understanding the dementias
DESCRIPTION
Understanding the Dementias. B. Heath Gordon, Ph.D. 1,2,3 11.08.13. Disclosures. None. Objectives. Upon completion of this 1-hour learning activity, attendants should be able to: Identify the primary types and causes of dementing illnesses - PowerPoint PPT PresentationTRANSCRIPT
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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
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DisclosuresNone
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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
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Perceptions of Cognitive Aging
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What is Dementia? now
(Major & Mild Neurocognitive Disorders)
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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
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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
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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
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CausesProgressive disease
Vascular disease
Trauma
Tumors
Substance-induced
Infection
Metabolic disorders
Endocrine disorders
Epileptic disorders
Toxic reactions
Anoxia
Vitamin deficiency
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Primary Types of Progressive Dementia
Alzheimer disease (DAT)
Vascular dementia (VaD)
Dementia with Lewy bodies (DLB)
Frontotemporal lobar dementia (FTD)
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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
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Alzheimer disease (DAT)
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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
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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
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Progression
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Vascular Dementia (VaD)
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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)
Cognitive deficits represent a significant decline
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
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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
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Stroke-Related Behaviors
Stroke A ≠ Stroke B
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Frontal LobeMotor cortex
Motor function, fine motor coordination
Premotor cortexFrontal eye fields, motor planning
Prefrontal cortex“Executive functions”Planning, organizing, monitoring, inhibitingMotor speech area
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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
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OrbitofrontalEmotionally dysregulated
Behaviorally disinhibited
Impulsive
Poor smell discrimination
Pseudopsychopathic syndrome
DisorganizedLack of social gracesPoor appreciation for feelings of others or negative aspects of behavior
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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
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Symptom Origin?
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Dementia with Lewy Bodies (DLB)
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Criteria for DLBMemory impairment: Learning & Recall
One or more impairments in the following:Speech and/or understanding languageSkilled movement Object recognitionJudgment, planning, switching tasks, etc (executive functioning)
Cognitive deficits represent a significant decline
Evidence from medical exam of related illness
Deficits cause significant impairment in social or occupational functioning
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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
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Frontotemporal Dementia (FTD)
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Criteria for FTDMemory impairment: Learning & Recall
One or more impairments in the following:Speech and/or understanding languageSkilled movement Object recognitionJudgment, planning, switching tasks, etc (executive functioning)
Cognitive deficits represent a significant decline
Evidence from medical exam of related illness
Deficits cause significant impairment in social or occupational functioning
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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
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Positive Behavior Approach
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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
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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
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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
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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)
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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
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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
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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
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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)
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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
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“A”Antecedents
“B”Behavior
“C”Consequences
Learning Behavior Model: ABCs of
Behavior
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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)
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ABCs of Resident BehaviorTo identify the Antecedents and Consequences, ask the ‘W’ questions
WhatWhy WhenWhereWho
(Burgio & Stevens)
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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?:
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Behavioral DisturbancesWhy do behavioral disturbances occur?
Internal factorsMemory loss
Sensory changes
Loss of communication skill
Pain/discomfort
(Burgio & Stevens)
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Behavioral DisturbancesWhy do behavioral disturbances occur?
External factorsOver stimulation
Lack of stimulation
Lack of activity
Too many demands(Burgio & Stevens)
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Behavioral DisturbancesWhy do behavioral disturbances occur?
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)
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Behavioral DisturbancesWhy do behavioral disturbances occur?
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)
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Behavioral DisturbancesWhy do behavioral disturbances occur?
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)
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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
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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
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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
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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
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Therapeutic Communication: Skills to Change the As and Cs
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 . . . “
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Therapeutic Communication: Skills to Change the As and Cs
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”
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Therapeutic Communication: Skills to Change the As and Cs
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
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Behavior ManagementPositive Reinforcement
Planned Ignoring
Distraction & Diversion
Replacing Disruptive Behaviors
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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
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Positive Reinforcement Ways to give positive reinforcement
Attention
Praise and Appreciation
Acknowledgement
Comfort
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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.
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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.
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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