understanding the dementias

Understanding the Dementias

B. Heath Gordon, Ph.D.1,2,3

11.08.13

1. G.V. (Sonny) Montgomery VAMC 2. UMMC School of Medicine, Division of Geriatrics3. Private Practice, Jackson, MS

DisclosuresNone

ObjectivesUpon completion of this 1-hour learning activity, attendants should

be able to:

1. Identify the primary types and causes of dementing illnesses

2. Describe the cognitive and behavioral features of different dementing illnesses

3. Identify a behavioral model and techniques for managing challenging behaviors in loved ones with dementia

Perceptions of Cognitive Aging

What is Dementia? now

(Major & Mild Neurocognitive Disorders)

DSM-IV-TR (2000)Multiple cognitive deficits:

Memory Impaired ability to learn new things or recall old information

Plus (one or more of the following): Language disturbance

Difficulty performing motor activities (w/ intact motor ability)

Failure to recognize or identify objects (w/ intact senses)

Impaired planning, organizing, sequencing, or abstracting ability

Key PointsSymptom must interfere with daily life

Represents a decline from a higher level of functioning

Does not occur exclusively during an episode of delirium

Not better accounted for by another mental health condition

DSM-5 (2013)Major and Mild Neurocogitive Disorders (NCDs)

Evidence in cognitive decline in one or more areas based on

1. Self-report or an informant, AND2. Clinical assessment

Subtypes of NCD are specified E.g., Probable major neurocognitive disorder due to Alzheimer disease, with behavioral disturbance, moderate

Greater alignment with consensus criteriaE.g., Probable vs. Possible Alzheimer disease

CausesProgressive disease

Vascular disease

Trauma

Tumors

Substance-induced

Infection

Metabolic disorders

Endocrine disorders

Epileptic disorders

Toxic reactions

Anoxia

Vitamin deficiency

Primary Types of Progressive Dementia

Alzheimer disease (DAT)

Vascular dementia (VaD)

Dementia with Lewy bodies (DLB)

Frontotemporal lobar dementia (FTD)

Other TypesParkinson’s disease

Huntington’s disease

Multiple sclerosis

Pick’s disease

Hydrocephalus

Creutzfeld-Jacob disease

Substance-induced

persisting dementia

HIV-related dementia

Dementia pugilistica

Multiple etiologies

Alzheimer disease (DAT)

Criteria for DATMemory impairment: Learning & Recall

One or more impairments in the following:Speech and/or understanding language = aphasiaSkilled movement = apraxiaObject recognition = agnosiaJudgment, planning, switching tasks, etc. = executive functioning

Cognitive deficits represent a significant decline

Gradual start and decline in cognition (vs. sudden)

Deficits cause significant impairment in social or occupational functioning

Features of DATGenerally a gradual onset with initial difficulty remembering recent events (perhaps mood changes) that becomes global and affects long-term memory

Accounts for ~60-80% of all dementing illnesses

Due to neuronal atrophy, synapse loss, abnormal accumulation of neuritic plaques and neurofibrillary tangles

Progression

Vascular Dementia (VaD)

Criteria for VaDMemory impairment: Learning or Recall

One or more impairments in the following:Speech and/or understanding languageSkilled movement Object recognitionJudgment, planning, switching tasks, etc (executive functioning)


Focal neurological signs and symptoms or lab evidence indicative of cerebrovascular disease

Deficits cause significant impairment in social or occupational functioning and are a significant decline

Features of VaDGenerally an abrupt onset of cognitive deficits and step-wise pattern of decline

Multiple injuries to the brain due to inadequate blood supply

Where injury occurs determine type of cognitive deficitsImpairment in memory

memory retrieval > new learningDeficits in attention/concentrationImpairment in judgmentPersonality and mood changes

Stroke-Related Behaviors

Stroke A ≠ Stroke B

Frontal LobeMotor cortex

Motor function, fine motor coordination

Premotor cortexFrontal eye fields, motor planning

Prefrontal cortex“Executive functions”Planning, organizing, monitoring, inhibitingMotor speech area

Dorsolateral Dysexecutive syndrome

Poor problem-solving, reasoning, sequencing, maintaining behaviors (perseverative)

Poor motivation

Poor insight and judgment

Slow learning, environmental dependence, poor memory attention, forgetting temporal sequence of events

Blunted and apathetic affect but anger when aroused

OrbitofrontalEmotionally dysregulated

Behaviorally disinhibited

Impulsive

Poor smell discrimination

Pseudopsychopathic syndrome

DisorganizedLack of social gracesPoor appreciation for feelings of others or negative aspects of behavior

Medial FrontalAssociated with anterior cingulate

Akinetic and apathetic with bilateral damage

Little initiation of movement or speech

Lack of interest and indifference

Emotional blunting

Memory impairment (amnesia with confabulation)

Incontinence

Lower extremity weakness

Symptom Origin?

