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Alzheimer

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Title: Alzheimer


1
Alzheimers Disease and Dementia Care for
Health Plan Case Managers
  • Karen Bugg RN LMSW
  • Institute for Health Care Studies
  • Michigan State University
  • August 16th 17th 2010

2
What does dementia mean?
3
Dementia and the Brain
  • Injury to brain cells causes dementia.
  • Dementia causes a decline in a persons ability
    to think, understand, and remember and affects a
    persons function.
  • Dementia gets worse over time.

4
Dementia
  • Because of memory loss
  • no longer self-sufficient
  • requires ongoing help or supervision
  • functional dependency

5
Activities of Daily Living
  • Bathing
  • Dressing
  • Feeding Self
  • Toileting
  • Transferring
  • Telephone
  • Driving
  • Shopping
  • Meal Preparation
  • Managing Finances
  • Managing Medications

6
Causes of Dementia
  • Alzheimers disease is the most common cause of
    dementia.
  • Other common causes are
  • Vascular dementia
  • Dementia with Lewy bodies

7
Alzheimers definition
  • A progressive degenerative neurological disease.
  • Most common form of dementia in the elderly.
  • Nearly 75 of all dementia cases.

8
Alzheimers in the United States
  • 5.3 million people
  • One person is newly diagnosed every 70 seconds
  • 7th leading cause of death
  • Rates are expected to double every 20 years

9
Alzheimers Disease - Statistics
  • 6-8 of all persons age 65 and older
  • 30-50 of all persons age 85 and older
  • By 2029, all baby boomers will be at least 65
    years old
  • 5.3 million cases currently, will increase to 18
    million by 2040

10
Race Ethnicity
  • Older African Americans and Hispanics are much
    more likely than older whites to have Alzheimers
    disease and other dementias.

11
Michigan
  • In 2008, sixty-eight percent of nursing home
    residents were cognitively impaired.

12
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13
Current Dilemmas in Dementia Care
  • Alzheimers disease is under diagnosed,
    particularly among patients who do not speak
    English as their primary language.
  • Pre-Alzheimers impairments are often attributed
    to normal aging.
  • Denial and fear often delay evaluation.
  • Typical lag time between symptom onset and
    diagnosis is two years.
  • Most patients are not diagnosed by their primary
    care physicians.

14
Impact on health care
  • Today, there are about 4,700 providers, up from
    about 3,300 five years ago.   
  • Alzheimer's disease now accounts for 10.1 percent
    of hospice admissions nationwide, up from 5.5
    percent in 2000.   
  • ALHs beds have tripled over the decade from
    600,000 to 2,000,000..   

15
The Future of Alzheimers Disease
  • Treatment with current FDA approved drugs
  • Disease modifying drugs to induce remission
  • Medications to reverse memory loss
  • Cure

16
Investigational Treatments
  • Passive immunotherapy
  • Active immunization
  • Secretase inhibitors
  • Gene therapies
  • Neurotrophics

17
Brain Anatomy Function
  • Related to Memory

18
Healthy Brain Cells
  • Billions of neurons
  • Axons message transmitters
  • Dendrites message receivers
  • Groups of neurons have special functions

19
Healthy Brain Processes
  • Communication
  • Metabolism
  • Repair

20
Brain Communication
  • Neurotransmitters
  • A chemical messenger between neurons that excite
    or inhibit.

21
Brain Metabolism
  • Brain needs lots of blood to nourish cells with
    oxygen and glucose.
  • Or death to cells.

22
Brain Repair
  • Neurons can live 100 years or more.
  • They must maintain and repair.
  • Injury and illness can destroy.
  • New neurons can be generated in some areas.

23
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24
The Frontal Lobes
  • Help you to do more than one thing at once.
  • Prioritize what to focus on.
  • Sense how much time is passing.

25
When dementia affects the frontal lobes, you may
  • Have difficulty focusing on a task and paying
    attention to what is going on.
  • Be overwhelmed when a caregiver talks and touches
    at the same time.
  • Have difficulty following the logic of an
    argument.
  • Need the most important words said first in a
    sentence.

26
You may also
  • Need short and simple words and sentences.
  • Refuse a bath because you cant think of how to
    do it.
  • Be unable to stop striking or grabbing someone
    because you cant control impulses.

