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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 – PowerPoint PPT presentation

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Title: Dementia Boot Camp


1
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

2
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

3
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.

4
Risk Based Dementia Prevention
  • Nutrition
  • Mental exercise
  • Physical activities
  • Stress management
  • Other lifestyle choices
  • http//www.alzprevention.org/

5
Alternative ApproachMotivational Interviewing
6
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

7
Medicare Annual Wellness Visit
  • Normalizes cognitive assessment and screening
  • Sets individual baseline
  • Identify early changes
  • Standardizes simplifies approach
  • Research into tools, phone screening

8
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

9
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/
10
Diagnosis
  • Physical exam
  • (Especially neurological cardiac)
  • Lab studies
  • Imaging study
  • Cognitive evaluation emotional screen
  • (What works what doesnt work)
  • Functional assessment
  • Review medications

11
What could it be?Identifying underlying issue
  • Possibilities
  • Normal aging
  • Mild cognitive impairment
  • Acute confusion or delirium
  • Dementia

12
DEMENTIA
Lewy Body Dementia
Alzheimers Disease
70-80 Other Dementias
Fronto- Temporal Lobe Dementia
13
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

14
AD Memory
  • Early on Storage, not retrieval problem
  • Later on Storage and retrieval
  • Retained Emotional and motor memory

15
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

16
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

17
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

18
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!

19
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

20
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

21
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

22
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

23
Public awareness/community engagement
  • TV/magazine/health care offices public service
    ads
  • Research/conference blips
  • Non-profit local efforts (fund raising/public
    awareness)

24
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!!!

25
Public awareness/community engagement
  • Alternative approaches
  • Going to where people are
  • Using informal opinion leaders
  • Prostate cancer screening in African American
    communities
  • Churches, barber shops, hair salons

26
Brain Failure
  • Structural brain failure
  • Chemical brain failure

27
Structural Brain Failure
  • One way street
  • Depending on type of dementia, changes happen in
    different areas resulting in different changes

28
Memories
  • Losses
  • Where when you are
  • What is going on
  • Where you want to go
  • What you want to do
  • Preserved abilities
  • Confabulation!
  • Emotional memories
  • Motor memories

29
Issues of Understanding
  • Losses
  • Cant interpret information
  • Cant make sense of words
  • Gets off target
  • Preserved abilities
  • picks up on facial expression
  • picks up on tone of voice

30
Language Issues
  • Losses
  • Cant find the right words
  • Not able to say what you mean
  • Cant make needs known
  • Preserved abilities -
  • automatic speech
  • singing
  • swearing
  • turn taking

31
Sensory Changes
  • Losses
  • Awareness of body and position
  • Ability to locate and express pain
  • Awareness of feeling in most of body
  • Preserved Abilities
  • 4 areas can be sensitive
  • Any of these areas can be hypersensitive
  • Need for sensation can become extreme

32
Self-Care Changes
  • Losses
  • initiation termination
  • tool manipulation
  • sequencing
  • Preserved Abilities
  • motions and actions
  • the doing part
  • cued activity

33
Issues of Impulses Emotions
  • Losses
  • becomes labile extreme
  • think it - say it
  • want it - do it
  • see it - use it
  • Preserved
  • desire to be respected
  • desire to be in control
  • regret after action

34
Chemical failure
  • Fluctuations
  • Extremely good moments and
  • Extremely bad moments

35
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

36
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

37
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

38
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
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