Overview of Alzheimer

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Overview of Alzheimers Disease and Other
Dementias

• Colloquium
• The Aging Population, Alzheimers and Other
  Dementias
• Law Public Policy
• University of Iowa College of Law
• January 26, 2012
• Kathleen Coen Buckwalter, PhD, RN, FAAN
• Prof. Emerita of Gerontological Nursing
• Co-Director, National Health Law and Policy
  Resource Center

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More than confusion

• Many things can interfere with memory
• Being overloaded having too much going on at one
  time
• Medications, even ones taken according to
  directions
• Illness and disease that are unrelated to brain
  disease
• Unfamiliar surrounding such as relocation or
  hospitalization

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Dementia

• Permanent loss of mental abilities caused by
  damage to brain cells
• NOT a normal part of aging!
• The common end result of many entities
• diseases
• traumas
• infections
• drugs

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Dementia Essential Features

• Progressive loss of intellectual abilities . . .
• MEMORY impairment
• Short-term early
• Long-term later
• Loss of LANGUAGE
• Loss of ability to express oneself
• Loss of ability to understand what is said

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Dementia Essential Features

• Loss of PURPOSEFUL MOVEMENT
• Has the physical ability
• Cant perform the task (e.g., getting dressed)
• Loss of ability to accurately interpret SENSORY
  INFORMATION
• Cannot understand what is seen, heard, felt
• Not related to sensory impairment

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Dementia Essential Features

• Impairments in . . .
• Abstract thinking
• Ability to reason
• Judgement
• Impulse control
• Personality changes
• Not him/herself

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Who has dementia? REVISED

• Dementia is a generic term
• Many different types
• Alzheimers disease ? Most common type
• Risk increases with advancing age
• 25 of 80 year olds
• 33 of 85 year olds
• 50 of 90 year olds

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Who has dementia? REVISED

• Common problem among nursing home residents 50
  to 80 have dementia
• Increasing problem among those in assisted
  living add statistic here

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Dementia Types
Types

• Alzheimers Typea.k.a. Alzheimers Disease
  Most common
• 360,000 new cases annually
• 4 million Americans afflicted
• 4th leading cause of death
• 14 million (1 out of 45) by the year 2050
• 80 of population in nursing homes
• Leading cause of behavioral symptoms

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Dementia Types
Types

• Vascular, a.k.a., Multi Infarct 2nd most
  common
• Mixed Alzheimers AND Vascular 3rd most common

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Dementia Types
Types

• Dementia due to . . .
• HIV Disease
• Parkinsons Disease
• Huntingtons Disease
• Head Trauma
• Substance-Induced Persisting Dementia

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Dementia Types
Types

• Dementia due to . . .
• Picks Disease
• Creutzfeldt-Jakob Disease

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Dementia Types
Types

• Not specifically listedin DSM-IV . . .
• Diffuse Lewy Body Disease
• Frontal Lobe Dementia
• Many medical causes!
• Normal Pressure Hydrocephalus
• Anoxic damage
• Vitamin deficiency

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Dementia Types
Types

• Bottom Line
• All Alzheimers is DEMENTIA . . .
• but not all DEMENTIA is Alzheimers!!

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Dementia Types
Types

• LOTs of variability in presentation!
• Within specific types . . .
• BETWEEN types . . .
• Overlapping syndromes are common
• Dementia AND delirium
• Alzheimers AND vascular dementia

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Reversible Dementia

• Multiple health problems may cause confusion
• Always explore alternative causes
• Treatment of underlying physical problem may
  arrest losses
• Problems not fully reversible but remaining
  capacity may be preserved

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D-E-M-E-N-T-I-A

• D rugs
• E motion
• M etabolic
• E ndocine
• N utrition
• T rauma
• I nfection
• A lcoholism

Like working a puzzle . . .
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Diagnosis of AlzheimersNew Criteria and
Guidelines

• Preclinical Alzheimers Disease
• Mild cognitive impairment (MCI) due to Alzeimers
  Disease
• Dementia due to Alzheimers Disease

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Stages of Dementia for Behavioral and
Environmental Approaches

• Early - Forgetful
• Middle - Confused
• Later - Ambulatory
• Terminal - Endstage

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Early Forgetful

• Short-term memory impaired
• Loses things
• Forgets
• Blames stress, fatigue
• Compensates with lists, memory aids
• Depression common

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Later Confused

• Loss of memory
• Increasing disorientation
• Time
• Place
• Person
• Things

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Confused Example

• Helen crochets using a single simple stitch but
  doesnt remember that she is retired - and
  sometimes puts her bra on over her blouse.
• Harold, greets everyone like his oldest friend
  (Nice to see you! So good of you to drop by! Im
  great! How are you?) but doesnt know his own
  wife.