27
Temporal Lobes
  • The temporal lobes help you
  • Understand language
  • Speak
  • Read and write.

28
When dementia affects the temporal lobes, you
may
  • Make non-sense words.
  • Use the wrong sounds when talking.
  • Substitute words or use fewer words.
  • Say yes when you mean no.
  • Not understand what someone tells you.
  • Not understand what you read.
  • Use swear words without realizing it.

29
Parietal Lobes
  • The parietal lobes
  • Help you locate and arrange objects in space.
  • Tell your brain to pay attention to everything
    that is in the space you see.

30
When dementia affects the parietal lobes, you may
  • Use excessive energy putting an arm into a shirt
    sleeve.
  • Put a glass down on the edge of a plate, rather
    than beyond it.
  • Have difficulty responding to objects on the left
    side of your visual field.
  • Have difficulty tolerating clutter, many objects,
    and movement in the room.

31
You may also
  • Feel angry, frustrated, and tired from all of the
    confusing objects and sounds in the environment.
  • Respond better when a caregiver approaches from
    the front.
  • Resist stepping into a tub or shower because you
    cant see the side of the tub, where your feet
    or hands should go, or how deep the water is.

32
Hippocampus
  • The hippocampus creates your memory of recent
    events such as
  • What someone just said.
  • What you had for lunch.
  • Who just visited you an hour ago.
  • Where you parked your car.

33
When dementia affects the hippocampus, you may
  • Repeat a question over and over again.
  • Forget that a family member just visited.
  • Be surprised or angry when a caregiver begins to
    remove clothing when you just agreed to take a
    shower.
  • Lose items repeatedly or store them in the wrong
    place.

34
The Aging Brain
  • And Memory

35
Namenesia

Hi. Im, Im, Im. Youll have to forgive me,
Im terrible with names.
36
Roomnesia
Now why did I come in here?
37
Fleeting thought syndrome
A.K.A. the senior moment
38
Memory loss is not a normal part of aging
39
Decline in mental ability is not inevitable as
people age
  • Neuroplasticity
  • Cognitive reserve

40
Cognitive Reserve
  • Relationship between brain pathology and
    cognitive effect moderated by CR
  • CR markers education, occupation, leisure
    interests
  • Greater CR causes less impact on function with
    similar level of pathology
  • Greater CR leads to steeper decline once
    pathology overwhelms

Yaakov Stern
41
Types of Memory
  • Episodic memory
  • Semantic memory
  • Working memory
  • Procedural memory

42
The Aging Brain
  • Brain tissue volume decreases with age due to
    white matter loss.
  • Regional loss may be gender specific.
  • Frontal regions are more vulnerable to decline.
  • Neurogenesis growth of new brain cells.

43
Aging Vulnerable Processes
  • Processing speed
  • Working memory
  • Divided attention
  • Complex visual processing
  • Long term memory
  • Episodic memory
  • Source recall

44
Preserved Abilities with Aging
  • Priming - an unconscious influence of past
    experience on current performance or behavior.

45
Visual Priming
  • C H _ _ M _ _ K
  • O _ T _ _ U S
  • D _ N O _ _ U R
  • P R _ _ T I _ _ _ I T _ _ _

46
Preserved Abilities with Aging
  • Priming - an unconscious influence of past
    experience on current performance or behavior.
  • Inhibition of stimulus-bound responding.

47
Stroop test
48
Common Causes of Poor Memory
  • Insomnia and impaired sleep (apnea)
  • Drug side effects (antihistamines)
  • Menopause
  • Depression
  • Attention Deficit Disorder
  • Head injury
  • Chemotherapy

49
Problem Medications
  • Antiarrythmics
  • Antiemetics
  • Antihistamines
  • Antiparkinson Agents
  • Antipsychotics
  • Antispasmotics
  • Skeletal Muscle Relaxants
  • Tricyclic Antidepressants

50
Uncommon Causes of Poor Memory
  • Young onset Alzheimers disease
  • Mosquito and tick born disease
  • Brain tumors
  • Toxin and heavy metal exposure
  • Anesthesia
  • Seizures

51
Early Warning Signs of Dementia
  • Frequent repeating / defensive answers
  • Word finding difficulty
  • Mistakes with bills / checkbook
  • Changes in hygiene / grooming
  • Mistakes with medications
  • Geographic disorientation

