Alzheimer’s Disease
and Dementia Care
for Health Plan Case Managers
Karen Bugg RN LMSW
Institute for Health Care Studies
Michigan State University
August 16th & 17th 2010
What does “dementia”
mean?
Dementia and the Brain



Injury to brain cells causes dementia.
Dementia causes a decline in a
person’s ability to think, understand,
and remember and affects a person’s
function.
Dementia gets worse over time.
Dementia
Because of memory loss:



no longer self-sufficient
requires ongoing help or supervision
functional dependency
Activities of Daily Living





Bathing
Dressing
Feeding Self
Toileting
Transferring


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Telephone
Driving
Shopping
Meal Preparation
Managing Finances
Managing
Medications
Causes of Dementia


Alzheimer’s disease is the most
common cause of dementia.
Other common causes are:
– Vascular dementia
– Dementia with Lewy bodies
Alzheimer’s definition



A progressive degenerative
neurological disease.
Most common form of dementia in the
elderly.
Nearly 75% of all dementia cases.
Alzheimer’s in the United
States




5.3 million people
One person is
newly diagnosed
every 70 seconds
7th leading cause
of death
Rates are expected
to double every 20
years
Alzheimer’s Disease - Statistics




6-8% of all persons age 65 and older
30-50% of all persons age 85 and
older
By 2029, all baby boomers will be at
least 65 years old
5.3 million cases currently, will
increase to 18 million by 2040
Race & Ethnicity

Older African Americans and Hispanics
are much more likely than older whites
to have Alzheimer’s disease and other
dementias.
Michigan

In 2008, sixty-eight percent of nursing home
residents were cognitively impaired.
Current Dilemmas in
Dementia Care





Alzheimer’s disease is under diagnosed,
particularly among patients who do not speak
English as their primary language.
Pre-Alzheimer’s impairments are often attributed
to “normal” aging.
Denial and fear often delay evaluation.
Typical lag time between symptom onset and
diagnosis is two years.
Most patients are not diagnosed by their primary
care physicians.
Impact on health care



Today, there are about
4,700 providers, up from
about 3,300 five years
ago.
Alzheimer's disease now
accounts for 10.1 percent
of hospice admissions
nationwide, up from 5.5
percent in 2000.
ALH’s beds have tripled
over the decade from
600,000 to 2,000,000..
The Future of Alzheimer’s
Disease


Treatment with current FDA approved
drugs
Disease modifying drugs to induce
remission

Medications to reverse memory loss

Cure
Brain Anatomy &
Function
Related to Memory
Healthy Brain Cells




Billions of neurons
Axons = message
transmitters
Dendrites =
message receivers
Groups of neurons
have special
functions
Healthy Brain Processes



Communication
Metabolism
Repair
Brain Communication

Neurotransmitters
– A chemical
messenger between
neurons that excite
or inhibit.
Brain Metabolism


Brain needs lots of
blood to nourish
cells with oxygen
and glucose.
Or death to cells.
Brain Repair




Neurons can live 100 years or more.
They must maintain and repair.
Injury and illness can destroy.
New neurons can be generated in some
areas.
The Frontal Lobes



Help you to do
more than one
thing at once.
Prioritize what to
focus on.
Sense how much
time is passing.
When dementia affects the
frontal lobes, you may:




Have difficulty focusing on a task and
paying attention to what is going on.
Be overwhelmed when a caregiver
talks and touches at the same time.
Have difficulty following the logic of an
argument.
Need the most important words said
first in a sentence.
You may also:



Need short and simple words and
sentences.
Refuse a bath because you can’t think of
how to do it.
Be unable to stop striking or grabbing
someone because you can’t control
impulses.
Temporal Lobes

The temporal lobes
help you:
– Understand
language
– Speak
– Read and write.
When dementia affects the
temporal lobes, you may:







Make non-sense words.
Use the wrong sounds when talking.
Substitute words or use fewer words.
Say “yes” when you mean “no”.
Not understand what someone tells
you.
Not understand what you read.
Use swear words without realizing it.
Parietal Lobes

The parietal lobes:
– Help you locate and
arrange objects in
space.
– Tell your brain to
pay attention to
everything that is in
the space you see.
When dementia affects the
parietal lobes, you may:




Use excessive energy putting an arm
into a shirt sleeve.
Put a glass down on the edge of a
plate, rather than beyond it.
Have difficulty responding to objects
on the left side of your visual field.
Have difficulty tolerating clutter, many
objects, and movement in the room.
You may also:



Feel angry, frustrated, and tired from all of
the confusing objects and sounds in the
environment.
Respond better when a caregiver
approaches from the front.
Resist stepping into a tub or shower
because you can’t see: the side of the tub,
where your feet or hands should go, or how
deep the water is.
Hippocampus

The hippocampus
creates your memory
of recent events such
as:
– What someone just said.
– What you had for lunch.
– Who just visited you an
hour ago.
– Where you parked your
car.
When dementia affects the
hippocampus, you may:




Repeat a question over and over again.
Forget that a family member just visited.
Be surprised or angry when a caregiver
begins to remove clothing when you just
agreed to take a shower.
Lose items repeatedly or store them in the
wrong place.
The Aging Brain
And Memory
Namenesia
“Hi. I’m, I’m, I’m…. You’ll have to forgive me,
I’m terrible with names.”
Roomnesia
Now why did I come in here?
Fleeting thought syndrome
A.K.A…. “the senior moment”
Memory loss is not a
normal part of aging
Decline in mental ability is
not inevitable as people
age
Neuroplasticity
Cognitive reserve
Cognitive Reserve



