Alzheimer’s Alzheimer’s Disease and Disease and

Dementia Care Dementia Care for Health Plan Case Managersfor Health Plan Case Managers

Karen Bugg RN LMSWKaren Bugg RN LMSWInstitute for Health Care Institute for Health Care

StudiesStudiesMichigan State UniversityMichigan State UniversityAugust 16August 16thth & 17 & 17thth 2010 2010

What does What does “dementia” mean?“dementia” mean?

Dementia and the Dementia and the BrainBrain Injury to brain cells causes Injury to brain cells causes

dementia.dementia. Dementia causes a decline in a Dementia causes a decline in a

person’s ability to think, person’s ability to think, understand, and remember and understand, and remember and affects a person’s function.affects a person’s function.

Dementia gets worse over time.Dementia gets worse over time.

DementiaDementia

Because of memory loss:Because of memory loss:

no longer self-sufficient no longer self-sufficient requires ongoing help or requires ongoing help or

supervision supervision functional dependencyfunctional dependency

Activities of Daily Activities of Daily LivingLiving BathingBathing DressingDressing Feeding SelfFeeding Self ToiletingToileting TransferringTransferring

TelephoneTelephone DrivingDriving ShoppingShopping Meal PreparationMeal Preparation Managing Managing

FinancesFinances Managing Managing

Medications Medications

Causes of DementiaCauses of Dementia Alzheimer’s disease is the most Alzheimer’s disease is the most

common cause of dementia.common cause of dementia. Other common causes are:Other common causes are:

– Vascular dementiaVascular dementia– Dementia with Lewy bodiesDementia with Lewy bodies

Alzheimer’s definitionAlzheimer’s definition A progressive degenerative A progressive degenerative

neurological disease.neurological disease. Most common form of dementia Most common form of dementia

in the elderly.in the elderly. Nearly 75% of all dementia cases. Nearly 75% of all dementia cases.

Alzheimer’s in the Alzheimer’s in the United StatesUnited States

5.3 million people 5.3 million people One person is One person is

newly diagnosed newly diagnosed every 70 secondsevery 70 seconds

7th leading cause 7th leading cause of deathof death

Rates are expected Rates are expected to double every 20 to double every 20 years years

Alzheimer’s Disease - Alzheimer’s Disease - StatisticsStatistics 6-8% of all persons age 65 and 6-8% of all persons age 65 and

olderolder 30-50% of all persons age 85 and 30-50% of all persons age 85 and

olderolder By 2029, all baby boomers will be at By 2029, all baby boomers will be at

least 65 years oldleast 65 years old 5.3 million cases currently, will 5.3 million cases currently, will

increase to increase to 18 million18 million by 2040 by 2040

Race & Ethnicity Older African Americans and

Hispanics are much more likely than older whites to have Alzheimer’s disease and other dementias.

MichiganMichigan

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

Current Dilemmas in Current Dilemmas in Dementia CareDementia Care

Alzheimer’s disease is under diagnosed, Alzheimer’s disease is under diagnosed, particularly among patients who do not particularly among patients who do not speak English as their primary language.speak English as their primary language.

Pre-Alzheimer’s impairments are often Pre-Alzheimer’s impairments are often attributed to “normal” aging.attributed to “normal” aging.

Denial and fear often delay evaluation.Denial and fear often delay evaluation. Typical lag time between symptom onset Typical lag time between symptom onset

and diagnosis is two years.and diagnosis is two years. Most patients are not diagnosed by their Most patients are not diagnosed by their

primary care physicians.primary care physicians.

Impact on health careImpact on health care Today, there are about Today, there are about

4,700 providers, up from 4,700 providers, up from about 3,300 five years about 3,300 five years ago.   ago.   

Alzheimer's disease now Alzheimer's disease now accounts for 10.1 accounts for 10.1 percent of hospice percent of hospice admissions nationwide, admissions nationwide, up from 5.5 percent in up from 5.5 percent in 2000.    2000.   

ALH’s beds have tripled ALH’s beds have tripled over the decade from over the decade from 600,000 to 2,000,000.600,000 to 2,000,000..    .   

The Future of The Future of Alzheimer’s DiseaseAlzheimer’s Disease

Treatment with current FDA Treatment with current FDA approved drugsapproved drugs

Disease modifying drugs to induce Disease modifying drugs to induce remissionremission

Medications to reverse memory lossMedications to reverse memory loss CureCure

Brain Anatomy & Brain Anatomy & FunctionFunctionRelated to MemoryRelated to Memory

Healthy Brain CellsHealthy Brain Cells Billions of neuronsBillions of neurons Axons = message Axons = message

transmitterstransmitters Dendrites = Dendrites =

message receiversmessage receivers Groups of neurons Groups of neurons

have special have special functionsfunctions

Healthy Brain Healthy Brain ProcessesProcesses CommunicationCommunication MetabolismMetabolism RepairRepair

Brain CommunicationBrain Communication NeurotransmitterNeurotransmitter

ss– A chemical A chemical

messenger messenger between neurons between neurons that excite or that excite or inhibit.inhibit.

Brain MetabolismBrain Metabolism Brain needs lots Brain needs lots

of blood to of blood to nourish cells with nourish cells with oxygen and oxygen and glucose.glucose.

Or death to cells.Or death to cells.

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

some areas.some areas.

The Frontal LobesThe Frontal Lobes Help you to do Help you to do

more than one more than one thing at once.thing at once.

Prioritize what Prioritize what to focus on.to focus on.

Sense how Sense how much time is much time is passing.passing.

When dementia affects When dementia affects the frontal lobes, you the frontal lobes, you may:may: Have difficulty focusing on a task and Have difficulty focusing on a task and

paying attention to what is going on.paying attention to what is going on. Be overwhelmed when a caregiver Be overwhelmed when a caregiver

talks and touches at the same time.talks and touches at the same time. Have difficulty following the logic of Have difficulty following the logic of

an argument.an argument. Need the most important words said Need the most important words said

first in a sentence.first in a sentence.

You may also:You may also: Need short and simple words and Need short and simple words and

sentences.sentences. Refuse a bath because you can’t Refuse a bath because you can’t

think of how to do it.think of how to do it. Be unable to stop striking or Be unable to stop striking or

grabbing someone because you grabbing someone because you can’t control impulses.can’t control impulses.

Temporal LobesTemporal Lobes The temporal The temporal

lobes help you:lobes help you:– Understand Understand

languagelanguage– SpeakSpeak– Read and write.Read and write.

When dementia affects When dementia affects the temporal lobes, you the temporal lobes, you may:may: Make non-sense words.Make non-sense words. Use the wrong sounds when talking.Use the wrong sounds when talking. Substitute words or use fewer words.Substitute words or use fewer words. Say “yes” when you mean “no”.Say “yes” when you mean “no”. Not understand what someone tells Not understand what someone tells

you.you. Not understand what you read.Not understand what you read. Use swear words without realizing it.Use swear words without realizing it.