52
Alzheimers Disease
  • And related disorders

53
Alois Alzheimer 1864-1915
54
Risk Factors
  • Advancing age
  • 65 or older
  • Mild cognitive impairment (MCI)
  • Family history
  • Genetics
  • Young onset
  • Downs Syndrome

55
DSM-IV Diagnosis
  • Decreased cognitive functioning including
  • Memory impairment
  • One or more of
  • Aphasia
  • Apraxia
  • Agnosia
  • Inability to plan, organize, sequence
  • Inability to comprehend abstract concepts

56
DSM-IV Diagnosis
  • These deficits cause significant impairment in
    daily functioning.
  • Gradual onset and continued decline.
  • Not due to other physical or mental medical
    conditions or during the course of a delirium.

57
The Alzheimer Brain
  • Massive cell loss changes the entire brain during
    Alzheimers progression.
  • The cortex shrivels. This damages the brains
    ability to think, plan, and remember.
  • The hippocampus shrivels, which affects the
    ability to form new memories.
  • Ventricles (fluid-filled spaces) grow larger.

58
The Alzheimer Brain
  • Underneath the microscope
  • Alzheimer tissue has less nerve cells and
    synapses.
  • Plaques (abnormal clusters of protein fragments)
    build up between nerves.
  • Dead and dying nerve cells remain in the brain.
  • Plaques and tangles are the prime suspects of
    cell death and tissue loss.

59
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60
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61
Alzheimers progression
  • The early stages of Alzheimers may begin up to
    20 years before a diagnosis is made.
  • Mild to moderate stages last 2-10 years.
  • Severe Alzheimers lasts 1-5 years.

62
Stages of Alzheimers
  • http//www.nia.nih.gov/Alzheimers/Publications/sta
    ges.htm

63
Vascular Dementia
  • Second most common form of dementia.
  • Caused by problems with the supply of blood to,
    or within the brain.

64
Risk Factors
  • Hypertension
  • Diabetes
  • Genetic

65
Symptoms of vascular dementia
  • May develop suddenly then decline in steps.
  • Memory loss may not be the first symptom.
  • Concentration problems.
  • Changes in mood.
  • Physical weakness.
  • Difficulty communicating or conversing.

66
Types of vascular dementia
  • Large stroke (cortical) associated with physical
    impairments.
  • Small stroke (lacune) in the basal ganglia or
    thalamus strategic.
  • Small vessel disease (sub-cortical).
  • Intracranial bleed (intracerebral subdural).

67
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68
Dementia with Lewy Bodies
  • Discovered in 1912 by Frederich Lewy.
  • Common cause of dementia in the elderly.
  • Dopaminergic, cholinergic, noradrenergic,
    serotonergic, and glutaminergic systems affected,
    decreased dopamine D2 receptors.
  • Over 50 of Parkinsons patients develop PDD
    dementiaa Lewy Body dementia.

69
Dementia with Lewy Bodies
  • May coexist with AD
  • 10 to 30 of AD cases have LBs.
  • 32 to 89 of DLB cases have AD changes.
  • AD pathology in DLB is different, less severe,
    more diffuse plaques, rare tangles.
  • Familial form of DLB associated with triplication
    of SNCA gene.

70
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71
Symptoms of Lewy Body Dementia
  • Episodes of altered consciousness
  • Fluctuating cognition
  • Recurrent visual hallucinations
  • Parkinsonism
  • Extreme sensitivity to anitpsychotics
  • Sleep disorders

72
Frontotemporal Dementia
  • Frontal temporal areas of the cortex are
    affectedPicks bodies form and impair neuronal
    function.
  • Fairly common10 to 15 of cases.
  • Onsetage 40-65 60 average.
  • Can last longer than Alzheimers.
  • May be hereditary in 38-60 of cases.

73
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74
The Frontal Lobes
  • Help you to do more than one thing at once.
  • Prioritize what to focus on.
  • Sense how much time is passing.

75
Temporal Lobes
  • The temporal lobes help you
  • Understand language
  • Speak
  • Read and write

76
Symptoms of FTD
  • Behavior and personality changes
  • Personal and social awareness impaired
  • Disinhibition
  • Repetitive behaviors
  • Fixations/obsessions
  • Impulsive
  • Hyperorality

77
Other Dementia Types
  • Wernicke-Korsakoff Syndrome
  • Cognitive problems after chemotherapy
  • Normal pressure hydrocephalus
  • Jakob-Creutzfeld
  • Head Injury

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79
Dementia Diagnostic Process
80
Referrals to a memory program
  • You suspect or know that a dementia problem
    exists
  • AND
  • you are concerned about patient independence or
    ability to manage ADLs at home,
  • OR
  • you are concerned about a caregivers ability to
    manage a patient at home.

