteoporosis, cardiovascular diseases à mobility restrictions and
chronic pain
- Sensory limitations
• Psychological conditions: e.g. Dementia and depression; self-esteem and self-efficacy
• Contextual conditions:
- Dependence can be the result of model of interaction and social attention
- Excessive protection à stereotypes or prejudiced attitudes towards the elderly à premature loss of
independence, higher rates of early mortality and depression (the “self-fulfilling prophecy”)

Little's Model (1988) on the interactive process between the elderly and their caregivers:
- Negative expectations of the caregiver in relation to the ability of the elderly
person to perform an independent behavior
- Overprotective behaviors
- Deprives the elderly person of opportunities to carry out the behavior
- Lack of practice and loss of habits with an associated perception of feeling
useless à decreased capacity and increased dependence
- Initial negative expectations are met

The probability of disability increases with age: approx. 80% of people> 85 years suffer from some kind of disability in
daily life
Women: prevalence rates higher than those of men
Higher rate for mobility-related disabilities

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BADL and IADL à
- Básicas: vestirse, comer, arreglo personal, movilidad, utilizar esfínteres…
- Limpiar, telefonear, hacer compras, cuidar, lavar y arreglar ropa…

Assessment tools
- Information given by others: direct and retrospective or immediate observation by family or professionals
- Katz Index: observations on the best performance of the elderly in BADL
- IADL scale of the Philadelphia Geriatric Center (Lawton and Brody scale): dependent / independent, 8 áreas
- FAQ

Intervention programs
• Elderly people: behavioral plasticity à optimize their behavior in daily life through learning strategies and / or
environmental manipulations
• In the past: focus on the BADL
• Today:
- including more IADL (people living alone in their own home or community)
- Interventions focused on physical aids and environmental reorganization rather than on the acquisition of
skills.

Importance of a detailed and reliable assessment of the skills of the elderly and the presence of possible dependent
behaviors. Differentiate between real limitations and limitations due to overprotection offered by the medium in
which it is immersed

Program of skills of daily living (Executioner, 2000): personal hygiene, cleaning, prevention of accidents at home,
purchase and conservation of food, preparation of meals and use of kitchen utensils, etc.

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