Parietal LobesParietal Lobes The parietal The parietal

lobes:lobes:– Help you locate Help you locate

and arrange and arrange objects in space.objects in space.

– Tell your brain to Tell your brain to pay attention to pay attention to everything that is everything that is in the space you in the space you see.see.

When dementia affects When dementia affects the parietal lobes, you the parietal lobes, you may:may: Use excessive energy putting an arm Use excessive energy putting an arm

into a shirt sleeve.into a shirt sleeve. Put a glass down on the edge of a Put a glass down on the edge of a

plate, rather than beyond it.plate, rather than beyond it. Have difficulty responding to objects Have difficulty responding to objects

on the left side of your visual field.on the left side of your visual field. Have difficulty tolerating clutter, many Have difficulty tolerating clutter, many

objects, and movement in the room.objects, and movement in the room.

You may also:You may also: Feel angry, frustrated, and tired from Feel angry, frustrated, and tired from

all of the confusing objects and sounds all of the confusing objects and sounds in the environment.in the environment.

Respond better when a caregiver Respond better when a caregiver approaches from the front. approaches from the front.

Resist stepping into a tub or shower Resist stepping into a tub or shower because you can’t see: the side of the because you can’t see: the side of the tub, where your feet or hands should tub, where your feet or hands should go, or how deep the water is.go, or how deep the water is.

HippocampusHippocampus The hippocampus The hippocampus

creates your memory creates your memory of recent events such of recent events such as:as:– What someone just What someone just

said.said.– What you had for What you had for

lunch.lunch.– Who just visited you Who just visited you

an hour ago.an hour ago.– Where you parked Where you parked

your car.your car.

When dementia affects When dementia affects the hippocampus, you the hippocampus, you may:may: Repeat a question over and over again.Repeat a question over and over again. Forget that a family member just visited.Forget that a family member just visited. Be surprised or angry when a caregiver Be surprised or angry when a caregiver

begins to remove clothing when you just begins to remove clothing when you just agreed to take a shower.agreed to take a shower.

Lose items repeatedly or store them in Lose items repeatedly or store them in the wrong place.the wrong place.

The Aging BrainThe Aging BrainAnd MemoryAnd Memory

Namenesia

“Hi. I’m, I’m, I’m…. You’ll have to forgive me,

I’m terrible with names.”

Roomnesia

Now why did I come in here?

A.K.A…. “the senior moment”

Fleeting thought syndromeFleeting thought syndrome

Memory loss is not a Memory loss is not a normal part of agingnormal part of aging

Decline in mental Decline in mental ability is not inevitable ability is not inevitable as people ageas people age

NeuroplasticityNeuroplasticityCognitive reserveCognitive reserve

Cognitive ReserveCognitive Reserve Relationship between brain Relationship between brain pathology pathology and cognitive effect and cognitive effect moderated by CRmoderated by CR CR markers: education, occupation, CR markers: education, occupation, leisure interests leisure interests

Greater CR causes less impact on Greater CR causes less impact on function with similar level of function with similar level of

pathology pathology Greater CR leads to steeper decline Greater CR leads to steeper decline once pathology overwhelms once pathology overwhelms

Yaakov Stern

Types of MemoryTypes of Memory Episodic memory Episodic memory Semantic memory Semantic memory Working memory Working memory Procedural memory Procedural memory

The Aging BrainThe Aging Brain

Brain tissue volume decreases with Brain tissue volume decreases with age due to white matter loss.age due to white matter loss.

Regional loss may be gender Regional loss may be gender specific.specific.

Frontal regions are more vulnerable Frontal regions are more vulnerable to decline.to decline.

Neurogenesis = growth of new brain Neurogenesis = growth of new brain cells.cells.

Aging: Vulnerable Aging: Vulnerable ProcessesProcesses Processing speedProcessing speed Working memoryWorking memory Divided attentionDivided attention Complex visual processing Complex visual processing Long term memoryLong term memory

– Episodic memoryEpisodic memory– Source recallSource recall

Preserved Abilities with Preserved Abilities with AgingAging Priming - an unconscious Priming - an unconscious

influence of past experience on influence of past experience on current performance or behavior.current performance or behavior.

Visual PrimingVisual PrimingC H _ _ M _ _ KC H _ _ M _ _ K

O _ T _ _ U SO _ T _ _ U S

D _ N O _ _ U RD _ N O _ _ U R

P R _ _ T I _ _ _ I T _ _ _ P R _ _ T I _ _ _ I T _ _ _

Preserved Abilities with Preserved Abilities with AgingAging Priming - an unconscious Priming - an unconscious

influence of past experience on influence of past experience on current performance or behavior.current performance or behavior.

Inhibition of stimulus-bound Inhibition of stimulus-bound responding.responding.

blue white red brown green

redred brownbrown white white blueblue greengreen

white white blueblue green green brown brown redred

brownbrown red red greengreen white white blueblue

greengreen whitewhite brownbrown blue blue redred

Stroop test

Common Causes of Poor Common Causes of Poor MemoryMemory Insomnia and impaired sleep (apnea)Insomnia and impaired sleep (apnea) Drug side effects (antihistamines)Drug side effects (antihistamines) MenopauseMenopause DepressionDepression Attention Deficit DisorderAttention Deficit Disorder Head injuryHead injury ChemotherapyChemotherapy

Problem MedicationsProblem Medications

Antiarrythmics Antiarrythmics Antiemetics Antiemetics AntihistaminesAntihistamines Antiparkinson AgentsAntiparkinson Agents AntipsychoticsAntipsychotics AntispasmoticsAntispasmotics Skeletal Muscle RelaxantsSkeletal Muscle Relaxants Tricyclic AntidepressantsTricyclic Antidepressants

Uncommon Causes of Uncommon Causes of Poor MemoryPoor Memory Young onset Alzheimer’s diseaseYoung onset Alzheimer’s disease Mosquito and tick born diseaseMosquito and tick born disease Brain tumorsBrain tumors Toxin and heavy metal exposureToxin and heavy metal exposure Anesthesia Anesthesia SeizuresSeizures

Early Warning Signs of Early Warning Signs of DementiaDementia Frequent repeating / defensive Frequent repeating / defensive

answersanswers Word finding difficultyWord finding difficulty Mistakes with bills / checkbookMistakes with bills / checkbook Changes in hygiene / groomingChanges in hygiene / grooming Mistakes with medicationsMistakes with medications Geographic disorientationGeographic disorientation

Alzheimer’s DiseaseAlzheimer’s DiseaseAnd related disordersAnd related disorders

Alois Alzheimer 1864-1915Alois Alzheimer 1864-1915

Risk FactorsRisk Factors Advancing ageAdvancing age

– 65 or older65 or older Mild cognitive impairment (MCI)Mild cognitive impairment (MCI) Family historyFamily history GeneticsGenetics

– Young onset Young onset Down’s SyndromeDown’s Syndrome

DSM-IV DiagnosisDSM-IV Diagnosis Decreased cognitive functioning Decreased cognitive functioning

including:including:– Memory impairmentMemory impairment– One or more of:One or more of:

AphasiaAphasia ApraxiaApraxia AgnosiaAgnosia Inability to plan, organize, sequenceInability to plan, organize, sequence Inability to comprehend abstract conceptsInability to comprehend abstract concepts

DSM-IV DiagnosisDSM-IV Diagnosis These deficits cause significant These deficits cause significant

impairment in daily functioning.impairment in daily functioning. Gradual onset and continued Gradual onset and continued

decline.decline. Not due to other physical or Not due to other physical or

mental medical conditions or mental medical conditions or during the course of a delirium.during the course of a delirium.

