dementia care update · (plaques) that build up between brain cells ... locked doors 20 applicable...

DEMENTIA CARE UPDATE

Introduction to Dementia Care

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42%of residents in assisted

living have Alzheimer’s

disease or another form

of dementia

3

Alzheimer's disease is

the sixth leading

cause of death in the

United States.

More than 5 million

Americans are living

with the disease.

1 in 3 seniors dies

with Alzheimer's or

another dementia.

In 2012, 15.4 million

caregivers provided

more than 17.5 billion

hours of unpaid care

valued at $216 billion.

Nearly 15% of caregivers

for people with

Alzheimer's or another

dementia are long-

distance caregivers.

In 2013, Alzheimer's will

cost the nation $203

billion. This number is

expected to rise to $1.2

trillion by 2050.

4Source: Alzheimer’s Association, www.alz.org

• Not a specific disease

• A general term that describes a wide range of

symptoms associated with a decline in memory or

other thinking skills severe enough to reduce a

person's ability to perform everyday activities

• Alzheimer's disease accounts for 60 to 80 percent

of cases

• Vascular dementia, which occurs after a stroke, is

the second most common dementia type

WHAT IS DEMENTIA?

Source: Alzheimer’s Association, www.alz.org 5

DEMENTIA

Alzheimer’s DiseaseVascular Dementia

Lewy Body

Parkinson’s

Disease

Frontotemporal

Mixed Dementia

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At least two of the following core mental functions

must be significantly impaired to be considered

dementia:

• Memory

• Communication and language

• Ability to focus and pay attention

• Reasoning and judgment

• Visual perception

SYMPTOMS OF DEMENTIA

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#1: Alzheimer’s disease

#2: Vascular dementia

CAUSES OF DEMENTIA

• Dementia with Lewy bodies

• Mixed dementia

• Parkinson’s disease

• Frontotemporal dementia

• Creutzfeldt-Jakob disease

• Normal pressure

hydrocephalus

• Huntington’s disease

• Wernicke-Korsakoff

Syndrom

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Symptoms:

• Difficulty remembering names and recent events

• Apathy and depression

• Impaired judgment

• Disorientation

• Confusion

• Behavior changes

• Difficulty speaking, swallowing and walking

ALZHEIMER’S DISEASE

Source: Alzheimer’s Association 9

Brain changes:

• Deposits of the protein

fragment beta-amyloid

(plaques) that build up

between brain cells

• Twisted strands of the

protein tau (tangles) that

build up inside cells

• Evidence of nerve cell

damage and death in the

brain




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STAGES

Source: Alzheimer’s Association

Stage 1 No impairment

The person does not experience any memory problems. An interview

with a medical professional does not show any evidence of symptoms

of dementia.

Stage 2 Very mild cognitive decline

The person may feel as if he or she is having memory lapses —

forgetting familiar words or the location of everyday objects. But no

symptoms of dementia can be detected during a medical examination

or by friends, family or co-workers.

Stage 3 Mild cognitive decline

Friends, family or co-workers begin to notice difficulties. During a

detailed medical interview, doctors may be able to detect problems in

memory or concentration.

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STAGES


Stage 4 Moderate cognitive decline

At this point, a careful medical interview should be able to detect

clear-cut symptoms in several areas: forgetfulness of recent events,

greater difficulty performing complex tasks, such as planning dinner.

Stage 5 Moderately severe cognitive decline

Gaps in memory and thinking are noticeable, and individuals begin to

need help with day-to-day activities.

Stage 6 Severe cognitive decline

Memory continues to worsen, personality changes may take place

and individuals need extensive help with daily activities.

14

STAGES


Stage 7 Very severe cognitive decline

In the final stage of this disease, individuals lose the ability to respond

to their environment, to carry on a conversation and, eventually, to

control movement.

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Symptoms:

• Impaired judgment or ability to plan steps needed

to complete a task is more likely to be the initial

symptom, as opposed to the memory loss often

associated with the initial symptoms of Alzheimer's

• Occurs because of brain injuries such as

microscopic bleeding and blood vessel blockage

• The location of the brain injury determines how the

individual's thinking and physical functioning are

affected

VASCULAR DEMENTIA


Brain changes:

• Brain imaging can often detect blood vessel

problems implicated in vascular dementia

• In the past, evidence for vascular dementia was

used to exclude a diagnosis of Alzheimer's disease

(and vice versa)

