Catching Your BreathChasing COPD Management in People with Dementia

Craig EdlinRespiratory Physiotherapist

Complex Care Services (previously known as HARP)

What we will cover

Part One:

• Highlights of managing COPD in people with dementia• Diagnosis and Intervention

• Self-management – inhalers, action plans & being active / pulmonary rehabilitation

https://lungfoundation.com.au/health-professionals/guidelines/copd/copd-x-concise-guide-for-primary-care/

Part Two:

• Theories of learning for people with dementia to support self-management

Carer Involvement

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COPD and Cognitive Impairment

• Prevalence approx. 32% (Yohannes et al., 2017)

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• Mechanism likely multifactorial – hypoxia, multi-morbidity, co-prevalent, inflammation…

• Screen early for cognitive impairment

(Chang et al., 2012)

Diagnosis(https://copdx.org.au/copd-x-plan/confirm-diagnosis/)

• COPD is an umbrella term• Phenotype development continues - e.g. 27-28% asthma overlap

• Need respiratory function tests• Laboratory based

• People with dementia often perform poorly on RFTs → under-diagnosis (Frohnhofen et al., 2011)

• Clinical history

• Consider referral to specialist if diagnostic uncertainty or complexity• Pulmonary hypertension / cor pulmonale, malignancy, haemoptysis, frequent

exacerbations/antibiotic unresponsiveness, bronchiectasis, interstitial lung disease

Carer Involvement

Intervention(https://copdx.org.au/copd-x-plan/o-optimise-function/)

• Discuss smoking cessation at every opportunity

• Stepwise approach to medication therapy

• Optimise co-morbidities and non-pharmacological interventions

Carer Involvement

Falls - Sinuses - Sleep - Reflux Swallowing - Continence - Carer Stress

Self-management of COPD

• What is it?• Intervention that is personalised, structured, develops disease

management skills, positive adaptations; with goals of improving health, emotional and social well-being, QoL and forms alliances with HCPs; an iterative process of motivating behaviour change (Effing et al., 2016)

• Can improve HR-QoL & reduce respiratory related hospital admissions (Lenferink et al., 2017)

• Length of intervention matters (Jonkman et al., 2016)

→Action plans, inhalers and being active / exercising

Carer Involvement

Action Plans(https://lungfoundation.com.au/health-professionals/clinical-resources/copd/copd-action-plan/)

• Action plans reduce ED presentations and in-hospital resource utilisation (Howcroft et al., 2016)

• Personalise symptoms to what patient experiences• i.e. loss of appetite, reduced energy, coughing, sleep

• Consider appropriateness for at home antibiotics and steroids – self-initiated or through clinician contact

Carer Involvement

Bespoke, simplifiedactionplan

Carer Involvement

Inhalershttps://copdx.org.au/copd-x-plan/o-optimise-function/o5-inhaler-technique-and-adherence/

• Which inhaler to prescribe?• Within class devices are clinically equivalent

• Minimise different types of inhalers (Bosnic-Anticevich et al., 2017)

Carer Involvement

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Inhalershttps://copdx.org.au/copd-x-plan/o-optimise-function/o5-inhaler-technique-and-adherence

• Which inhaler to prescribe?• Within class devices are clinically equivalent• Minimise different types of inhalers (Bosnic-Anticevich et al., 2017)

• Device considerations • Frequency• Simplicity and dexterity required• Steps required• Force of inhalation needed• If possible, trial different devices - get placebos• Is changing the device necessary

• At some stage nebulised bronchodilators and steroids may be appropriateCarer Involvement

Inhaler Technique

• Do I look like an idiot?

• Humour me…it is my job

• 50-83% of people have at least one critical inhaler technique error (Sriram & Percival, 2016)

• Correct inhaler use reduces exacerbations (Melani et al., 2011)

• Review technique at every opportunity

Carer Involvement

Activity, Exercise & Pulmonary Rehabilitation

• 10% of people with COPD access PR (Holland et al., 2017)

• Up to 50% never attend and 33% do not finish (Holland et al., 2017)

• Main barriers are travel, poor mobility and distressing dyspnoea

• Starting within 2 weeks after an exacerbation might reduce presentations (Matsui, Jo, Fushimi, & Yasunaga, 2017)