Dementia with Lewy Bodies (DLB)

Criteria for DLBMemory impairment: Learning & Recall



Evidence from medical exam of related illness


Features of DLBAssociated with abnormal structures called Lewy Bodies in the brain

Gradual start and progression of cognitive declineFluctuating cognition and variability in alertness/attentionAbrupt confusionMemory deficits (memory retrieval more than learning new information)

Parkinsonism Bradykinesia (loss of spontaneous movement) Rigidity (muscle stiffness)TremorShuffling gait

Visual hallucinations (well-formed, detailed, recurrent)

Frequent falls

Frontotemporal Dementia (FTD)

Criteria for FTDMemory impairment: Learning & Recall



Evidence from medical exam of related illness


Features of FTDLoss of brain tissue in frontal and temporal lobes

Associated with abnormal structures in the brain (Pick’s Bodies)

Gradual start and progression of cognitive decline:

Behavioral & personality changes are significant loss of personal (hygiene) and social (tact) awarenessDisinhibited and impulsiveLoss of initiative, indecision, lack of spontaneity

Impairment in speech and/or understanding language

Object recognition impairment

Impairment in skilled movement

Positive Behavior Approach

IntroductionModels for Understanding Behavior

Different types of disruptive behavior/agitation

Mixing three models

Matching Interventions to Disruptive Behaviors

Based on environmental links

Individualized to ability and preference

Behavior SymptomsBehavioral Disturbances: Behaviors we don’t want to see but are present.

Physically AggressiveHittingKicking Biting

Physically Non-AggressivePacingInappropriate disrobing

Verbal AggressionCursingScreamingThreatening

Verbally Non-AggressiveCryingRepeated QuestionsConstant Requests

Behavior SymptomsBehavioral Deficits: Behaviors we do want to see but are not present.

Decreased social skills

Apathy/Decreased display of emotion

Physical dependency/ADL limitations greater than indicated by illness/disease

Unable to interact with their surroundings

Behaviors Rated by Dimension

VERBAL/VOCAL

VERBALLY NONAGGRESSIVE VERBALLY AGGRESSIVE -complaining -cursing and verbal aggression -negativism -making strange noises -repetitive questions -verbal sexual advances -constant, unwarranted requests -screaming for attention

NONAGGRESSIVE AGGRESSIVE

PHYSICALLY NONAGGRESSIVE PHYSICALLY AGGRESSIVE -repetitious mannerisms -physical sexual advances -inappropriate robbing and disrobing -hurting self or others -eating inappropriate substances -throwing things -handling things inappropriately -tearing things -pacing, aimless wandering -grabbing -intentional falling -pushing -general restlessness -spitting -hoarding things -kicking and hitting -hiding things -biting PHYSICAL

(Cohen-Mansfield, 2000)

Model for Understanding Behavior

Role of Individual QualitiesPersonal History, Habits, PreferencesPersonality StyleNeurological/Brain structure and chemistryMental & Physical Abilities, Deficits

Role of Environmental Qualities

INTERNAL NEEDS: EXTERNAL DEMANDS:Physical Physical SurroundingsEmotional Social Surroundings

Learning Behavior ModelA connection occurs between antecedents, behavior, and consequences

Disruptive behavior is learned through reinforcement from others

Goal: reinforce positive, appropriate behavior and do not reinforce negative, disruptive behavior

Unmet Needs Model

Person Environment Fit Model Learning Behavior Model

Based on Cohen-Mansfield, 2000

Unmet needsand

Direct effects ofdementia

EnvironmentPhysical

Psychosocial

Life long habits & Personality

Current abilities Physical & Mental

Need-Driven Behavior

Benefit of Behavioral ModelsAll models focus on the reason or cause for the behavior.

Need to understand behavior before you actDoes not decrease the person’s ability to interact, which is already difficult.

Focuses on psychosocial interventions, and does not have the drawbacks of medication.