The Alzheimer BrainThe Alzheimer Brain Massive cell loss Massive cell loss

changes the entire changes the entire brain during brain during Alzheimer’s Alzheimer’s progression.progression.– The cortex shrivels. This The cortex shrivels. This

damages the brain’s damages the brain’s ability to think, plan, and ability to think, plan, and remember.remember.

– The hippocampus The hippocampus shrivels, which affects shrivels, which affects the ability to form new the ability to form new memories.memories.

– Ventricles (fluid-filled Ventricles (fluid-filled spaces) grow larger.spaces) grow larger.

The Alzheimer BrainThe Alzheimer Brain Underneath the Underneath the

microscope:microscope:– Alzheimer tissue has Alzheimer tissue has

less nerve cells and less nerve cells and synapses.synapses.

– Plaques (abnormal Plaques (abnormal clusters of protein clusters of protein fragments) build up fragments) build up between nerves.between nerves.

– Dead and dying nerve Dead and dying nerve cells remain in the brain.cells remain in the brain.

– Plaques and tangles are Plaques and tangles are the prime suspects of the prime suspects of cell death and tissue cell death and tissue loss.loss.

Alzheimer’s Alzheimer’s progressionprogression

The early stages of The early stages of Alzheimer’s may Alzheimer’s may begin up to 20 begin up to 20 years before a years before a diagnosis is made.diagnosis is made.

Mild to moderate Mild to moderate stages last 2-10 stages last 2-10 years.years.

Severe Alzheimer’s Severe Alzheimer’s lasts 1-5 years.lasts 1-5 years.

Stages of Alzheimer’sStages of Alzheimer’s http://www.nia.nih.gov/Alzheimers

/Publications/stages.htm

Vascular DementiaVascular Dementia Second most Second most

common form of common form of dementia.dementia.

Caused by Caused by problems with problems with the supply of the supply of blood to, or blood to, or within the brain.within the brain.

Risk Factors Risk Factors HypertensionHypertension DiabetesDiabetes GeneticGenetic

Symptoms of vascular Symptoms of vascular dementiadementia May develop suddenly then decline in May develop suddenly then decline in

steps.steps. Memory loss may not be the first Memory loss may not be the first

symptom.symptom. Concentration problems.Concentration problems. Changes in mood.Changes in mood. Physical weakness.Physical weakness. Difficulty communicating or conversing.Difficulty communicating or conversing.

Types of vascular Types of vascular dementiadementia Large stroke (cortical) associated Large stroke (cortical) associated

with physical impairments.with physical impairments. Small stroke (lacune) in the basal Small stroke (lacune) in the basal

ganglia or thalamus “strategic”.ganglia or thalamus “strategic”. Small vessel disease (sub-cortical).Small vessel disease (sub-cortical). Intracranial bleed (intracerebral Intracranial bleed (intracerebral

subdural).subdural).

Dementia with Lewy Dementia with Lewy BodiesBodies Discovered in 1912 by Frederich Lewy.Discovered in 1912 by Frederich Lewy. Common cause of dementia in the elderly.Common cause of dementia in the elderly. Dopaminergic, cholinergic, noradrenergic, Dopaminergic, cholinergic, noradrenergic,

serotonergic, and glutaminergic systems serotonergic, and glutaminergic systems affected, decreased dopamine D2 affected, decreased dopamine D2 receptors.receptors.

Over 50% of Parkinson’s patients develop Over 50% of Parkinson’s patients develop PDD dementia—a Lewy Body dementia.PDD dementia—a Lewy Body dementia.

Dementia with Lewy Dementia with Lewy BodiesBodies

May coexist with AD –May coexist with AD –– 10 to 30% of AD cases have LBs.10 to 30% of AD cases have LBs.– 32 to 89% of DLB cases have AD 32 to 89% of DLB cases have AD

changes.changes.– AD pathology in DLB is different, less AD pathology in DLB is different, less

severe, more diffuse plaques, rare severe, more diffuse plaques, rare tangles.tangles.

– Familial form of DLB associated with Familial form of DLB associated with triplication of SNCA gene.triplication of SNCA gene.

Symptoms of Lewy Symptoms of Lewy Body DementiaBody Dementia Episodes of altered consciousnessEpisodes of altered consciousness Fluctuating cognitionFluctuating cognition Recurrent visual hallucinationsRecurrent visual hallucinations ParkinsonismParkinsonism Extreme sensitivity to Extreme sensitivity to

anitpsychoticsanitpsychotics Sleep disordersSleep disorders

Frontotemporal Frontotemporal DementiaDementia Frontal temporal areas of the cortex Frontal temporal areas of the cortex

are affected—Pick’s bodies form and are affected—Pick’s bodies form and impair neuronal function.impair neuronal function.

Fairly common—10 to 15% of cases.Fairly common—10 to 15% of cases. Onset—age 40-65; 60 average.Onset—age 40-65; 60 average. Can last longer than Alzheimer’s.Can last longer than Alzheimer’s. May be hereditary in 38-60% of cases.May be hereditary in 38-60% of cases.

The Frontal LobesThe Frontal Lobes Help you to do Help you to do

more than one more than one thing at once.thing at once.

Prioritize what Prioritize what to focus on.to focus on.

Sense how Sense how much time is much time is passing.passing.

Temporal LobesTemporal Lobes The temporal The temporal

lobes help you:lobes help you:– Understand Understand

languagelanguage– SpeakSpeak– Read and writeRead and write

Symptoms of FTDSymptoms of FTD Behavior and personality changesBehavior and personality changes Personal and social awareness Personal and social awareness

impairedimpaired DisinhibitionDisinhibition Repetitive behaviorsRepetitive behaviors Fixations/obsessionsFixations/obsessions ImpulsiveImpulsive HyperoralityHyperorality

Other Dementia TypesOther Dementia Types Wernicke-Korsakoff SyndromeWernicke-Korsakoff Syndrome Cognitive problems after Cognitive problems after

chemotherapychemotherapy Normal pressure hydrocephalusNormal pressure hydrocephalus Jakob-CreutzfeldJakob-Creutzfeld Head InjuryHead Injury

Dementia Diagnostic Dementia Diagnostic ProcessProcess

Referrals to a memory Referrals to a memory programprogram

You suspect or know that a dementia You suspect or know that a dementia problem exists problem existsANDAND

you are concerned about patient you are concerned about patient independence or ability to manage independence or ability to manage ADL’s at home,ADL’s at home,OROR

you are concerned about a caregiver’s you are concerned about a caregiver’s ability to manage a patient at home.ability to manage a patient at home.