• That practice is no longer considered consistent

with pathologic evidence, which shows that the

brain changes of several types of dementia can be

present simultaneously

VASCULAR DEMENTIA


• An acute confusional state

• Medical condition that results in confusion and

other disruptions in thinking and behavior, including

changes in perception, attention, mood and activity

level

• Individuals living with dementia are highly

susceptible to delirium

• Can easily go unrecognized

DELIRIUM

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Regulatory Requirements

for Dementia Care

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Applicable Regulations

• Applicability

• Mild Cognitive Impairment

• Fire clearance

• Training

• Adequate staffing

• Medical assessments and

appraisals

• Safety modifications

• Personal grooming and

hygiene items

CARE OF PERSONS WITH DEMENTIA

• 87705

• Wrist bands and egress

alert devices

• Exit alarms

• Delayed egress

• Locked doors

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• Plan of operations

• Philosophy

• Assessments

• Admission procedures

• Activity programming

• Staff qualifications

• Staff training

• Physical environment

ADVERTISING DEMENTIA SPECIAL CARE…

• 87706

• Changes in condition

• Success indicators

• Admission agreement

• Advertisements

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• Direct care staff: 6 hours of orientation within the

first four weeks

• Various methods of instruction allowed

• 8 hours of inservice training every 12-months

• Require topics

• Documentation

• Trainer requirements

TRAINING REQUIREMENTS IF ADVERTISING…

• 87707

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• 40 hours total orientation

• 20 hours before working independently

• 6 hours dementia

• 4 hours postural supports, hospice

• 20 hours within first 4 weeks of employment


2016 CAREGIVER ORIENTATION TRAINING

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• 20 hours annually


• 4 hours postural supports, hospice

2016 CAREGIVER ONGOING TRAINING

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CCG CAN HELP

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Co-Morbidities

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• Complications related to the disease

• Significant concern for safety and quality of life

• Often related to eventual cause of death

• Creates risk management issues for the provider

CO-MORBIDITIES IN DEMENTIA CARE

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Swallowing Disorders

Dysphagia:

Occurs when there is a

problem with any part of

the swallowing process.

SWALLOWING DISORDERS

Aspiration:

Occurs when liquids or

solids are breathed into

the respiratory system

instead of properly being

swallowed I into the

stomach.


Monitoring Residents for Dysphagia and Aspiration

• Choking on foods, liquids or medication

• Coughing during or after eating

• Wet sounding voice


Monitoring Residents for

Dysphagia and Aspiration

(cont.)

•Extra effort to chew or

swallow

• “Pocketing” food



Interventions for Residents

With Swallowing Difficulties

1. Have Resident sit upright when eating.

2. Tilt the resident’s head slightly forward when

eating.

3. Ensure the resident remains sitting or standing

upright for at least 15-20 minutes after finishing a

meal.

4. Minimize distractions in dining area.

INTERVENTIONS/SWALLOWING DISORDERS

(cont.)

5. Do not encourage residents to talk until he/she

has swallowed his/her food.

6. Cut food into small pieces.

7. Encourage swallowing more than once after each

bite or drink.


(cont.)

8. Modified diets if physician ordered.

9. Request a speech therapy evaluation from the

physician to evaluate swallowing.



Examples of Modified Diets for

Residents with Cognitive

Impairment and Swallowing

Disorders

• Thick liquids

• Soft foods

• Pureed

• Minced, ground and

chopped

MODIFIED DIETS/ SWALLOWING DISORDERS

Pneumonia

PNEUMONIA

Causes of

Pneumonia

Bacteria

• Bacteria enters through inhalation or the

bloodstream.

• Bacteria infect the alveoli.

• Immune system responds by releasing white blood

cells to attack bacterium.

• Release of white blood cells also triggers body to

respond with fever, chills and fatigue.

CAUSES OF PNEUMONIA

Virus

• Virus enters body through droplets that enter the

mouth or nose.

• Virus invades cells around the alveoli and airways.

• Attacked cells die which leads to swift response

from body’s immune system

• Fluid leaks into alveoli which affects the

transportation of oxygen into bloodstream.

CAUSES OF PNEUMONIA

Fungus

• Least common cause of pneumonia

• Fungi enters body through inhalation of spores, or

through the bloodstream

• Fungi travel to alveoli and surrounding cells.

• White blood cells are released to destroy the fungi,

which also triggers the body to respond with fever,

chills and fatigue.