81
Clinical Pearl
  • Normal motor examination
  • Cognition worse than behavior....... Think
    Alzheimers
  • Behavior worse than cognition....... Think
    frontal lobe (Picks)
  • Parkinsonian signs on examination
  • No hallucinations early in illness Think
    vascular dementia
  • Detailed visual hallucinations early
  • Think Lewy Body dementia

82
Key points regarding diagnosis
  • The MMSE is a disorganized, fair quality
    screening tool.
  • The Clock Drawing test has drawbacks and
    limitations.
  • 90 of the diagnosis is based upon collateral
    history, which may be inaccurate.
  • A physical and neurological exam is mandatory.

83
Key points regarding diagnosis
  • History and examination findings should not be
    interpreted in a clinical vacuum.
  • Few text book situations occur and overlap
    conditions are common.
  • Not everyone with dementia has Alzheimers
    disease and some have protracted delirium.

84
Benefits of Medical Assessment
  • Diagnostic clarification
  • Identify medical conditions affecting capacity
  • Identify means to enhance capacity
  • Identify less restrictive alternatives
  • Preemptive planning

85
What the health care team must do for the patient
  • Give a clear diagnosis and prognosis
  • Exude optimism
  • Lessen fear and the stigma of dementia
  • Prescribe cognition stabilizer(s)
  • Inform where resources are located

86
What the health care team must do for the
caregivers
  • Provide closure
  • Exude confidence
  • Relieve guilt
  • Provide reassurance
  • Provide support resources
  • Set care giving limits

87
Diagnostic challenges
  • Less than half of all Alzheimers patients know
    that they have the disease.
  • 2/3 are not diagnosed until they reach the
    moderate stage.
  • Published clinical guidelines to facilitate
    diagnosis are infrequently used.

88
Diagnostic challenges
  • No blood or imaging test can reliably diagnose
    any type of dementia.
  • Most diagnoses are made by neurologists and
    neuropsychologists.
  • Demand will soon exceed their supply.
  • Primary physicians will become more responsible
    for diagnosing dementia by necessity.

89
Misperceptions Clarified
  • Alzheimers disease can be accurately diagnosed
    in up to 97 of cases using simple assessment
    techniques in the office.
  • New advancements in treatment will make a real
    impact in the lives of dementia patients.
  • It is terrible to have Alzheimers disease and
    not know it.

90
LTC Rules of Thumb
  • AD can be diagnosed in LTC setting.
  • Imaging is less important.
  • Careful medication review is critical (any
    antihistamine, bladder drug, sleeping pill, TCA,
    potent analgesic, and measurable drug can
    worsen memory and behavior).

91
Dementia Diagnostic Process
  • Review of symptom onset and progression
  • Memory testing
  • Physical and neurological examinations
  • Blood tests
  • Brain imaging

92
Mental Status Testing
  • Orientation
  • Learning and memory
  • Three word item recall
  • Naming ability
  • Name parts of objects
  • Gnosis
  • Describe function of objects
  • Tempoparietal function
  • Language comprehension, ideomotor praxis,
    left-right discrimination
  • Visual constructions
  • Clock drawing, cube copying
  • Working memory
  • Add coins

93
Mental Status Testing
  • Abstraction
  • Explain similarities
  • Attention and concentration
  • Digit span
  • Months of the year reversed
  • Language
  • Fluency, repetition, reading
  • Spatial and object memory
  • Recall where an item was hidden
  • Remote memory
  • Details about significant past events

94
Common Screening Tools
  • Folstein Mini-Mental State Examination
  • Montreal Cognitive Assessment Screening (MOCA)
  • Mini-Cog
  • Functional Activities Questionnaire
  • The Seven Minute Screen
  • Clock Drawing Test

95
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96
Lab Testing
  • CBC, CMP
  • B-12
  • TSH
  • Syphilis testing
  • CSF analysis

97
Brain Imaging
  • CT Scanning
  • MRI
  • PET Scanning

98
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100
Treatment Modalities
  • Pharmacological
  • Behavioral
  • Palliative not curable

101
Realistic Goals of Dementia Treatment
  • Attenuate cognitive and functional decline.
  • Prevent / decrease behavioral and psychiatric
    symptoms.
  • Delay nursing home placement.
  • Lengthen period of self-sufficiency.
  • Reduce caregiver burden.