Clinical PearlClinical PearlNormal motor examinationNormal motor examinationCognition worse than behavior.......Cognition worse than behavior....... Think Think

Alzheimer’sAlzheimer’sBehavior worse than cognition.......Behavior worse than cognition....... Think frontal Think frontal

lobe (Pick’s)lobe (Pick’s)Parkinsonian signs on examinationParkinsonian signs on examinationNo hallucinations early in illnessNo hallucinations early in illness Think vascular Think vascular

dementiadementiaDetailed visual hallucinations earlyDetailed visual hallucinations early

Think Lewy Body dementiaThink Lewy Body dementia

Key points regarding Key points regarding diagnosisdiagnosis The MMSE is a disorganized, fair The MMSE is a disorganized, fair

quality screening tool.quality screening tool. The Clock Drawing test has The Clock Drawing test has

drawbacks and limitations.drawbacks and limitations. 90% of the diagnosis is based upon 90% of the diagnosis is based upon

collateral history, which may be collateral history, which may be inaccurate.inaccurate.

A physical and neurological exam is A physical and neurological exam is mandatory.mandatory.

Key points regarding Key points regarding diagnosisdiagnosis History and examination findings History and examination findings

should not be interpreted in a should not be interpreted in a clinical vacuum.clinical vacuum.

Few text book situations occur and Few text book situations occur and overlap conditions are common.overlap conditions are common.

Not everyone with dementia has Not everyone with dementia has Alzheimer’s disease and some Alzheimer’s disease and some have protracted delirium.have protracted delirium.

Benefits of Medical Benefits of Medical AssessmentAssessment Diagnostic clarificationDiagnostic clarification Identify medical conditions affecting Identify medical conditions affecting

capacitycapacity Identify means to enhance capacityIdentify means to enhance capacity Identify less restrictive alternatives Identify less restrictive alternatives Preemptive planningPreemptive planning

What the health care What the health care team must do for the team must do for the patientpatient Give a clear diagnosis and Give a clear diagnosis and

prognosisprognosis Exude optimismExude optimism Lessen fear and the stigma of Lessen fear and the stigma of

dementiadementia Prescribe cognition stabilizer(s)Prescribe cognition stabilizer(s) Inform where resources are locatedInform where resources are located

What the health care What the health care team must do for the team must do for the caregiverscaregivers Provide closureProvide closure Exude confidenceExude confidence Relieve guiltRelieve guilt Provide reassuranceProvide reassurance Provide support resourcesProvide support resources Set care giving limitsSet care giving limits

Diagnostic challengesDiagnostic challenges Less than half of all Alzheimer’s Less than half of all Alzheimer’s

patients know that they have the patients know that they have the disease.disease.

2/3 are not diagnosed until they 2/3 are not diagnosed until they reach the moderate stage.reach the moderate stage.

Published clinical guidelines to Published clinical guidelines to facilitate diagnosis are facilitate diagnosis are infrequently used.infrequently used.

Diagnostic challengesDiagnostic challenges

No blood or imaging test can reliably No blood or imaging test can reliably diagnose any type of dementia.diagnose any type of dementia.

Most diagnoses are made by Most diagnoses are made by neurologists and neuropsychologists.neurologists and neuropsychologists.

Demand will soon exceed their supply.Demand will soon exceed their supply. Primary physicians will become more Primary physicians will become more

responsible for diagnosing dementia responsible for diagnosing dementia by necessity.by necessity.

Misperceptions Misperceptions ClarifiedClarified Alzheimer’s disease can be accurately Alzheimer’s disease can be accurately

diagnosed in up to 97% of cases using diagnosed in up to 97% of cases using simple assessment techniques in the simple assessment techniques in the office.office.

New advancements in treatment will New advancements in treatment will make a real impact in the lives of make a real impact in the lives of dementia patients.dementia patients.

It is terrible to have Alzheimer’s It is terrible to have Alzheimer’s disease and not know it. disease and not know it.

Dementia Diagnostic Dementia Diagnostic ProcessProcess Review of symptom onset and Review of symptom onset and

progressionprogression Memory testingMemory testing Physical and neurological examinationsPhysical and neurological examinations Blood testsBlood tests Brain imagingBrain imaging

Mental Status TestingMental Status Testing OrientationOrientation Learning and memoryLearning and memory

– Three word item recallThree word item recall Naming abilityNaming ability

– Name parts of objectsName parts of objects GnosisGnosis

– Describe function of objects Describe function of objects Tempoparietal functionTempoparietal function

– Language comprehension, ideomotor praxis, left-right Language comprehension, ideomotor praxis, left-right discriminationdiscrimination

Visual constructionsVisual constructions– Clock drawing, cube copyingClock drawing, cube copying

Working memoryWorking memory– Add coinsAdd coins

Mental Status TestingMental Status Testing AbstractionAbstraction

– Explain similaritiesExplain similarities Attention and concentrationAttention and concentration

– Digit spanDigit span– Months of the year reversedMonths of the year reversed

LanguageLanguage– Fluency, repetition, readingFluency, repetition, reading

Spatial and object memorySpatial and object memory– Recall where an item was hiddenRecall where an item was hidden

Remote memoryRemote memory– Details about significant past eventsDetails about significant past events

Common Screening Common Screening ToolsTools Folstein Mini-Mental State ExaminationFolstein Mini-Mental State Examination Montreal Cognitive Assessment Montreal Cognitive Assessment

Screening (MOCA)Screening (MOCA) Mini-CogMini-Cog Functional Activities QuestionnaireFunctional Activities Questionnaire The Seven Minute ScreenThe Seven Minute Screen Clock Drawing Test Clock Drawing Test

Lab TestingLab Testing CBC, CMPCBC, CMP B-12B-12 TSHTSH Syphilis testing Syphilis testing CSF analysisCSF analysis

Brain ImagingBrain Imaging CT ScanningCT Scanning MRIMRI PET ScanningPET Scanning

Treatment ModalitiesTreatment Modalities PharmacologicalPharmacological BehavioralBehavioral Palliative; not curablePalliative; not curable

Realistic Goals of Realistic Goals of Dementia TreatmentDementia Treatment

Attenuate cognitive and functional Attenuate cognitive and functional decline.decline.