CAUSES OF PNEUMONIA

Signs and Symptoms

to Monitor:

• Drowsiness

• High Fever

• Rapid Breathing

• Chills

PNEUMONIA

Signs and Symptoms to

Monitor (cont.):

• Cough

• Chest Pain

• Blue tint to lips or nails

• Flu like symptoms

• Inability to clear throat

PNEUMONIA

PNEUMONIA

Complications of Pneumonia

Especially in Residents with

Cognitive Impairment

1. Septic Shock

Untreated bacteria growth

in the bloodstream can

cause normal circulation

to shut down. In some

cases, body tissues can

swell uncontrollably and

cause organ failure.

COMPLICATIONS OF PNEUMONIA

2. Lung Abscess

In some cases of

pneumonia, a cavity forms

within the affected area

and fills with puss.


3. Acute Respiratory Distress Syndrome (ARDS)

Sometimes pneumonia becomes so widespread

in the lungs breathing becomes increasingly

difficult. As a result, the body does not receive

enough oxygen to function properly.

COMPLICATION OF PNEUMONIA

4. Pleural Effusion

This condition occurs when fluid accumulates in

the membrane that surrounds the lungs. When

this membrane becomes inflamed form

pneumonia, it is more susceptible to fluid

retention and infection.


PNEUMONIA

Interventions to

Avoid Pneumonia

• Good nutrition and

hydration

• Regular physical

activities

• Monitor for aspiration

INTERVENTIONS TO AVOID PNEUMONIA

• Manage Dysphagia

• Report symptoms to

physician immediately

INTERVENTIONS TO AVOID PNEUMONIA

Pressure Ulcers

Factors that Contribute to Skin Problems:

• Poor nutrition

• Dehydration

• Lack of ability to ambulate or move about easily

• Inability to turn in bed or from side to side in chair

PRESSURE ULCERS

Factors That Contribute to Skin Problems (cont.)

• Decreased sensation

• Poor circulation

• Shearing

• Loss of bladder and/or bowel control

• Decreased activity

• Poor cognitive function (especially residents with

dementia)

PRESSURE ULCERS

PRESSURE ULCERS

Strategies to Keep the

Resident’s Skin Healthy

• Turn and reposition

minimally every 2 hours

• Hydrate skin with topical

application of lotions/creams

STRATEGIES FOR HEALTHY SKIN

• Utilization of a barrier

cream/ointment for

incontinence

• Meticulous incontinent

care

• Adequate hydration and

nutrition

STRATEGIES FOR HEALTHY SKIN

PRESSURE ULCERS

Complications with

Pressure Ulcers

1. Blood Poisoning – condition when bacteria

enters the blood stream. Requires immediate

medication attention, or could progress to sepsis

which is life threatening.

2. Infection in the Bone – also known as

“Osteomyelitis”. Infection enters bone through

outside wound or from the bloodstream. If left

untreated may cause permanent bone damage.

COMPLICATIONS WITH PRESSURE ULCERS

3. Infection with Antibiotic – Resistant Bacteria:

a bacteria that is not killed or controlled by

antibiotics. This is a serious health problem for

the resident and everyone in the facility.

4. Pain and Associated Depression –

Persistent and chronic pain from pressure ulcers

can cause emotional distress and depression.

5. Amputation – severe ulcers can lead to

amputation of infected extremity.

COMPLICATIONS WITH PRESSURE ULCERS

Four Stages of Pressure Ulcer:

Stage 1: The initial sign of a pressure ulcer is

reddening of the skin. At this point, the wound is only

superficial and the skin is typically unbroken. A

Stage 1 pressure ulcer will heal quickly when the

pressure point is relieved on the area.

PRESSURE ULCERS

Stage 2 – This stage is

characterized by a blister

on the surface of the skin.

The blister can be broken

or unbroken. There are

now layers of the skin that

have become injured, so

the wound is no longer

superficial.

PRESSURE ULCERS

Stage 3 – In this stage, the wound has progressed

through all layers of the skin. The affected area is at

high risk for contracting a serious infection. Relieving

the pressured area is essential, along with additional

padding or coverings to protect the wound and

promote healing. Surgery may be needed to remove

dead tissue.

PRESSURE ULCER

Stage 4: This is the final and most severe stage of a

pressure ulcer. The wound has now progressed

through the skin layers and has reached underlying

muscle, tendons, and bone. The wound itself may

not appear large in diameter when observing the

skin, but the depth of the wound is very severe.

PRESSURE ULCER

PRESSURE ULCERS

Preventing Pressure Ulcers

PRESSURE ULCERS

Urinary Tract Infections

Types of Infections Associated with Urination:

• Bladder Infection

• Kidney Infection

• Urethra Infection

URINARY TRACT INFECTIONS (UTI’S)

Causes and Risk Factors of UTI’s

Escherichia Coli Bacteria (E. Coli)

Chlamydia and Mycoplasma

Bowel Incontinence

Kidney Stones

Immobility

Dehydration

Lack of Nutrition


Common Symptoms:

Burning pain while urinating

Frequent/Urgent urination

Abdominal or pelvic pain

Itching or tenderness in lower

abdomen

Fever and chills


Common Symptoms (Cont.)