102
Pharmacologic Arsenal
  • FDA Approved Medications for Treatment of
    Alzheimers Dementia
  • Cholinesterase Inhibitors Prevent the breakdown
    of acetylcholine
  • Donepezil (Aricept), Galantamine (Razadyne),
    Rivastigmine (Exelon)
  • Glutamate Regulator
  • Memantine (Namenda)

103
Pharmacologic Arsenal
  • Medications for the treatment of mood disorders
    and behaviors
  • Antidepressants
  • fluoxetine, citalopram, mirtazepine, sertraline,
    venlaxafine
  • Antipsychotics
  • haloperidol, risperidone, quetiapine,
    zasperidone
  • Anxiolytics
  • buspirone, lorazepam

104
Other Therapies
  • Dynamic psychotherapy
  • Aromatherapy
  • Music therapy
  • Phototherapy
  • Electroconvulsive therapy

105
Prevention of Dementia
  • Stay mentally and physically active
  • Socialize
  • Live a healthy lifestyle
  • Eat a balanced diet

106
Working with clients who have dementia
  • Behaviors of Dementia
  • Behavior Management

107
Cognitive changes
  • These are changes in memory, thinking, and
    learning.
  • Involve a variety of mental skills such as
    attention, problem-solving, memory, language ,
    visual-perceptual skills, and other aspects of
    reasoning and intellect.

108
Dementia can cause difficult behaviors
  • Changes in the brain can cause problems with a
    persons ability to think, understand, and
    respond appropriately.
  • The behaviors result from the disease itself, not
    because the person is trying intentionally to be
    mean or uncooperative.

109
Dementia Behaviors
  • Repetitive questioning or hoarding/obsessive
    behavior
  • Poor judgment
  • Disinhibition
  • Impulsiveness
  • Wandering
  • Insomnia or somnolence

110
Dementia Behaviors
  • Irritability, agitation, restlessness, aggression
  • Social withdrawal, apathy, depression, suicidal
    ideation
  • Hallucinations-sensory
  • An object or event is believed to be perceived
  • Delusions-thoughts
  • Untrue beliefs based on pathology
  • Paranoia and unfounded accusations

111
Prevalence of dementia
  • The reported dementia prevalence in Assisted
    Living and Special Care Units ranges from 40-67.
  • Dementia afflicts a substantial portion of
    elderly patients on the medical-surgical units of
    general hospitals.
  • ALFA (2006) Lyketos, Sheppard, Rabins (2000)

112
Prevalence of behavioral symptoms
  • 56 of residents in AL settings had behavioral
    symptoms related to dementia.
  • Current management methods are insufficient to
    respond to the needs of residents.
  • Boustani and associates (2005)

113
Challenges of dementia
  • Functional challenges
  • Personality changes
  • Mood changes
  • Resistance
  • Lack of Insight
  • Apathy
  • Shadowing
  • Repeating
  • Agitation
  • Aggression
  • Paranoia
  • Wandering
  • Delusions
  • Hallucinations

114
Framework for care
  • Provides for person-centered planning.
  • Organizes the many theories, approaches,
    strategies, and techniques.
  • Comprehensive assessment.
  • Maximize functional independence and morale of
    individuals with dementia.

115
The Habilitation Domains
  • The top 3
  • Physical
  • Functional
  • Emotional

116
The Habilitation Domains
  • Social
  • Sensory
  • Communication

117
The Five Tenets
  • Tenet 1
  • Make the physical environment work.
  • Tenet 2
  • Know that communication remains possible.
  • Tenet 3 Focus on remaining skills.

118
The Five Tenets
  • Tenet 4
  • Live in the patients world behavioral changes.
  • Tenet 5 Enrich the patients life.

119
Link behavior to an unmet need.
  • Link the behavior to one of three human needs
  • Love
  • Usefulness
  • Expression of raw emotions

120
Look at behavior as a means of communication.
  • What is the person trying to communicate?
  • Is it worth responding to or is it simply
    annoying?
  • Pick your battles.