Prevent / decrease behavioral and Prevent / decrease behavioral and psychiatric symptoms.psychiatric symptoms.

Delay nursing home placement.Delay nursing home placement. Lengthen period of self-sufficiency.Lengthen period of self-sufficiency. Reduce caregiver burden.Reduce caregiver burden.

Pharmacologic ArsenalPharmacologic ArsenalFDA Approved Medications for FDA Approved Medications for

Treatment of Alzheimer’s Dementia Treatment of Alzheimer’s Dementia

Cholinesterase Inhibitors:Cholinesterase Inhibitors: Prevent the Prevent the breakdown of acetylcholinebreakdown of acetylcholine– Donepezil (Aricept), Galantamine Donepezil (Aricept), Galantamine

(Razadyne), Rivastigmine (Exelon)(Razadyne), Rivastigmine (Exelon)

Glutamate Regulator:Glutamate Regulator:– Memantine (Namenda)Memantine (Namenda)

Pharmacologic ArsenalPharmacologic ArsenalMedications for the treatment of mood Medications for the treatment of mood

disorders and behaviorsdisorders and behaviors

AntidepressantsAntidepressants– fluoxetine, citalopram, mirtazepine, fluoxetine, citalopram, mirtazepine,

sertraline, venlaxafinesertraline, venlaxafine AntipsychoticsAntipsychotics

– haloperidol, risperidone, quetiapine, haloperidol, risperidone, quetiapine, zasperidonezasperidone

AnxiolyticsAnxiolytics– buspirone, lorazepambuspirone, lorazepam

Prevention of DementiaPrevention of Dementia

Stay mentally and physically activeStay mentally and physically active

SocializeSocialize

Live a healthy lifestyleLive a healthy lifestyle

Eat a balanced dietEat a balanced diet

Working with clients Working with clients who have dementiawho have dementia

Behaviors of DementiaBehaviors of DementiaBehavior ManagementBehavior Management

Cognitive changesCognitive changes These are changes in These are changes in memory, memory,

thinkingthinking, and , and learninglearning..

Involve a variety of mental skills such Involve a variety of mental skills such as attention, problem-solving, as attention, problem-solving, memory, language , visual-memory, language , visual-perceptual skills, and other aspects perceptual skills, and other aspects of reasoning and intellect.of reasoning and intellect.

Dementia can cause difficult Dementia can cause difficult behaviorsbehaviors Changes in the brain can cause Changes in the brain can cause

problems with a person’s ability problems with a person’s ability to think, understand, and respond to think, understand, and respond appropriately.appropriately.

The behaviors result from the The behaviors result from the disease itself, not because the disease itself, not because the person is trying intentionally to be person is trying intentionally to be mean or uncooperative.mean or uncooperative.

Dementia BehaviorsDementia Behaviors Repetitive questioning or Repetitive questioning or

hoarding/obsessive behaviorhoarding/obsessive behavior Poor judgmentPoor judgment DisinhibitionDisinhibition ImpulsivenessImpulsiveness WanderingWandering Insomnia or somnolenceInsomnia or somnolence

Dementia BehaviorsDementia Behaviors– Irritability, agitation, restlessness, Irritability, agitation, restlessness,

aggressionaggression– Social withdrawal, apathy, depression, Social withdrawal, apathy, depression,

suicidal ideationsuicidal ideation– Hallucinations-sensoryHallucinations-sensory

An object or event is believed to be An object or event is believed to be perceivedperceived

– Delusions-thoughtsDelusions-thoughts Untrue beliefs based on pathologyUntrue beliefs based on pathology Paranoia and unfounded accusationsParanoia and unfounded accusations

Prevalence of Prevalence of dementiadementia The reported dementia prevalence in The reported dementia prevalence in

Assisted Living and Special Care Units Assisted Living and Special Care Units ranges from 40-67%.ranges from 40-67%.

Dementia afflicts a substantial portion Dementia afflicts a substantial portion of elderly patients on the medical-of elderly patients on the medical-surgical units of general hospitals.surgical units of general hospitals.

ALFA (2006); Lyketos, Sheppard, Rabins (2000)ALFA (2006); Lyketos, Sheppard, Rabins (2000)

Prevalence of Prevalence of behavioral symptomsbehavioral symptoms 56% of residents in AL settings 56% of residents in AL settings

had behavioral symptoms had behavioral symptoms related to dementia.related to dementia.

Current management methods Current management methods are insufficient to respond to are insufficient to respond to the needs of residents.the needs of residents.

Boustani and associates (2005)Boustani and associates (2005)

Challenges of Challenges of dementiadementia Functional Functional challengeschallenges Personality changesPersonality changes Mood changesMood changes ResistanceResistance Lack of InsightLack of Insight ApathyApathy ShadowingShadowing

RepeatingRepeating AgitationAgitation AggressionAggression ParanoiaParanoia WanderingWandering DelusionsDelusions HallucinationsHallucinations

Framework for careFramework for care Provides for person-centered planning. Provides for person-centered planning. Organizes the many theories, Organizes the many theories,

approaches, strategies, and approaches, strategies, and techniques.techniques.

Comprehensive assessment.Comprehensive assessment. Maximize functional independence and Maximize functional independence and

morale of individuals with dementia.morale of individuals with dementia.

The Habilitation The Habilitation DomainsDomains The top 3:The top 3:

– PhysicalPhysical– FunctionalFunctional– EmotionalEmotional

The Habilitation The Habilitation DomainsDomains Social Social Sensory Sensory CommunicationCommunication

The Five TenetsThe Five Tenets

Tenet #1: Tenet #1: Make the physical environment work.Make the physical environment work.

Tenet #2: Tenet #2: Know that communication remains Know that communication remains

possible.possible.

Tenet #3: Focus on remaining skills.Tenet #3: Focus on remaining skills.

The Five TenetsThe Five Tenets

Tenet #4: Tenet #4: Live in the patient’s world: Live in the patient’s world:

behavioral changes.behavioral changes.

Tenet #5: Enrich the patient’s life.Tenet #5: Enrich the patient’s life.

Link behavior to an Link behavior to an unmet need.unmet need. Link the behavior to one of three Link the behavior to one of three

human needs:human needs:– LoveLove– UsefulnessUsefulness– Expression of raw emotionsExpression of raw emotions

Look at behavior as Look at behavior as a means of a means of communication.communication.

– What is the person trying to What is the person trying to communicate?communicate?

– Is it worth responding to or is it Is it worth responding to or is it simply annoying?simply annoying?

– Pick your battles.Pick your battles.

What happened What happened before?before? To help determine reasons for a To help determine reasons for a

patient’s behavior, look at its patient’s behavior, look at its antecedents.antecedents.

Sudden behavior Sudden behavior changeschanges May indicate relationship issues.May indicate relationship issues. May indicate medical or physical May indicate medical or physical

problem.problem. May indicate environmental May indicate environmental

change.change.