• 41% of people accessing PR have cognitive impairment (Cleutjens et al., 2017a) and they drop-out more (Cleutjens et al., 2017b); as do people with frailty (Maddocks et al., 2016)

• People with cognitive impairment get similar benefits (Cleutjens et al., 2017b)

• Generally people with diagnosis of dementia are excluded from studies (Yohannes, 2014)

Carer Involvement

Pulmonary Rehabilitation

• Home based PR is likely equal to centre-based (Holland et al., 2017; Horton et al., 2018)

• 1-2 weekly phone calls

• Similar social benefits

• Dose - exercised less intensely but more frequently

• For people with dementia• Paradigm shift towards offering home based PR / activity promotion

• Focus on accessing community / meaningful activity based

• Address anxiety, fear of falling and social isolation

• Offer at-home or centre-based rehabilitation

Carer Involvement

Part One: Highlights

•Diagnose early – respiratory function tests• Screen for cognitive impairment• Stepwise management of medications

• Self-management• Inhalers• Action plans• Relevant activity and exercise at home or centre-based

Carer Involvement

Part Two:

Can People with Dementia Learn?

No and Yes

• Progressive neurological disease

• Ultimately limits ability

• Requires compensatory strategies• Carer relationship – monitoring and taking action• Simplification of management plan – focus on inhalers, action plans & activity

• However, people with dementia can still learn and relearn… they may require a different approach

• Self-management as a form of learning and rehabilitation

Models of Learning

RepetitionPerson-centred

Care

Multi-disciplinary

Working

Geriatric Care

Carer Involved

Rehabilitationin Dementia(≈ self-management)

Concept of personhood:Tom Kitwood (1997)

Carer Involvement

Models of LearningAn Oversimplification

‘A theory of rehabilitation without a model of learning is a car without an engine’ (Baddeley, 1993)

Impaired explicit (declarative) memoryin dementia / cognitive impairment= errorful learning may not be effective

Trial and Error Learning

What other ways to learn are there for people with dementia?

Implicit Memory

• Techniques• Errorless learning• Constant practice conditions• Priming

• Examples• Inhaler technique• Understanding action plan• Learning to use oxygen

equipment• Taking medications

Carer Involvement

(Halteren-Van Tilborg,Scherder and Hulstijn, 2007; Donaghey,Mcmillan and O‘Neill, 2010; Dechamps et al., 2011; Middleton and Schwartz, 2012; De Werd et al., 2013; Kleynen et al., 2014; Fish et al., 2015; Kleynen et al., 2015; Stoykov and Madhavan, 2015; Roberts et al., 2016; Voigt-Radloffet al., 2017; Ries, 2018)

Where & When

• Context-specific – in their own environment

• Remove distractions

• Tailor to individual – analogies, make relevant / interesting, what they or their carer think will work

• Simplify instructions – minimum needed

• Write it down and put it somewhere it will be seen

• Activity / exercise can goal based but relevant

• People with dementia will likely need more time and repetition

• Patient – health-care professional relationship

Carer Involvement

General Advice

• Consider MyAgedCare for Aged Care Assessment to support carer and patient

• Utilise home visiting services to assist with at home management

Be in for the long haul –you will see better returns

Thank you!

Resources

• https://copdx.org.au/

• https://www.nationalasthma.org.au/living-with-asthma/how-to-videos

• http://lungfoundation.com.au/patient-support/copd/inhaler-technique-fact-sheets

• https://copdx.org.au/wp-content/uploads/2011/08/lungfoundation.com.au_wp-content_uploads_2014_02_08.-Using-your-inhalation-devices.pdf

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Chang, S. S., Chen, S., Mcavay, G. J. & Tinetti, M. E. (2012). 'Effect of coexisting chronic obstructive pulmonary disease and cognitive impairment on health outcomes in olderadults', J Am Geriatr Soc, 60(10), pp. 1839-46.

Cleutjens, F., Spruit, M. A., Ponds, R., Vanfleteren, L., Franssen, F. M. E., Dijkstra, J. B., Gijsen, C., Wouters, E. F. M. & Janssen, D. J. A. (2017a). 'The Impact of Cognitive Impairment on Efficacy of Pulmonary Rehabilitation in Patients With COPD', Journal of the American Medical Directors Association, 18(5), pp. 420-426.

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