121
What happened before?
  • To help determine reasons for a patients
    behavior, look at its antecedents.

122
Sudden behavior changes
  • May indicate relationship issues.
  • May indicate medical or physical problem.
  • May indicate environmental change.

123
Assess for delirium
  • Abrupt state of confusion
  • Disturbance of consciousness
  • Impairment of cognition and perception
  • One or more underlying causes
  • May be associated with hyperactivity or lethargy

124
Symptoms of delirium
  • Many types of cognitive - behavioral symptoms can
    occur including visual hallucinations, delusions,
    paranoia, manic behavior, aggression, apathy, and
    impaired memory.
  • Sun-downing is not specific to delirium.

125
Risk factors for delirium
  • Severe illness
  • Hypo perfusion
  • Hypoxia
  • Infection
  • Drug toxicity
  • Fractures
  • Alcoholism

126
Risk factors for delirium
  • Dementia (25-50 of all cases)
  • Impaired ADLs
  • Sensory impairment
  • Urinary retention
  • Fecal impaction
  • Physical restraint use
  • Sleep deprivation

127
Assess for pain
  • Ask the resident.
  • Interview the caregivers.
  • Review the medical record for pain-related
    diagnoses.
  • Physical examination and lab studies.

128
Assess for pain
  • Use a validated pain rating system
  • Facial expression
  • Posture
  • Vocalizations
  • Appetite
  • Interactivity

129
Pain Rating Scales
  • Verbal 0-10 scale
  • Abbey pain scale
  • Pain assessment for the dementing elderly
  • Faces Pain scale
  • Pain assessment in advanced dementia (PAINAD)
  • Checklist of nonverbal pain indicators CNPI)

130
Evaluate the consequences
  • Do the behaviors need to change for the comfort
    and the safety of the patient or the caregiver?
  • Some behaviors do not bother the patientdo they
    need to be modified?

131
Set the tone
  • Relax. Center.
  • Use a clear, low, loving tone of voice.
  • Calm, gentle, matter-of-fact approach.
  • Humor.
  • Cheerful.

132
Set the tone
  • Use the mirroring technique.
  • Chat about a happy topic before starting a task.
  • Use short, simple sentences, familiar words.

133
Build trust
  • Use non-threatening, factual words who, what,
    when, where, and how.
  • Avoid asking why something happened or why they
    did something.

134
Do not attempt to reason
  • People with dementia lose their ability to
    reason.
  • Insight is often impaired.

135
Rephrasing
  • The individual is validated/comforted when their
    own words are acknowledged by another.
  • Repeat the gist of what the person has said,
    using the same key words.
  • Use a similar tone and cadence.

136
Use redirection to stop undesired behavior
  • Can the patient be distracted with another
    activity, treat, topic of conversation?
  • You may have to say, Now we are going to
    rather than asking or suggesting a task or
    activity.

137
Reminiscing
  • Exploring the past can help re-establish familiar
    coping methods and ways of handling stress.
  • Use always and never to trigger earlier
    memories.

138
Easier to change the environment
  • Under stimulation
  • Restlessness, pacing, wandering, or calling out.
  • Over stimulation
  • Nervousness, agitation, physical aggression.

139
Progressively Lowered Stress Threshold Concept
(PLST)
  • A proactive intervention to reduce likelihood of
    challenging behaviors.
  • Based on premise that those with dementia have a
    decreased ability to respond to stressors.
  • The cumulative effect of stressors prompts
    behaviors.

140
Stabilize the environment
  • Routine daily schedule.
  • Create a level of quiet and peace.
  • Make sure the patient is comfortable.

141
Maximize sensory input
  • Validate the patients reality without
    exacerbating anxiety
  • Keep simple, but provide multi-sensorial
    opportunities
  • Music
  • Fabrics, pets
  • Touch

142
Identify and Use the Preferred Sense
  • Enables caregiver to speak the persons language
    and improve communication.
  • Builds trust.
  • Vision
  • Hearing
  • Touch
  • Smell

143
Touch
  • Confused individuals often need to feel the
    presence of another human being.
  • Pleasant memories are often evoked.
  • Personal space must be respected.