Assess for deliriumAssess for delirium

Abrupt state of confusionAbrupt state of confusion Disturbance of consciousnessDisturbance of consciousness Impairment of cognition and perceptionImpairment of cognition and perception One or more underlying causes One or more underlying causes May be associated with hyperactivity or May be associated with hyperactivity or

lethargylethargy

Symptoms of deliriumSymptoms of delirium Many types of cognitive - Many types of cognitive -

behavioral symptoms can occur behavioral symptoms can occur including visual hallucinations, including visual hallucinations, delusions, paranoia, manic delusions, paranoia, manic behavior, aggression, apathy, and behavior, aggression, apathy, and impaired memory.impaired memory.

““Sun-downing” is not specific to Sun-downing” is not specific to delirium.delirium.

Risk factors for Risk factors for deliriumdelirium Severe illnessSevere illness Hypo perfusionHypo perfusion HypoxiaHypoxia InfectionInfection Drug toxicity Drug toxicity FracturesFractures AlcoholismAlcoholism

Risk factors for Risk factors for deliriumdelirium Dementia (25-50% of all cases)Dementia (25-50% of all cases) Impaired ADLsImpaired ADLs Sensory impairmentSensory impairment Urinary retentionUrinary retention Fecal impactionFecal impaction Physical restraint usePhysical restraint use Sleep deprivationSleep deprivation

Assess for painAssess for pain Ask the resident.Ask the resident. Interview the caregivers.Interview the caregivers. Review the medical record for Review the medical record for

pain-related diagnoses.pain-related diagnoses. Physical examination and lab Physical examination and lab

studies.studies.

Assess for painAssess for pain

Use a validated pain rating system:Use a validated pain rating system: Facial expressionFacial expression PosturePosture VocalizationsVocalizations AppetiteAppetite InteractivityInteractivity

Pain Rating ScalesPain Rating Scales Verbal 0-10 scaleVerbal 0-10 scale Abbey pain scaleAbbey pain scale Pain assessment for the dementing Pain assessment for the dementing

elderlyelderly Faces Pain scaleFaces Pain scale Pain assessment in advanced dementia Pain assessment in advanced dementia

(PAINAD)(PAINAD) Checklist of nonverbal pain indicators Checklist of nonverbal pain indicators

CNPI)CNPI)

Evaluate the Evaluate the consequencesconsequences Do the behaviors need to change Do the behaviors need to change

for the comfort and the safety of for the comfort and the safety of the patient or the caregiver?the patient or the caregiver?

Some behaviors do not bother the Some behaviors do not bother the patient—do they need to be patient—do they need to be modified?modified?

Set the toneSet the tone Relax. Center.Relax. Center. Use a clear, low, loving tone of Use a clear, low, loving tone of

voice.voice. Calm, gentle, matter-of-fact Calm, gentle, matter-of-fact

approach.approach. Humor.Humor. Cheerful.Cheerful.

Set the toneSet the tone Use the mirroring technique.Use the mirroring technique. Chat about a happy topic before Chat about a happy topic before

starting a task.starting a task. Use short, simple sentences, Use short, simple sentences,

familiar words.familiar words.

Build trustBuild trust

Use non-threatening, factual Use non-threatening, factual words: who, what, when, where, words: who, what, when, where, and how.and how.

Avoid asking why something Avoid asking why something happened or why they did happened or why they did something.something.

Do not attempt to Do not attempt to reasonreason People with dementia lose their People with dementia lose their

ability to reason.ability to reason. Insight is often impaired.Insight is often impaired.

RephrasingRephrasing The individual is The individual is

validated/comforted when their validated/comforted when their own words are acknowledged by own words are acknowledged by another.another.

Repeat the gist of what the person Repeat the gist of what the person has said, using the same key has said, using the same key words.words.

Use a similar tone and cadence.Use a similar tone and cadence.

Use redirection to stop Use redirection to stop undesired behaviorundesired behavior Can the patient be distracted with Can the patient be distracted with

another activity, treat, topic of another activity, treat, topic of conversation?conversation?

You may have to say, “Now we You may have to say, “Now we are going to…” rather than asking are going to…” rather than asking or suggesting a task or activity.or suggesting a task or activity.

ReminiscingReminiscing Exploring the past can help re-Exploring the past can help re-

establish familiar coping methods establish familiar coping methods and ways of handling stress.and ways of handling stress.

Use “always” and “never” to Use “always” and “never” to trigger earlier memories.trigger earlier memories.

Easier to change the Easier to change the environmentenvironment Under stimulationUnder stimulation

– Restlessness, pacing, wandering, or Restlessness, pacing, wandering, or calling out.calling out.

Over stimulationOver stimulation– Nervousness, agitation, physical Nervousness, agitation, physical

aggression.aggression.

Progressively Lowered Progressively Lowered Stress Threshold Stress Threshold Concept (PLST)Concept (PLST) A proactive intervention to reduce A proactive intervention to reduce

likelihood of challenging behaviors.likelihood of challenging behaviors. Based on premise that those with Based on premise that those with

dementia have a decreased ability dementia have a decreased ability to respond to stressors.to respond to stressors.

The cumulative effect of stressors The cumulative effect of stressors prompts behaviors.prompts behaviors.

Stabilize the Stabilize the environmentenvironment Routine; daily schedule.Routine; daily schedule. Create a level of quiet and peace.Create a level of quiet and peace. Make sure the patient is Make sure the patient is

comfortable.comfortable.

Maximize sensory Maximize sensory inputinput Validate the patient’s reality Validate the patient’s reality

without exacerbating anxietywithout exacerbating anxiety Keep simple, but provide multi-Keep simple, but provide multi-

sensorial opportunitiessensorial opportunities MusicMusic Fabrics, petsFabrics, pets TouchTouch

Identify and Use the Identify and Use the Preferred SensePreferred Sense Enables caregiver to speak the Enables caregiver to speak the

person’s language and improve person’s language and improve communication.communication.

Builds trust.Builds trust.– VisionVision– HearingHearing– TouchTouch– SmellSmell

TouchTouch Confused individuals often need Confused individuals often need

to feel the presence of another to feel the presence of another human being.human being.

Pleasant memories are often Pleasant memories are often evoked.evoked.

Personal space must be Personal space must be respected.respected.

MusicMusic When words are gone, melodies When words are gone, melodies

return.return. Comforts, reduces agitation and Comforts, reduces agitation and

stress.stress. Provides channel for expression Provides channel for expression

of emotion.of emotion. Enhances communication.Enhances communication.

Consider life Consider life experiencesexperiences Former life experiences can play Former life experiences can play

a major role in behavior.a major role in behavior. At times, thinking of the person’s At times, thinking of the person’s

former role may help in the former role may help in the development of activities.development of activities.

