overview of alzheimer’s disease and other dementias colloquium the aging population, alzheimer’s...
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Overview of Alzheimer’s Overview of Alzheimer’s Disease and Other Disease and Other
DementiasDementiasColloquium
The Aging Population, Alzheimer’s and Other Dementias:Law & Public Policy
University of Iowa College of LawJanuary 26, 2012
Kathleen Coen Buckwalter, PhD, RN, FAANProf. Emerita of Gerontological Nursing
Co-Director, National Health Law and Policy Resource Center
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More than “confusion”More than “confusion”
Many things can interfere with memory Being overloaded; having too much going
on at one time Medications, even ones taken according to
directions Illness and disease that are unrelated to
brain disease Unfamiliar surrounding such as relocation
or hospitalization
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DementiaDementia
Permanent loss of mental abilities caused by damage to brain cells
NOT a “normal” part of aging! The common end result of many entities
diseases traumas infections drugs
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Dementia: Essential FeaturesDementia: Essential Features
Progressive loss of intellectual abilities . . .
MEMORY impairment Short-term early Long-term later
Loss of LANGUAGE Loss of ability to express oneself Loss of ability to understand what is said
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Dementia: Essential FeaturesDementia: Essential Features
Loss of PURPOSEFUL MOVEMENT Has the physical ability Can’t perform the task (e.g., getting
dressed) Loss of ability to accurately
interpret SENSORY INFORMATION Cannot understand what is seen,
heard, felt Not related to sensory impairment
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Dementia: Essential FeaturesDementia: Essential Features
Impairments in . . . Abstract thinking Ability to reason Judgement Impulse control
Personality changes Not “him/herself”
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Who has dementia?Who has dementia? REVISEDREVISED Dementia is a “generic term”
Many different types Alzheimer’s disease Most common type
Risk increases with advancing age 25% of 80 year olds 33% of 85 year olds 50% of 90 year olds
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Who has dementia? Who has dementia? REVISEDREVISED
Common problem among nursing home residents: 50% to 80% have dementia
Increasing problem among those in assisted living: [add statistic here]
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Dementia: TypesDementia: Types
Alzheimer’s Typea.k.a. Alzheimer’s Disease = Most common 360,000 new cases annually 4 million Americans afflicted 4th leading cause of death 14 million (1 out of 45) by the year 2050 80% of population in nursing homes Leading cause of behavioral symptoms
Types
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Dementia: TypesDementia: Types
Vascular, a.k.a., Multi Infarct = 2nd most common
Mixed Alzheimer’s AND Vascular = 3rd most common
Types
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Dementia: TypesDementia: Types
Dementia due to . . . HIV Disease Parkinson’s Disease Huntington’s Disease Head Trauma Substance-Induced Persisting Dementia
Types
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Dementia: TypesDementia: Types
Dementia due to . . . Pick’s Disease Creutzfeldt-Jakob Disease
Types
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Dementia: TypesDementia: Types
Not specifically listedin DSM-IV . . . Diffuse Lewy Body Disease Frontal Lobe Dementia
Many medical causes! Normal Pressure Hydrocephalus Anoxic damage Vitamin deficiency
Types
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Dementia: TypesDementia: Types
Bottom Line:
All Alzheimer’s is DEMENTIA . . .but not all DEMENTIA is
Alzheimer’s!!
Types
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Dementia: TypesDementia: Types
LOTs of variability in presentation! Within specific types . . . BETWEEN types . . .
Overlapping syndromes are common Dementia AND delirium Alzheimer’s AND vascular dementia
Types
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““Reversible” DementiaReversible” Dementia
Multiple health problems may cause “confusion”
Always explore alternative causes Treatment of underlying physical
problem may arrest losses Problems not fully “reversible” but
remaining capacity may be preserved
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D-E-M-E-N-T-I-AD-E-M-E-N-T-I-A
D rugsE motionM etabolicE ndocineN utritionT raumaI nfectionA lcoholism
Like working a puzzle . . .
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Diagnosis of Alzheimer’s:Diagnosis of Alzheimer’s:New Criteria and GuidelinesNew Criteria and Guidelines
Preclinical Alzheimer’s Disease Mild cognitive impairment (MCI) due to
Alzeimer’s Disease Dementia due to Alzheimer’s Disease
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Stages of Dementia for Stages of Dementia for Behavioral and Environmental Behavioral and Environmental ApproachesApproaches
Early - Forgetful Middle - Confused Later - Ambulatory Terminal - Endstage
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Early: ForgetfulEarly: Forgetful
Short-term memory impaired Loses things Forgets
Blames stress, fatigue
Compensates with lists, memory aids
Depression common
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Later: ConfusedLater: Confused
Loss of memory Increasing
disorientation Time Place Person Things
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Confused: ExampleConfused: Example
“Helen” crochets using a single simple stitch but doesn’t remember that she is retired - and sometimes puts her bra on over her blouse.
“Harold,” greets everyone like his oldest friend (“Nice to see you! So good of you to drop by! I’m great! How are you?”) but doesn’t know his own wife.