144
Music
  • When words are gone, melodies return.
  • Comforts, reduces agitation and stress.
  • Provides channel for expression of emotion.
  • Enhances communication.

145
Consider life experiences
  • Former life experiences can play a major role in
    behavior.
  • At times, thinking of the persons former role
    may help in the development of activities.

146
Need for staff training is critical.
  • Staff who are trained in dementia and its
    management are better prepared to care for
    residents.
  • But, nearly 88 of resident assistants thought
    that confusion was a normal consequence of aging.
  • Hawes and Phillips (2000) Luxenberg (2003),
    Alzheimers Association (2005).

147
Education and training will be key
  • Growing elderly population.
  • Projected nursing workforce shortage.
  • Rates of staff turnover are likely to increase.
  • Retention of adequate staff will become even more
    difficult in the future.
  • Callahan, 2001 General Accounting Office GAO,
    2001 Noelker, 2001, Stone, 2001.

148
Awareness of Abuse
  • A closer look at agitation/aggression

149
Abuse
  • Physical, psychological, sexual, and/or financial
    maltreatment, that may be the result of the
    actions of others or may result from neglect by
    others or by self.
  • (Dyer et al., 2000).

150
Prevalence of elder abuse
  • All forms are under-reported
  • 1 to 4 all elders
  • 5.4 to 11.9 for demented elderly

151
Risk factors for elder abuse
  • Excessive physical and psychological demands
    associated with care giving
  • Advanced age
  • Poor health and physical frailty
  • Impaired activities of daily living

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Risk factors for elder abuse
  • Alcohol and substance abuse
  • Psychopathology
  • History of abusive behavior
  • Poor pre-morbid relationships

153
Risk factors for elder abuse
  • Families caring for relatives with Alzheimers
    Disease in the community are particularly
    vulnerable to episodes of violent behavior.
  • Caregiver depression
  • Living arrangement with immediate family member,
    but not spouse
  • Paveza, Cohen, et al. The Gerontologist, 1992

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Abuse from care recipients
  • 57-67 of dementia patients manifest some form of
    aggressive behavior.
  • Nearly 16 patient to caregiver violence.
  • In one study, 66.2 of nursing home assistants
    reported minor physical injuries on a daily
    basis, with 58.2 experiencing more serious
    injury in last 12 months.

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Neuroanatomy of Aggression
  • Many areas of the brain are involved
  • Prefrontal cortices (trouble thinking)
  • Left temporal lobe (short fuse)
  • Limbic system (anxiety moodiness)
  • Hypothalamus
  • Amygdala
  • Brainstem

156
Neurophysiology of Aggression
  • Complex interplay of neurotransmitters and
    hormones
  • Serotonin
  • Norepinephrine
  • Testosterone

157
Diagnose the cause of agitation
  • Infection
  • Injury
  • Pain or discomfort
  • Illness physical, psychiatric
  • Sleep disorders
  • Medication side effects or interactions
  • Environmental triggers
  • People triggers

158
Prevention of agitation or aggressive behavior
  • Address the causes or antecedents
  • Provide a structured environment
  • Provide appropriate activity
  • Address emotional needs
  • Modify caregiver communication techniques and
    approaches
  • Provide sunlight

159
Treatment of agitation and aggression
  • Behavioral
  • Pharmacological

160
Behavioral treatment of agitation and aggression
  • Identify the level of agitation and respond
    accordingly.
  • Mild validate and talk.
  • Moderate structure environment distract.
  • Severe establish understandable limits decrease
    stimuli.

161
Behavioral treatment of aggression
  • Panic Phase
  • Intervention is needed to prevent injury.
  • Get away (pre-planned exit strategy).
  • Obtain assistance.

162
Rescue
  • 911
  • Facility code-response team

163
Psychiatric Hospitalization
  • Careful consideration.
  • Behavioral and pharmacological treatment first.
  • Goal is to eliminate aggressive symptoms and
    return to his/her environment.

164
Medications to treat agitation and aggression
  • No medications are approved by the FDA for the
    specific treatment of aggression.
  • Medications that are used must be monitored to
    determine effectiveness.

165
Medications
  • SSRI Antidepressants
  • Used to treat lowered serotonin levels.
  • sertraline, fluoxetine, citalopram, escitalopram,
    etc.
  • Some effect can be noted in 3 to 5 days, but can
    take two weeks for full effect.