Need for staff training Need for staff training is critical.is critical.Staff who are trained in dementia and Staff who are trained in dementia and

its management are better prepared its management are better prepared to care for residents.to care for residents.

But, nearly 88% of resident assistants But, nearly 88% of resident assistants thought that confusion was a normal thought that confusion was a normal consequence of aging. consequence of aging.

Hawes and Phillips (2000); Luxenberg (2003), Alzheimer’s Association (2005).Hawes and Phillips (2000); Luxenberg (2003), Alzheimer’s Association (2005).

Education and training Education and training will be keywill be key Growing elderlyGrowing elderly population. population. Projected nursing workforce shortage.Projected nursing workforce shortage. Rates of staff turnover are likely to Rates of staff turnover are likely to

increase.increase. RetentionRetention of adequate staff will become of adequate staff will become

even more difficult in the future.even more difficult in the future.

Callahan, 2001; General Accounting Office [GAO], 2001; Noelker, 2001,Callahan, 2001; General Accounting Office [GAO], 2001; Noelker, 2001, Stone, 2001.Stone, 2001.

Awareness of AbuseAwareness of Abuse

A closer look at A closer look at agitation/aggressionagitation/aggression

AbuseAbuse

Physical, psychological, sexual, Physical, psychological, sexual, and/or financial maltreatment, and/or financial maltreatment, that may be the result of the that may be the result of the actions of others or may result actions of others or may result from neglect by others or by self.from neglect by others or by self.

(Dyer et al., 2000).(Dyer et al., 2000).

Prevalence of elder abusePrevalence of elder abuse

All forms are under-reportedAll forms are under-reported 1% to 4% all elders 1% to 4% all elders 5.4% to 11.9 % for demented 5.4% to 11.9 % for demented

elderly elderly

Risk factors for elder abuseRisk factors for elder abuse

Excessive physical and Excessive physical and psychological demands psychological demands associated with care givingassociated with care giving

Advanced ageAdvanced age Poor health and physical frailtyPoor health and physical frailty Impaired activities of daily livingImpaired activities of daily living

Risk factors for elder abuseRisk factors for elder abuse

Alcohol and substance abuseAlcohol and substance abuse PsychopathologyPsychopathology History of abusive behaviorHistory of abusive behavior Poor pre-morbid relationshipsPoor pre-morbid relationships

Risk factors for elder abuseRisk factors for elder abuse

Families caring for relatives with Families caring for relatives with Alzheimer’s Disease in the Alzheimer’s Disease in the community are particularly community are particularly vulnerable to episodes of violent vulnerable to episodes of violent behavior.behavior.

Caregiver depressionCaregiver depression Living arrangement with immediate Living arrangement with immediate

family member, but not spousefamily member, but not spousePaveza, Cohen, et al. The Gerontologist, 1992Paveza, Cohen, et al. The Gerontologist, 1992

Abuse from care recipientsAbuse from care recipients

57-67% of dementia patients manifest 57-67% of dementia patients manifest some form of aggressive behavior.some form of aggressive behavior.

Nearly 16% patient to caregiver Nearly 16% patient to caregiver violence.violence.

In one study, 66.2% of nursing home In one study, 66.2% of nursing home assistants reported minor physical assistants reported minor physical injuries on a daily basis, with 58.2% injuries on a daily basis, with 58.2% experiencing more serious injury in last experiencing more serious injury in last 12 months.12 months.

Neuroanatomy of Neuroanatomy of AggressionAggression

Many areas of the brain are involvedMany areas of the brain are involved Prefrontal cortices (trouble thinking)Prefrontal cortices (trouble thinking) Left temporal lobe (short fuse)Left temporal lobe (short fuse) Limbic system (anxiety; moodiness)Limbic system (anxiety; moodiness)

– HypothalamusHypothalamus– AmygdalaAmygdala

BrainstemBrainstem

Neurophysiology of Neurophysiology of AggressionAggression Complex interplay of Complex interplay of

neurotransmitters and hormonesneurotransmitters and hormones Serotonin Serotonin NorepinephrineNorepinephrine TestosteroneTestosterone

Diagnose the cause of Diagnose the cause of agitationagitation InfectionInfection InjuryInjury Pain or discomfortPain or discomfort Illness: physical, psychiatricIllness: physical, psychiatric Sleep disordersSleep disorders Medication side effects or interactionsMedication side effects or interactions Environmental triggersEnvironmental triggers People triggersPeople triggers

Prevention of agitation or Prevention of agitation or aggressive behavioraggressive behavior Address the causes or antecedentsAddress the causes or antecedents Provide a structured environmentProvide a structured environment Provide appropriate activityProvide appropriate activity Address emotional needsAddress emotional needs Modify caregiver communication Modify caregiver communication

techniques and approachestechniques and approaches Provide sunlightProvide sunlight

Treatment of agitation and Treatment of agitation and aggressionaggression BehavioralBehavioral PharmacologicalPharmacological

Behavioral treatment of Behavioral treatment of agitation and aggressionagitation and aggression

Identify the level of agitation and Identify the level of agitation and respond accordingly.respond accordingly.

Mild:Mild: validate and talk. validate and talk.Moderate:Moderate: structure environment; structure environment;

distract.distract.Severe:Severe: establish understandable establish understandable

limits; decrease stimuli.limits; decrease stimuli.

Behavioral treatment of Behavioral treatment of aggressionaggression

Panic PhasePanic Phase Intervention is needed to prevent Intervention is needed to prevent

injury.injury. Get away (pre-planned exit Get away (pre-planned exit

strategy).strategy). Obtain assistance.Obtain assistance.

RescueRescue

911911 Facility code-response teamFacility code-response team

Psychiatric HospitalizationPsychiatric Hospitalization

Careful consideration.Careful consideration. Behavioral and pharmacological Behavioral and pharmacological

treatment first.treatment first. Goal is to eliminate aggressive Goal is to eliminate aggressive

symptoms and return to his/her symptoms and return to his/her environment.environment.

Medications to treat Medications to treat agitation and aggressionagitation and aggression No medications are approved by No medications are approved by

the FDA for the specific treatment the FDA for the specific treatment of aggression.of aggression.

Medications that are used must Medications that are used must be monitored to determine be monitored to determine effectiveness.effectiveness.

MedicationsMedications

SSRI AntidepressantsSSRI Antidepressants– Used to treat lowered serotonin levels.Used to treat lowered serotonin levels.– sertraline, fluoxetine, citalopram, sertraline, fluoxetine, citalopram,

escitalopram, etc.escitalopram, etc.– Some effect can be noted in 3 to 5 Some effect can be noted in 3 to 5

days, but can take two weeks for full days, but can take two weeks for full effect.effect.

