Dementia Boot Camp

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Dementia Boot Camp

• Melanie Bunn, RN, MS, GNP
• melanie.bunn_at_yahoo.com
• Geriatric Grand Challenge Institute Dementia
  Care
• Duke University School of Nursing
• March, 2013

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Objectives

• Describe the structural chemical changes in the
  brain their effect on behavior function in
  people with dementia
• Discuss the limits of current systems of care for
  addressing the needs of people with dementia
  explore alternative approaches

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What are the currentissues/systems of care?

• Risk based dementia prevention
• Diagnosis (Medicare wellness visit)
• Public awareness/community engagement
• Care coordination transitions
• Safety issues
• Managing preventing comorbidity
• Behavioral management/skills
• End of Life Care

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Risk Based Dementia Prevention
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Non-compliance

• Acute illness 20 to 40
• Chronic illness 30 to 60
• Prevention 80
• See the pattern? Why?
• Christensen AJ. Patient adherence to medical
  treatment regimens bridging the gap between
  behavioral science and biomedicine. New Haven
  Yale University Press 2004. Current perspectives
  in psychology.

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SCREEN SHOTALZ prevention
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Risk Based Dementia Prevention

• Nutrition
• Mental exercise
• Physical activities
• Stress management
• Other lifestyle choices
• http//www.alzprevention.org/

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Traditional Approach
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Alternative ApproachMotivational Interviewing
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Screening for DementiaMedicare Annual Wellness
Visit
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DiagnosisPrevious Approaches

• Screening at health fairs
• Evaluation when symptoms are noticed
• Lack of insight/cooperation with assessment
• Absence of baseline
• Attitudes as a barrier to screening
• Untreatable
• Part of aging
• Something to be hidden

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Medicare Annual Wellness Visit

• Normalizes cognitive assessment and screening
• Sets individual baseline
• Identify early changes
• Standardizes simplifies approach
• Research into tools, phone screening

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SCREEN SHOTAnnual Wellness Visit
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Medicare Annual Wellness Visithttp//www.alz.org/
professionals_and_researchers_14899.asp

• Cordell CB, Borson S, Boustani M, Chodosh J,
  Reuben D, Verghese J, et al. Alzheimer's
  Association recommendations for operationalizing
  the detection of cognitive impairment during the
  Medicare Annual Wellness Visit in a primary care
  setting. Alzheimer's Dementia The Journal of
  the Alzheimer's Association. 2012. In Press.
• Alzheimer's Association Medicare Annual Wellness
  Visit Algorithm for the Assessment of Cognition
• Tools highlighted in the recommendations
• Medical Learning Network article on the Annual
  Wellness Visit (billing information on pages 4-6)
  
• Medicare Annual Wellness Visit Fact Sheet

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Diagnosis
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What should happen next?Dont assume, check it
out!

• Physical exam
• (Especially neurological cardiac)
• Lab studies
• Imaging study
• Cognitive evaluation emotional screen
• (What works what doesnt work)
• Functional assessment
• Review medications

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What could it be?Identifying underlying issue

• Possibilities
• Normal aging
• Mild cognitive impairment
• Acute confusion or delirium
• Dementia

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Differential Diagnosis
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DEMENTIA
Lewy Body Dementia
Alzheimers Disease
70-80 Other Dementias
Fronto- Temporal Lobe Dementia
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Go to slide
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Type of Dementia
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Alzheimers Disease
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AD Basic info

• Changes happen over months and years, not hours
  or days
• Usually, changes happen in a slow, steady,
  predictable manner
• STRUCTURAL and CHEMICAL changes
• Structural Plaques tangles
• Chemical Neurotransmitters drop
• Medications impact chemical changes, NOT
  structural changes

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AD Memory

• Early on Storage, not retrieval problem
• Later on Storage and retrieval
• Retained Emotional and motor memory

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AD Common changes

• MOOD
• Blame others defensive
• Blame self depressed
• Impulsive or indecisive
• MOBILITY
• Not impacted until later in disease
• COMMON ISSUES
• Getting lost
• Making mistakes words, finances, decisions
• Can be explainedbut pattern immerges

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Alzheimers

• New info lost
• Recent memory worse
• Problems finding words
• Mis-speaks
• More impulsive or indecisive
• Gets lost
• 2 major types YOUNG or TYPICAL onset
• Notice changes over 6 months 1 year

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Vascular Dementia
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Vascular disease

• Changes depend on where in the brain damage
  occurs so
• Each person and each disease is different
• Changes are often sudden, inconsistent and less
  predicable
• Not a brain disease a circulation disease
• Big change, improvement, plateau, big change
  (swelling then absorbed or revascularization)
• Associated with diabetes, heart disease, high
  blood pressure

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Vascular Dementia

• Can have bounce back bad days
• Judgment and behavior not the same
• Spotty loss (memory, mobility)
• Emotional energy shifts
• Memory, mood mobility can all be impairedor
  not!