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Confused: ExampleConfused: Example
“Mildred” avoids the question “How old are you?” with “Jack Benny and I are both 29.” When asked what she had for lunch, she replied, “I went to the Riviera and had pink champagne and caviar.”
“George” got lost walking in his neighborhood of 30 years -- as soon as he could no longer see his own house.
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Later Still: Ambulatory Later Still: Ambulatory DementiaDementia
Progressive loss of ability interferes with FUNCTION
Increasingly withdrawn and self-absorbed
Depression tends to resolve
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Ambulatory: Functional lossesAmbulatory: Functional losses
Willingness and ability to bathe Grooming Choosing among clothing Dressing Gait and mobility Toileting Communication, reading, and writing skills
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Ambulatory: BehaviorsAmbulatory: Behaviors
Behavioral symptoms more common Irritability Agitation Anxiety Pacing
Reduced tolerance for stress
Resistiveness to care
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Endstage DementiaEndstage Dementia
All abilities lost Mute No longer walks Little purposeful
activity Forgets to eat, chew,
swallow Complications are
common
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Symptoms: Not in distinct Symptoms: Not in distinct stages!stages! Losses and symptoms vary from person
to person, depending on Extent of brain cell death and loss Location of brain cell death and loss Speed with which losses occur
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Common Behavioral Common Behavioral SymptomsSymptoms Concealed memory losses Wandering Sleep disturbance Losing and hiding things Inappropriate sexual behaviors
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Common Behavioral Common Behavioral SymptomsSymptoms Repeating questions Repetitious actions Territoriality Hallucinations Delusions Illusions
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Catastrophic BehaviorsCatastrophic Behaviors
Agitation Combativeness Confusion Fearfulness Night wakening
Noisy behavior Purposeful
wandering Sudden withdrawal
from activities “Sundowning”
Unexpected, intense, and “out of proportion” reactions to a situation . . .
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Dementia Care PracticesDementia Care Practices
General Slow down, Eye contact, Cueing Redirecting, Distracting, Reassurance Comfort measures (pain meds, food) Individualized interventions Promote continuity between levels of care Pain management Interdisciplinary team approach Person vs. Disease focus
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Nursing Care Nursing Care Models/ApproachesModels/Approaches Need-Driven Dementia-Compromised
Behavior Model Understandable needs not disruptive behaviors Background/proximal factors
Progressively Lowered Stress Threshold Model Less able to manage stress as a disease
progresses Modify internal/external environment Support vs challenge, promote safety/comfort
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Other Models/Approaches to Other Models/Approaches to CareCare Person-Centered Approach (Kitwood)
Understanding vs management Well-being/personhood DCM
Validation (Feil) Response to feeling/meanings/internal context of
behavior Need to be valued*(Livingston, et al., 2005 and Old Age Task Force of the World
Federation of Biological Psychiatry) Using Oxford-Center Guidelines
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Formal/Informal Caregiver Formal/Informal Caregiver InterventionsInterventions Psychoeducation and Skills Training
Change interactions Behavioral management FIC Staff Education Services, social and cognitive support Family Counseling(Fossey et al., 2006; Maas et al., 1994; Mittelman et
al., 1996; Pusey & Richards, 2001; Schultz et al., 2002)
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Pharmacological Pharmacological InterventionsInterventions
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Non-Pharmacological Management Non-Pharmacological Management of Behavioral and Psychological of Behavioral and Psychological Symptoms of Dementia (BPSD): Best Symptoms of Dementia (BPSD): Best PracticesPractices Interventions No “easy” answers Complicated by changing clinical course
Principles of Care: Adjust daily routines Change reaction and responses to behaviors Monitor and adjust the environment, remove triggers Adjust interaction and communication strategies Gould
(2007) Williams (2005)
(Ballard et al., 2009; Burgener & Twigg, 2002; Smith & Buckwalter, 2005)
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Non-Pharmacological Non-Pharmacological Management, cont’dManagement, cont’d Cognitive training: Early Stage (Yu et al.,
2009) Cognitive stimulation, memory rehab, R.O.,
Neuropsychological Rehabilitation Structured Activities
“Simple Pleasures” Recreational Physical (exercise and movement)
(Alzheimer’s Assoc, 2007; Buettner et al., 2008; Cohen-Mansfield, Libin & Marx, 2007; Kolanowski, Litaker, & Buettner, 2005; Opie, Doyle, & O’Connor, 2002; Richeson et al., 2008; Volicer & Hurley, 2003)
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Socialization Pets Reminiscence, R.O. Video Respite Simulated Presence Therapy
Sensory Enhancement/Stim Expressive Arts Music Aromatherapy Snoezelen
(Burge-Allen, Stevana, & Burgio, 1999; Gerdner, 2005; Mahoney, Volicer, & Hurley, 2000; vanWeert et al., 2005)
Non-Pharmacological Management, Non-Pharmacological Management, cont’dcont’d
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SummarySummary
Alzheimer’s disease is INCURABLE, but not UNTREATABLE! Preserve & enhance remaining abilities Avoid unnecessary stress &
overstimulation Treat illness or other complications Provide education & guidance for families
and other caregivers