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Dementia/ Delirium an Overview


Medications may not be useful in treating sexual symptoms. Symptoms may indicate an atypical dementia such as Lewy Body Dementia or Pick s Disease. – PowerPoint PPT presentation

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Title: Dementia/ Delirium an Overview

Dementia/ Delirium an Overview
  • October 2011

Introduction to Harvest Healthcare
  • Experience. Education. Excellence.
  • Harvest is a leading full-service behavioral
    health provider, specializing in the delivery of
    progressive and innovative consultative
    behavioral health services for patients and
    residents residing in skilled nursing,
    rehabilitation, and assisted living facilities.
    Our multidisciplinary team of highly skilled
    professionals work together to offer a broad menu
    of services including but not limited to 24-hour
    prescriber on-call services and hospitalization
    support, comprehensive cognitive assessments,
    documentation review, OBRA compliance support and
    customized educational programs designed for the
    individual needs of your facility.

  • This presentation was developed for the
    continuing education of health care providers
  • At the conclusion of this presentation the
    audience will have a basic understanding of
    dementia and delirium, symptoms and management.
  • Mental health care professionals should be
    consulted for the treatment of patients with
    dementia or delirium.

Dementia (taken from Latin, originally meaning
"madness", from de- "without" ment, the root of
mens "mind")
  • Is a serious loss of cognitive ability in a
    previously unimpaired person, beyond what might
    be expected from normal aging.
  • It may be static, the result of a unique global
    brain injury, or progressive, resulting in
    long-term decline due to damage or disease in the
  • Although dementia is far more common in the
    geriatric population, it may occur in any stage
    of adulthood.

  • Is a non-specific illness syndrome (set of signs
    and symptoms) in which affected areas of
    cognition may be memory, attention, language, and
    problem solving.
  • It is normally required to be present for at
    least 6 months to be diagnosed cognitive
    dysfunction that has been seen only over shorter
    times, in particular less than weeks, must be
    termed delirium.
  • In all types of general cognitive dysfunction,
    higher mental functions are affected first in the

Diagnosis of Dementia
  • The earlier the better as there are medications
    that slow the process of cognitive loss.
  • Diagnosis is made through the review of medical
    history, review of medical record, medical
    evaluation and cognitive testing with multiple
  • MMSE is no longer the standard for detection as
    it is unreliable.

Orientation concerns
  • Especially in the later stages of the condition,
    affected persons may be
  • disoriented in time (not knowing what day of the
    week, day of the month, or even what year it is),
  • in place (not knowing where they are),
  • and in person (not knowing who they are or others
    around them).

Behavioral and psychological symptoms of dementia
  • Dementia is a condition in which individuals
    progressively lose cognitive function and, as a
    result, often develop difficult behaviors that
    cause stress for both patients and their
    caregivers. These behaviors, are collectively
    known as behavioral and psychological symptoms of
    dementia (BPSD).
  • BPSD include screaming, wandering, resisting
    care, hitting, and psychological symptoms such as
    depression, psychosis, and sexual disinhibition.

  • BPSD is prevalent in nursing homes where 67-78
    percent of patients have dementia and, of them,
    76 percent exhibit BPSD.
  • In fact, it is common for patients to be
    institutionalized because of BPSD, so clinicians
    must become proficient in assessing and managing
    these symptoms.

  • Acetylcholinesterase inhibitors Tacrine
    (Cognex), donepezil (Aricept), galantamine
    (Razadyne), and rivastigmine (Exelon) are
    approved by the United States Food and Drug
    Administration (FDA) for treatment of dementia
    induced by Alzheimer's disease. They may be
    useful for other similar diseases causing
    dementia such as Parkinson's or vascular
  • N-methyl-D-aspartate Blockers. Memantine
    (Namenda) is a drug representative of this class.
    It can be used in combination with
    acetylcholinesterase inhibitors.

Off-Label Medications
  • Antidepressant drugs Depression is frequently
    associated with dementia and generally worsens
    the degree of cognitive and behavioral
    impairment. Antidepressants effectively treat the
    cognitive and behavioral symptoms of depression
    in patients with Alzheimer's disease, but
    evidence for their use in other forms of dementia
    is weak.

Anxiolytic drugs Many patients with dementia
experience anxiety symptoms.
  • Although benzodiazepines like diazepam (Valium)
    have been used for treating anxiety in other
    situations, they are often avoided because they
    may increase agitation in persons with dementia
    and are likely to worsen cognitive problems or
    are too sedating. Buspirone (Buspar) is often
    initially tried for mild-to-moderate anxiety.
    There is little evidence for the effectiveness of
    benzodiazepines in dementia, whereas there is
    evidence for the effectiveness of antipsychotics
    (at low doses).