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Lewy Body Dementia
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LBD

• Fine motor changes
• Using hands
• Swallowing
• Mobility problems
• Rigidity
• Tremor
• Falls
• Periodic limb movements
• Fluctuations in abilities function (fine one
  day, impaired the next)

• Other changes
• Syncope
• Hallucinations
• Delusions
• Nightmares
• Insomnia
• Memory inconsistent (temporary loss of LT)
• Attention/executive function
• Visual spatial changes
• REM sleep BD

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LBD diagnosis (LBDA website)

• DEMENTIA plus
• 3 core symptoms
• fluctuating cognition (bad days good days)
• vivid visual hallucinations and/or delusions
• motor dysfunction
• OR
• 3 suggestive symptoms
• REM sleep behavior disorder with acting out of
  dreams or excessive daytime sleepiness
• abnormal brain CT/MRI
• extreme sensitivity to antipsychotics/other
  psychotrophic medications

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LBD Medications

• Reactions can be extreme unpredictable or
  opposite than expected
• Parkinsons Disease (tremors)
• Dont always help
• Make thinking and hallucinations worse
• Antipsychotics (hallucinations)
• Dont always help
• Make mobility worse
• AChEI/NMDA (thinking behaviors)
• Antidepressants

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Frontal Temporal Dementia
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Fronto-Temporal Dementias

• Many types
• Frontal impulse and behavior control loss (not
  memory issues)
• Says unexpected, rude, mean, odd things to others
• Dis-inhibited food, drink, sex, emotions,
  actions
• OCD type behaviors
• Hyperorality
• Temporal language loss
• Cant speak or get words out
• Cant understand what is said, sound fluent
  nonsense words

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Common combinations
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Public awareness/community engagement
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Public awareness/community engagement

• TV/magazine/health care offices public service
  ads
• Research/conference blips
• Non-profit local efforts (fund raising/public
  awareness)

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Public awareness/community engagement

• These are your communities and why you are
  here!!!
• Heres what Im doing community education
  programs through ANC, law enforcement education
  through CIT, profession education through ANC,
  Duke SON, AHEC sessions
• ANC, AA, AFA are all reaching out
• You have potential to make more impact!!!

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Public awareness/community engagement

• Alternative approaches
• Going to where people are
• www.alznc.org
• Using informal opinion leaders
• Prostate cancer screening in African American
  communities
• Churches, barber shops, hair salons

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Screen shotALZNC
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Brain Failure

• Structural brain failure
• Chemical brain failure

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Go to slide
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Structural Brain Failure

• One way street
• Depending on type of dementia, changes happen in
  different areas resulting in different changes

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Normal Brain
Alzheimers Brain
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(No Transcript)
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Hearing Sound Not Changed
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Understanding Language BIG CHANGE
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SENSORY MOTOR STRIP
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EXPRESSIVE LANGUAGE
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OTHER LANGUAGE
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(No Transcript)
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Chemical failure

• Fluctuations
• Extremely good moments and
• Extremely bad moments

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PET and Aging
ADEAR, 2003
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Positron Emission Tomography (PET) Alzheimers
Disease Progression vs. Normal Brains
Late Alzheimers
Early Alzheimers
Child
Normal
G. Small, UCLA School of Medicine.
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The 3 major problems (as I see it)

• Current systems of care are set up BY logical
  people FOR logical people
• Reimbursement is based on procedures acute care
  models doesnt recognize the complexity of
  people with dementia
• Efforts to improve systems of care arent keeping
  up with the focus on prevention and treatment

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Dementia update

• Prevalence
• Biology
• Genetics
• Risk factors
• Detection

• Developing treatments
• Testing therapies
• Caregiving
• Health disparities

http//www.nia.nih.gov/alzheimers/publication/2011
-2012- alzheimers-disease-progress-report/
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Screen shot Alz.gov
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NAPA

• Research developing new and targeted approaches
  to prevention and treatment.
• Tools for Clinicians
• Easier access to information to support
  caregivers www.alzheimers.gov
• Awareness campaign

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Alternative Approaches

• Geriatric Grand Challenge Institute Dementia
  Care
• Turning around system care views (inside-out?
  bottom-top?)
• Better communication b/t systems
• Better communication b/t families/informal and
  formal
• Smaller group settings
• Adult day programs/PACE

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Final Questions

• How do the structural chemical changes in the
  brain effect behavior function in people
  with dementia?
• What are the limits of current systems of care
  for addressing the needs of people with dementia
  what are some explore alternative approaches?

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Suggested Next Steps

• Go to the Alzheimers Association site and
  familiarize yourself with the Medicare Annual
  Wellness Visit algorithm and screening tools
• Download the 2011-2012 Alzheimers Disease
  Progress Report from the NIA/NIH Alzheimers site
• Review prevention recommendations on the AFA site