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Confused Example

• Mildred avoids the question How old are you?
  with Jack Benny and I are both 29. When asked
  what she had for lunch, she replied, I went to
  the Riviera and had pink champagne and caviar.
• George got lost walking in his neighborhood of
  30 years -- as soon as he could no longer see his
  own house.

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Later Still Ambulatory Dementia

• Progressive loss of ability interferes with
  FUNCTION
• Increasingly withdrawn and self-absorbed
• Depression tends to resolve

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Ambulatory Functional losses

• Willingness and ability to bathe
• Grooming
• Choosing among clothing
• Dressing
• Gait and mobility
• Toileting
• Communication, reading, and writing skills

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Ambulatory Behaviors

• Behavioral symptoms more common
• Irritability
• Agitation
• Anxiety
• Pacing
• Reduced tolerance for stress
• Resistiveness to care

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Endstage Dementia

• All abilities lost
• Mute
• No longer walks
• Little purposeful activity
• Forgets to eat, chew, swallow
• Complications are common

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Symptoms Not in distinct stages!

• Losses and symptoms vary from person to person,
  depending on
• Extent of brain cell death and loss
• Location of brain cell death and loss
• Speed with which losses occur

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Common Behavioral Symptoms

• Concealed memory losses
• Wandering
• Sleep disturbance
• Losing and hiding things
• Inappropriate sexual behaviors

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Common Behavioral Symptoms

• Repeating questions
• Repetitious actions
• Territoriality
• Hallucinations
• Delusions
• Illusions

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Catastrophic Behaviors

• Agitation
• Combativeness
• Confusion
• Fearfulness
• Night wakening

• Noisy behavior
• Purposeful wandering
• Sudden withdrawal from activities
• Sundowning

Unexpected, intense, and out of proportion
reactions to a situation . . .
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Dementia Care Practices

• General
• Slow down, Eye contact, Cueing
• Redirecting, Distracting, Reassurance
• Comfort measures (pain meds, food)
• Individualized interventions
• Promote continuity between levels of care
• Pain management
• Interdisciplinary team approach
• Person vs. Disease focus

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Nursing Care Models/Approaches

• Need-Driven Dementia-Compromised Behavior Model
• Understandable needs not disruptive behaviors
• Background/proximal factors
• Progressively Lowered Stress Threshold Model
• Less able to manage stress as a disease
  progresses
• Modify internal/external environment
• Support vs challenge, promote safety/comfort

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Other Models/Approaches to Care

• Person-Centered Approach (Kitwood)
• Understanding vs management
• Well-being/personhood
• DCM
• Validation (Feil)
• Response to feeling/meanings/internal context of
  behavior
• Need to be valued
• (Livingston, et al., 2005 and Old Age Task Force
  of the World Federation of Biological Psychiatry)
  Using Oxford-Center Guidelines

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Formal/Informal Caregiver Interventions

• Psychoeducation and Skills Training
• Change interactions
• Behavioral management
• FIC Staff Education
• Services, social and cognitive support
• Family Counseling
• (Fossey et al., 2006 Maas et al., 1994
  Mittelman et al., 1996 Pusey Richards, 2001
  Schultz et al., 2002)

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• Pharmacological Interventions

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Non-Pharmacological Management of Behavioral and
Psychological Symptoms of Dementia (BPSD) Best
Practices

• Interventions
• No easy answers
• Complicated by changing clinical course
• Principles of Care
• Adjust daily routines
• Change reaction and responses to behaviors
• Monitor and adjust the environment, remove
  triggers
• Adjust interaction and communication strategies
  Gould (2007) Williams (2005)
• (Ballard et al., 2009 Burgener Twigg, 2002
  Smith Buckwalter, 2005)

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Non-Pharmacological Management, contd

• Cognitive training Early Stage (Yu et al., 2009)
• Cognitive stimulation, memory rehab, R.O.,
  Neuropsychological Rehabilitation
• Structured Activities
• Simple Pleasures
• Recreational
• Physical (exercise and movement)

(Alzheimers Assoc, 2007 Buettner et al., 2008
Cohen-Mansfield, Libin Marx, 2007 Kolanowski,
Litaker, Buettner, 2005 Opie, Doyle,
OConnor, 2002 Richeson et al., 2008 Volicer
Hurley, 2003)
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Non-Pharmacological Management, contd

• Socialization
• Pets
• Reminiscence, R.O.
• Video Respite
• Simulated Presence Therapy
• Sensory Enhancement/Stim
• Expressive Arts
• Music
• Aromatherapy
• Snoezelen

(Burge-Allen, Stevana, Burgio, 1999 Gerdner,
2005 Mahoney, Volicer, Hurley, 2000 vanWeert
et al., 2005)
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Summary

• Alzheimers disease is INCURABLE, but not
  UNTREATABLE!
• Preserve enhance remaining abilities
• Avoid unnecessary stress overstimulation
• Treat illness or other complications
• Provide education guidance for families and
  other caregivers