Antipsychotic drugs Both typical antipsychotics
(such as Haloperidol) and atypical antipsychotics
such as (risperidone) increase the risk of death
in dementia-associated psychosis.
  • This means that any use of antipsychotic
    medication for dementia-associated psychosis is
    off-label and should only be considered after
    discussing the risks and benefits of treatment
    with these drugs, and after other treatment
    modalities have failed.
  • In the UK around 144,000 dementia sufferers are
    unnecessarily prescribed antipsychotic drugs,
    around 2000 patients die as a result of taking
    the drugs each year.

  • One of the greatest impacts on quality of life
    for patients with dementia is the presence of
    agitation behavior in the middle stages of the
    disease process.
  • More than half of patients with dementia exhibit
    some type of "agitation" behavior over the course
    of a year, in addition to depression or
  • Experts suggest that the best way to manage
    agitation is through environmental and atmosphere
    changes rather than medications. Medications are
    a last resort.

  • Behavior management experts define "agitation
    behavior" as "inappropriate verbal or motor
  • Non-aggressive Verbal Behavior Incoherent
    babbling, screaming or repetitive questions is
    frustrating to the caregiver and family members,
    especially as a sign that the person with
    dementia is "losing it."

  • Non-aggressive Physical Behavior Pacing,
    wandering, repetitive body motions, hoarding or
    shadowing represent ways for the person with
    dementia to communicate boredom, fear, confusion,
    search for safety or inability to verbalize a
    request for help or a feeling of pain.

  • Aggressive Verbal Behavior Cursing and abusive
    language can be shocking when the person with
    dementia was previously upright and proper.
  • Aggressive Physical Behavior Clearly, physically
    aggressive behavior such as hitting, scratching
    or kicking can be dangerous or life-threatening
    to the caregiver and care recipient.

  • Men are twice as likely to exhibit aggressive
    behavior, especially in the middle to late stages
    of the disease, or if they have major depression.
  • The degradation of different parts of the brain
    causes aberrant behavior. Other conditions, such
    as pain, can also lead to it.

  • Some caregivers cope by ignoring agitation
    behaviors. This is one of the worst things to do
    since it ultimately makes things worse for both
    the caregiver and the person with dementia.
  • The stress placed on the caregiver at home by
    these agitation behaviors often forces premature
    placement in a nursing facility, health problems
    for the caregiver and lessened quality of life
    for both.

Understanding Agitation Behavior
  • Experts say that all types of behavior are forms
    of communication. The patient is trying to tell
    you something even though the disease has robbed
    them of other ways (i.e., talking) of telling
  • They may be expressing depression or pain and
    the person does not know how to express it in
  • Some experts believe that agitation behavior is
    "the inability the deal with stress."

  • Refers to a state of confusion at the end of the
    day and into the night. The cause isn't known.
    But factors that may aggravate late-day confusion
  • Fatigue
  • Low lighting
  • Increased shadows

Some tips for reducing sundowning
  • Plan for activities and exposure to light during
    the day to encourage nighttime sleepiness.
  • Limit caffeine and sugar to morning hours.
  • Serve dinner early and offer a light snack
    before bedtime.
  • Keep a night light on to reduce agitation that
    occurs when surroundings are dark or unfamiliar.
  • In a strange or unfamiliar setting such as a
    hospital, bring familiar items such as
    photographs or a radio from home.

  • When sundowning occurs in a care facility, it may
    be related to the flurry of activity during staff
    shift changes. Staff arriving and leaving may cue
    some people with dementia to want to go home or
    to check on their children or other behaviors
    that were appropriate in the late afternoon in
    their past. It may help to occupy their time
    during that period.

Is Behavior Event-Related?
  • Organization by the caregiver will help a great
    deal in beginning to combat these behaviors
  • Modify the environment to reduce known stressors
    (e.g., shadowy lighting, mirrors, loud noises)
  • Note patterns of behavior and subtle (and not so
    subtle) clues that tension and anxiety are
    increasing (i.e., pacing, incoherent
  • Dysfunctional behavior often increases at the end
    of the day as stress builds as the person becomes

Certain stressors can trigger agitation behaviors.
  • As the caregiver, you have to use all of your
    senses to understand the environment and the
  • Fatigue
  • Change of Environment, Routine or Caregiver
  • Affective Responses to Perception of Loss
  • Responses to Overwhelming or Misleading Stimuli.
  • Excessive Demand
  • Delirium

  • If confusion and agitation increase late in the
    day, suspect that fatigue may be a factor.
  • Encourage rest or have quiet periods for up to
    two times a day.

Change of Environment, Routine or Caregiver
  • Sameness and routine help to minimize stress in
    the patient with Alzheimers Disease.