Fatigue

Blood in urine or cloudy urine

Foul or strong odor

Back or side pain

Confusion or rapid cognitive decline

Nausea and vomiting



Monitoring Residents

for UTI’s

• Observe for change in

condition

• Changes in behavior

• Resident is holding

his/her abdominal

area

• Increased urgency in

the need to void

MONITORING RESIDENTS FOR UTI’S

• Resident complains of

pain

• Smaller amounts of

urine when voiding

• Urine may smell foul,

and look cloudy and

dark in color

• Low grade fever

MONITORING RESIDENTS FOR UTI’S

Interventions to Avoid UTI’s

• Encourage/assist the resident to stay hydrated and

have balanced nutrition.

• Good incontinence care as well as proper hygiene

for the continent resident.

• Encourage/assist using the bathroom throughout

the day.

URINARY TRACT INFECTION (UTI’S)

Falls

• More than 1/3 of adults 65 and older fall each year

in the US.

• Men are more likely to die from a fall. However,

women are 67% more likely than men to have a

nonfatal fall injury.

• When an older adult falls, the effects go beyond

physical injury.

FALLS

Resident Risk Factors

of Falls:

• Effects of Medications

• Eyesight problems

• Hip, leg and foot

disorders

• Disease and illness

FALLS

Environmental Risk

Factors

• Elevated Bed Heights

• Low-seated chairs

• Poor lighting

• Slippery floors or non-

secured rugs

FALLS

Environmental Risk

Factors (Cont.)

• Clutter

• Poorly maintained

walking aids

• Lack of safety

equipment

FALLS

FALLS

Fall Risk Reduction

Strategies

Fall risk assessment

Condition of resident, medications used by resident,

history of falls, gait and balance assessment,

walking aid assessment, medical history, evaluation

by physical therapist, etc.

FALL RISK REDUCTION STRATEGIES

General strategies

• Observe environment for potentially unsafe

conditions.

• Identify residents who are “at risk” for falling and

implement specific fall risk reduction strategies for

that resident.

• Many others


Other Factors in Risk Reduction

Medications

Footwear

Exercise

Assistive Devices

FALLS

General Strategies

• Remind resident to request assistance as needed.

• Ensure all pathways are free from obstacles.

• Provide adequate lighting

• Provide appropriate chairs with arms that are solid

and secure.


FALLS

How to

Properly

Respond to a

Fall

Treating Alzheimer’s Disease

89

CURRENTLY APPROVED TREATMENTS

90

Name Brand name Approved For FDA Approved

1. donepezil Aricept All stages 1996

2. galantamine Razadyne Mild to moderate 2001

3. memantine Namenda Moderate to

severe

2003

4. rivastigmine Exelon All stages 2000

• Target key chemicals in the brain

(neurotransmitters) that are disrupted by

Alzheimer’s

• Do not cure the disease

• Do not treat the underlying cause

• May help to improve symptoms

CURRENT TREATMENTS

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• New drugs in development are trying to modify the

disease process itself

• Impacting one or more of the many brain changing

caused by Alzheimer’s disease

• Researchers believe effective treatment will require

a “cocktail” of medications

• Obstacles to progress: not enough volunteers, not

enough federal funding for research

TREATMENT HORIZON

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• Beta-amyloid

• Tau protein

• Inflammation

• Insulin resistance

• Brain imaging and biomarkers

TARGETS FOR FUTURE DRUGS

93

BETA-AMYLOID

94

http://www.alz.org/research/video/video_

pages/understanding_attacking_alz.html

Click on the link to view the video.

Make sure you’re connected to the internet.

INFLAMMATION

95

http://www.alz.org/research/video/video_pages

/inflammation.html



INSULIN RESISTANCE

96


/insulin_and_alz.html



http://www.alz.org/research/video/video_pages/understanding_attacking_alz.html

http://www.alz.org/research/video/video_pages/inflammation.html

http://www.alz.org/research/video/video_pages/insulin_and_alz.html

BRAIN IMAGING AND BIOMARKERS

97


/quest_for_biomarkers.html



http://www.alz.org/research/video/video_pages/quest_for_biomarkers.html

dementia care update · (plaques) that build up between brain cells ... locked doors 20 applicable...

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