Side effectsDrug interactionsLimited value (does not increase positive behavior)

AssumptionsAll behavior has meaning

Behavior is a way of communicating

Behavior can be a demonstration of a person’s abilities, disabilities, and challenges they face

Understanding the reason or cause is the best way to manage disruptive behaviors

Try psychosocial approaches before medications

Interventions must be person-centered

“A”Antecedents

“B”Behavior

“C”Consequences

Learning Behavior Model: ABCs of

Behavior

ABCs of Resident BehaviorThe ABCs of Behavioral Management

A = AntecedentB = BehaviorC = Consequence

Antecedent: what happens before the behavior

Consequence: what happens after the behavior (Burgio & Stevens)

ABCs of Resident BehaviorTo identify the Antecedents and Consequences, ask the ‘W’ questions

WhatWhy WhenWhereWho

(Burgio & Stevens)

Behavior Logs: Charting Behavior

Time & Date:Behavior: List & Describe:With whom? Number of people:Where?:Trigger Event(s):Interventions Tried: List & Describe:End Result(s):Effective?:

Behavioral DisturbancesWhy do behavioral disturbances occur?

Internal factorsMemory loss

Sensory changes

Loss of communication skill

Pain/discomfort

(Burgio & Stevens)


External factorsOver stimulation

Lack of stimulation

Lack of activity

Too many demands(Burgio & Stevens)


Caregiving situations

Factors in the caregiving routine can often cause the residents to react with a behavioral disturbance.

These factors includeToo much informationSpeaking too quicklyTouching without warning (Burgio & Stevens)


Verbal Pointing out reality is not useful with a resident who is confused or disoriented because of dementia

The resident with dementia cannot remember the correct information

Frequently reminding a resident of correct information gives a negative message

(Burgio & Stevens)


NonverbalThe nonverbal message, or your body language, emphasizes what you are saying to the resident

Body language also gives an emotional message by showing how you feel about the resident

Remember: Even though residents with dementia have trouble understanding what you are saying or doing, they still can receive the emotional message.

(Burgio & Stevens)

ExamplesYelling and Screaming:

Difficult symptoms because they disturb others

May be a means for getting attention

May be a response to over or under stimulation, fear, pain, hunger, feeling overwhelmed or depression

ExamplesResisting Care:

Can result from fear, feelings of powerlessness or misunderstanding, or if the resident feels rushed or treated roughly

Many times the person with cognitive loss is aware at some level of his/her loss of skills; the refusal may be the only way the person can have control and reduce feelings of powerlessness

ExamplesVerbal Aggression:

Includes arguing, cursing, threatening, swearing, or accusing

May be the result of a loss of impulse control

Anything that increases stress may cause this behavior

Verbal aggression may be a cry for help

May be a response to fear, pain, hunger, feeling overwhelmed or depression

Therapeutic Communication: Skills to Change the As and Cs

1. Identify yourself by name

2. Address Patient by name

3. Speak slowly and allow time to communicate

4. Give one-step instructions

5. Phrase questions in a simple multiple-choice format

6. Use positive statements whenever possible

7. Avoid negative statements


Effective communication involves positive choice of words

Don’t assume that the other person knows what you think or feel

Avoid blaming or over-generalizing“you are trying to be difficult”“you always . . . “ “you never . . . “


Effective communication involves active listening.

Sit or stand to face the person at a slight angle, to connect but allow personal space.

Avoid mind reading or judging what the other person is thinking or feeling BEFORE you listen

“you don’t want to hear what I say”“you are trying to be difficult” “you don’t care”


Effective communication involves understanding

Repeat what you heard make sure you heard what was said correctly:

“I heard you saying X, is that correct?”gives the other person the opportunity to correct miscommunication

Restate what the person’s actions sayAccept what feelings the person has

Behavior ManagementPositive Reinforcement

Planned Ignoring

Distraction & Diversion

Replacing Disruptive Behaviors

Positive ReinforcementWhen Patients are behaving in a manner that is appropriate, reward them.

Give them attention for these good behaviors

Remember:Reward behaviors you want to continueIgnore behaviors you want to end or not re-occur

Positive Reinforcement Ways to give positive reinforcement

Attention

Praise and Appreciation

Acknowledgement

Comfort

Positive ReinforcementPositive reinforcement can be used to change the C, Consequences.

Positive reinforcement is a consequence

When a behavior is followed by a positive reinforcer, the behavior is likely to occur again

Therefore, only use positive reinforcement for behaviors you want to re-occur. Don’t reinforce behavioral disturbances.

Positive Reinforcement Rules for reinforcing behavior:

1. Give reinforcement immediately following the desired behavior

2. Reinforcement should be given each time the desired behavior occurs

3. Make sure that the reinforcer is meaningful and personal to the Patient.

4. Patient should not get the reinforcer unless the desired behavior occurs

5. The reinforcer should be short-term.

Behavior Management Summary

There are a variety of tools to assist in managing behaviors to change the As & Cs

Behavior management skills such as positive reinforcement, planned ignoring, distraction/diversion, and replacing behaviors can be used to decrease disruptive behaviors

understanding the dementias

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