Affective Responses to Perception of Loss
  • This means that persons with dementia still have
    memories and perceptions of activities that they
    used to enjoy. They miss being able to drive a
    car, cook or care for children.
  • Safe activities should be substituted to deal
    with grief and loss.
  • Depression should be treated.

Responses to Overwhelming or Misleading Stimuli
  • Excessive, noise, commotion or people can trigger
    agitation behavior. Researchers have found that
    more than 23 people in a group (e.g., dining room
    or holiday party) can cause undue stress in a
    person with dementia. The television, mirror
    image, dolls or figurines may represent extra
    people in the environment.
  • Before medicating with anti-psychotic drugs, the
    health care team should consider these
    environmental factors.

Excessive Demand
  • Caregivers and families must accept that the
    individual has lost (and continues to lose)
    mental functions. No amount of quizzing, reality
    orientation, "brain exercises," retraining or
    pushing them to try harder will improve their
    mental capabilities. Indeed, it can cause stress
    and a sense of futility.
  • The best a caregiver can do is provide positive
    support and understanding, encourage independence
    and assist the individual when they are unable to
    perform a task.

  • Illnesses such as infections, pain, constipation,
    trauma or drug interactions may cause
    dementia-like symptoms.
  • Preventive measures such as good oral care,
    nutrition, simplified medication regimens and
    adequate fluid intake play an important role in

Some Specific "Problem" Behaviors
  • Wandering Caregivers should understand that
    individuals wanders for a reason. The exact
    reason may be hard to determine. Nevertheless,
    locking him/her in a room or restraining in a
    chair is inappropriate. Implement activities and
    adjust the environment to relieve agitation if
    possible. Minimize all safety risks.

Specific problem behaviors (BPSD)
  • Screaming Consider medical causes for screaming
    that the person cannot verbalize such as pain,
    depression or hearing loss.
  • Gathering/Shopping An individual with dementia
    who rearranges objects around the residence,
    hoards or appropriates others possessions can be
    a disruptive nuisance. Provide the individual
    with a "safe" place where s/he can store items
    (and you can retrieve them). You may provide the
    individual with a canvas "shopping bag."

  • Pacing An individual with dementia who paces
    incessantly can burn off too many calories.
    High-calorie finger foods may help the problem.
    You can try to reduce pacing by providing
    inviting places for the individual to sit and

  • Sexual Aggression Try to determine whether the
    sexual gesture is indeed sexual in nature and not
    an expression of the need to go to the bathroom.
  • Refer to psychiatry to determine treatment
    options. Medications may not be useful in
    treating sexual symptoms.
  • Symptoms may indicate an atypical dementia such
    as Lewy Body Dementia or Picks Disease. These
    may require different types of psychiatric and
    behavioral interventions.

  • Hallucinations/Illusions After you have removed
    confusing stimuli (e.g., shadowy lighting,
    televisions, dolls), refer to psychiatry to
    assess for signs of an atypical dementia such as
    Lewy Body Dementia or Picks Disease.
  • These may require different types of psychiatric
    and behavioral interventions.

What can be done
  • A simplified approach to managing agitation
    behaviors can be summed up as "Modify the
    environment, modify the behavior and medicate as
    a last resort."
  • Recent research is starting to show that some
    relatively basic interventions can be used to
    ease agitation behaviors.

Music Therapy
  • Some studies show that playing calming music or a
    favorite type of music can lead to a decrease in
    agitation. When used during meals, soothing music
    can increase food consumption when used during
    bathing, relaxing or favorite music can make it
    easier to give a bath. Experiment with relaxing,
    soothing, classical, religious or period (e.g.,
    1920s or Big Band) music.

Exercise and Movement
  • Light exercise, such as chair exercises as
    directed by a physical therapist or activities
    coordinator each day can help to maintain
    function of limbs and decrease problem behaviors.
    Walking after dinner several times each week may
    help reduce aggression.
  • When small groups of 3-4 people go on walks, it
    may lead to beneficial social interactions such
    as singing and talking.

  • Safe activities are a good way to get back in
    touch with their earlier life and find meaning
    throughout the disease process.
  • Activities can reflect either things the person
    enjoyed in the past or can reflect what they did
    for work.

  • Human interaction is essential for people with
    dementia. As mentioned, large groups and most
    strangers are definitely out. But you can
    introduce new individuals as a "new friend" or
    companion to spend time with the person who has
  • They can reminisce, converse, walk or perform
    activities together.

What can you do?
  • Help to identify dementia early by documenting
    memory loss and confusion.
  • Request a cognitive assessment from the Cognitive
    Assessment Program at Harvest.
  • Practice patience.
  • Be a detective and work toward finding the cause
    of agitation in an effort to resolve it.

Thought Provoking Questions
  • Can you describe sundowning and name some
    potential causes?
  • Can you identify some potential causes of
  • Can you describe the difference between delirium
    and dementia?