MedicationsMedications

Beta-blockers: propranolol, metropololBeta-blockers: propranolol, metropolol Antipsychotics: Risperdal, Haldol, Antipsychotics: Risperdal, Haldol,

quetiapinequetiapine Anti-convulsants: valproate, Tegretol, Anti-convulsants: valproate, Tegretol,

Neurontin, LamictalNeurontin, Lamictal Combination therapy, such asCombination therapy, such as

– buspirone + propranololbuspirone + propranolol– valproate + anti-psychotic medicationvalproate + anti-psychotic medication

About those About those benzodiazepinesbenzodiazepines Medications, such as Ativan and Medications, such as Ativan and

Xanax, are used for anxiety in Xanax, are used for anxiety in non-non-dementeddemented patients patients

When used with demented patients, When used with demented patients, they can increase confusion, falls, they can increase confusion, falls, and agitation.and agitation.

Limit to an as needed basis only.Limit to an as needed basis only. Avoid gels.Avoid gels.

When to report to APSWhen to report to APS

When the caregiver is unable to When the caregiver is unable to protect self and/or the care protect self and/or the care recipient from elder abuse.recipient from elder abuse.

Other interventions have been Other interventions have been unsuccessful.unsuccessful.

RecommendationsRecommendations

The likelihood of aggressive The likelihood of aggressive behaviors needs to be an behaviors needs to be an expectation among the demented expectation among the demented and mentally ill population.and mentally ill population.

Improved recognition and Improved recognition and assessment.assessment.

Education and training.Education and training. Improved reporting.Improved reporting.

Case Management and Case Management and Care CoordinationCare Coordination

Each case is unique.Each case is unique. It is never just about the patient.It is never just about the patient. Case management interventions Case management interventions

must be directed at the patient must be directed at the patient and and his/her caregiver(s).his/her caregiver(s).

Outpatient Case and Outpatient Case and Disease ManagementDisease Management

Case Management Case Management ProcessProcess– EngagementEngagement– AssessmentAssessment– Plan of Care CollaborationPlan of Care Collaboration– InterventionIntervention– EvaluationEvaluation

Assessment for Assessment for InterventionIntervention

Due to changes in the brain from Due to changes in the brain from dementia, a person needs the dementia, a person needs the environment and the caregiver to environment and the caregiver to compensate for impaired memory compensate for impaired memory functions.functions.

The more we know about how a person’s The more we know about how a person’s memory ability has changed, the more memory ability has changed, the more we can target successful strategies to we can target successful strategies to improve their quality of life.improve their quality of life.

EngagementEngagement With whom will you be working?With whom will you be working? Size up family dynamics.Size up family dynamics. Capacity/insight issues.Capacity/insight issues. Medical decision-making.Medical decision-making. Recognizing and responding to Recognizing and responding to

caregiver stress.caregiver stress. Empathetic approach.Empathetic approach.

AssessmentAssessment BiopsychosociaBiopsychosocia

ll– Active listening Active listening

approachapproach– Assess Assess

ability/stress of ability/stress of care providercare provider

AssessmentAssessment Patient GoalsPatient Goals Caregiver GoalsCaregiver Goals

– Long term care plans?Long term care plans? Existing Strengths and ResourcesExisting Strengths and Resources Medical RecordMedical Record Reassess at 6 monthsReassess at 6 months

Tools for AssessmentTools for Assessment Case management organizationsCase management organizations Biopsychosocial assessment tools Biopsychosocial assessment tools

via internetvia internet Katz activities of daily livingKatz activities of daily living Create a short formCreate a short form

Plan of Care Plan of Care CollaborationCollaboration PatientPatient Caregiver(s)Caregiver(s) Medical providersMedical providers Community resourcesCommunity resources

InterventionsInterventions What is needed to keep patient What is needed to keep patient

safe?safe? What will provide for patient’s What will provide for patient’s

dignity?dignity? What will improve patient’s quality What will improve patient’s quality

of life?of life? What offers least restrictive What offers least restrictive

environment?environment?

InterventionsInterventions What communication techniques What communication techniques

and behavioral approaches will be and behavioral approaches will be most effective?most effective?

What is needed to support the What is needed to support the caregiver?caregiver?

InterventionsInterventions Medication managementMedication management Financial securityFinancial security Environmental adjustmentsEnvironmental adjustments Personal care assistancePersonal care assistance Nutrition/hydrationNutrition/hydration Physical exercisePhysical exercise Social activitiesSocial activities Caregiver supportCaregiver support

InterventionsInterventions Identify key agenciesIdentify key agencies

– Alzheimer’s Association & othersAlzheimer’s Association & others– Area Agency or Commission on AgingArea Agency or Commission on Aging– Senior Neighbor Centers and ServiceSenior Neighbor Centers and Service– Social Security AdministrationSocial Security Administration– Veteran’s AdministrationVeteran’s Administration– Secretary of StateSecretary of State– MDCHMDCH– Medicare & MedicaidMedicare & Medicaid

InterventionsInterventions Identify Home SupportsIdentify Home Supports

– Adult day programsAdult day programs– Home delivered mealsHome delivered meals– Home helper servicesHome helper services– Respite careRespite care– TransportationTransportation

InterventionsInterventions Assist with long-term care planningAssist with long-term care planning

– DPOA or guardianship DPOA or guardianship – Housing advisorsHousing advisors– Long term care facilitiesLong term care facilities

PACEPACE AL AL AL dementiaAL dementia Skilled nursing facilitiesSkilled nursing facilities

HospiceHospice

The Alzheimer’s The Alzheimer’s Disease Bill of RightsDisease Bill of Rights To be informed of one’s diagnosis.To be informed of one’s diagnosis. To have appropriate medical care.To have appropriate medical care. To be productive in work and play for To be productive in work and play for

as long as possible.as long as possible. To be treated like an adult, not a To be treated like an adult, not a

child.child. To have expressed feelings taken To have expressed feelings taken

seriously.seriously.

The Alzheimer’s The Alzheimer’s Disease Bill of RightsDisease Bill of Rights To be free from psychotropic To be free from psychotropic

medications, if possible.medications, if possible. To live in a safe, structured, and To live in a safe, structured, and

predictable environment.predictable environment. To enjoy meaningful activities To enjoy meaningful activities

that fill each day.that fill each day. To be outdoors on a regular basis.To be outdoors on a regular basis.

The Alzheimer’s The Alzheimer’s Disease Bill of RightsDisease Bill of Rights To have physical contact, including To have physical contact, including

hugging, caressing, and hand-holding.hugging, caressing, and hand-holding. To be with individuals who know one’s To be with individuals who know one’s

life story, including cultural and life story, including cultural and religious traditions.religious traditions.

To be cared for by individuals who are To be cared for by individuals who are well trained in dementia care.well trained in dementia care.

The Best Friends Approach to Alzheimer’s Care, by Virginia Bell and David Troxel; The Best Friends Approach to Alzheimer’s Care, by Virginia Bell and David Troxel; 1997: Health Professions Press, Inc., Baltimore1997: Health Professions Press, Inc., Baltimore