166
Medications
  • Beta-blockers propranolol, metropolol
  • Antipsychotics Risperdal, Haldol, quetiapine
  • Anti-convulsants valproate, Tegretol, Neurontin,
    Lamictal
  • Combination therapy, such as
  • buspirone propranolol
  • valproate anti-psychotic medication

167
About those benzodiazepines
  • Medications, such as Ativan and Xanax, are used
    for anxiety in non-demented patients
  • When used with demented patients, they can
    increase confusion, falls, and agitation.
  • Limit to an as needed basis only.
  • Avoid gels.

168
When to report to APS
  • When the caregiver is unable to protect self
    and/or the care recipient from elder abuse.
  • Other interventions have been unsuccessful.

169
Recommendations
  • The likelihood of aggressive behaviors needs to
    be an expectation among the demented and mentally
    ill population.
  • Improved recognition and assessment.
  • Education and training.
  • Improved reporting.

170
Case Management and Care Coordination
  • Each case is unique.
  • It is never just about the patient.
  • Case management interventions must be directed at
    the patient and his/her caregiver(s).

171
Outpatient Case and Disease Management
  • Case Management Process
  • Engagement
  • Assessment
  • Plan of Care Collaboration
  • Intervention
  • Evaluation

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Assessment for Intervention
  • Due to changes in the brain from dementia, a
    person needs the environment and the caregiver to
    compensate for impaired memory functions.
  • The more we know about how a persons memory
    ability has changed, the more we can target
    successful strategies to improve their quality of
    life.

173
Engagement
  • With whom will you be working?
  • Size up family dynamics.
  • Capacity/insight issues.
  • Medical decision-making.
  • Recognizing and responding to caregiver stress.
  • Empathetic approach.

174
Assessment
  • Biopsychosocial
  • Active listening approach
  • Assess ability/stress of care provider

175
Assessment
  • Patient Goals
  • Caregiver Goals
  • Long term care plans?
  • Existing Strengths and Resources
  • Medical Record
  • Reassess at 6 months

176
Tools for Assessment
  • Case management organizations
  • Biopsychosocial assessment tools via internet
  • Katz activities of daily living
  • Create a short form

177
Plan of Care Collaboration
  • Patient
  • Caregiver(s)
  • Medical providers
  • Community resources

178
Interventions
  • What is needed to keep patient safe?
  • What will provide for patients dignity?
  • What will improve patients quality of life?
  • What offers least restrictive environment?

179
Interventions
  • What communication techniques and behavioral
    approaches will be most effective?
  • What is needed to support the caregiver?

180
Interventions
  • Medication management
  • Financial security
  • Environmental adjustments
  • Personal care assistance
  • Nutrition/hydration
  • Physical exercise
  • Social activities
  • Caregiver support

181
Interventions
  • Identify key agencies
  • Alzheimers Association others
  • Area Agency or Commission on Aging
  • Senior Neighbor Centers and Service
  • Social Security Administration
  • Veterans Administration
  • Secretary of State
  • MDCH
  • Medicare Medicaid

182
Interventions
  • Identify Home Supports
  • Adult day programs
  • Home delivered meals
  • Home helper services
  • Respite care
  • Transportation

183
Interventions
  • Assist with long-term care planning
  • DPOA or guardianship
  • Housing advisors
  • Long term care facilities
  • PACE
  • AL
  • AL dementia
  • Skilled nursing facilities
  • Hospice

184
The Alzheimers Disease Bill of Rights
  • To be informed of ones diagnosis.
  • To have appropriate medical care.
  • To be productive in work and play for as long as
    possible.
  • To be treated like an adult, not a child.
  • To have expressed feelings taken seriously.

185
The Alzheimers Disease Bill of Rights
  • To be free from psychotropic medications, if
    possible.
  • To live in a safe, structured, and predictable
    environment.
  • To enjoy meaningful activities that fill each
    day.
  • To be outdoors on a regular basis.

186
The Alzheimers Disease Bill of Rights
  • To have physical contact, including hugging,
    caressing, and hand-holding.
  • To be with individuals who know ones life story,
    including cultural and religious traditions.
  • To be cared for by individuals who are well
    trained in dementia care.
  • The Best Friends Approach to Alzheimers Care, by
    Virginia Bell and David Troxel 1997 Health
    Professions Press, Inc., Baltimore

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