Yaakov Stern

Relationship between brain pathology
and cognitive effect moderated by CR
CR markers: education, occupation,
leisure interests
Greater CR causes less impact on
function with similar level of
pathology
Greater CR leads to steeper decline
once pathology overwhelms
Types of Memory




Episodic memory
Semantic memory
Working memory
Procedural memory
The Aging Brain




Brain tissue volume decreases with age
due to white matter loss.
Regional loss may be gender specific.
Frontal regions are more vulnerable to
decline.
Neurogenesis = growth of new brain
cells.
Aging: Vulnerable Processes

Processing speed

Working memory

Divided attention

Complex visual processing

Long term memory
– Episodic memory
– Source recall
Preserved Abilities with
Aging

Priming - an unconscious influence of
past experience on current
performance or behavior.
Visual Priming
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Preserved Abilities with
Aging


Priming - an unconscious influence of
past experience on current
performance or behavior.
Inhibition of stimulus-bound
responding.
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Common Causes of Poor
Memory

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Insomnia and impaired sleep (apnea)
Drug side effects (antihistamines)
Menopause
Depression
Attention Deficit Disorder
Head injury
Chemotherapy
Problem Medications

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
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Antiarrythmics
Antiemetics
Antihistamines
Antiparkinson Agents
Antipsychotics
Antispasmotics
Skeletal Muscle Relaxants
Tricyclic Antidepressants
Uncommon Causes of
Poor Memory

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Young onset Alzheimer’s disease
Mosquito and tick born disease
Brain tumors
Toxin and heavy metal exposure
Anesthesia
Seizures
Early Warning Signs of
Dementia

Frequent repeating / defensive answers

Word finding difficulty

Mistakes with bills / checkbook

Changes in hygiene / grooming

Mistakes with medications

Geographic disorientation
Alzheimer’s Disease
And related disorders
Alois Alzheimer 1864-1915
Risk Factors

Advancing age
– 65 or older



Mild cognitive impairment (MCI)
Family history
Genetics
– Young onset

Down’s Syndrome
DSM-IV Diagnosis

Decreased cognitive functioning
including:
– Memory impairment
– One or more of:
Aphasia
 Apraxia
 Agnosia
 Inability to plan, organize, sequence
 Inability to comprehend abstract concepts

DSM-IV Diagnosis



These deficits cause significant
impairment in daily functioning.
Gradual onset and continued decline.
Not due to other physical or mental
medical conditions or during the
course of a delirium.
The Alzheimer Brain

Massive cell loss
changes the entire
brain during
Alzheimer’s
progression.
– The cortex shrivels. This
damages the brain’s
ability to think, plan,
and remember.
– The hippocampus
shrivels, which affects
the ability to form new
memories.
– Ventricles (fluid-filled
spaces) grow larger.
The Alzheimer Brain

Underneath the
microscope:
– Alzheimer tissue has
less nerve cells and
synapses.
– Plaques (abnormal
clusters of protein
fragments) build up
between nerves.
– Dead and dying nerve
cells remain in the
brain.
– Plaques and tangles are
the prime suspects of
cell death and tissue
loss.
Alzheimer’s progression



The early stages of
Alzheimer’s may
begin up to 20
years before a
diagnosis is made.
Mild to moderate
stages last 2-10
years.
Severe Alzheimer’s
lasts 1-5 years.
Stages of Alzheimer’s

http://www.nia.nih.gov/Alzheimers/Pu
blications/stages.htm
Vascular Dementia


Second most
common form of
dementia.
Caused by
problems with the
supply of blood to,
or within the brain.
Risk Factors



Hypertension
Diabetes
Genetic
Symptoms of vascular
dementia






May develop suddenly then decline in steps.
Memory loss may not be the first symptom.
Concentration problems.
Changes in mood.
Physical weakness.
Difficulty communicating or conversing.
Types of vascular
dementia




Large stroke (cortical) associated with
physical impairments.
Small stroke (lacune) in the basal
ganglia or thalamus “strategic”.
Small vessel disease (sub-cortical).
Intracranial bleed (intracerebral
subdural).
Dementia with Lewy
Bodies




Discovered in 1912 by Frederich Lewy.
Common cause of dementia in the elderly.
Dopaminergic, cholinergic, noradrenergic,
serotonergic, and glutaminergic systems
affected, decreased dopamine D2 receptors.
Over 50% of Parkinson’s patients develop
PDD dementia—a Lewy Body dementia.
Dementia with Lewy Bodies

May coexist with AD –
– 10 to 30% of AD cases have LBs.
– 32 to 89% of DLB cases have AD changes.
– AD pathology in DLB is different, less
severe, more diffuse plaques, rare tangles.
– Familial form of DLB associated with
triplication of SNCA gene.
Symptoms of Lewy Body
Dementia





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Episodes of altered consciousness
Fluctuating cognition
Recurrent visual hallucinations
Parkinsonism
Extreme sensitivity to anitpsychotics
Sleep disorders
Frontotemporal Dementia





Frontal temporal areas of the cortex
are affected—Pick’s bodies form and
impair neuronal function.
Fairly common—10 to 15% of cases.
Onset—age 40-65; 60 average.
Can last longer than Alzheimer’s.
May be hereditary in 38-60% of cases.
The Frontal Lobes



Help you to do
more than one
thing at once.
Prioritize what to
focus on.
Sense how much
time is passing.
Temporal Lobes

The temporal lobes
help you:
– Understand
language
– Speak
– Read and write
Symptoms of FTD







Behavior and personality changes
Personal and social awareness impaired
Disinhibition
Repetitive behaviors
Fixations/obsessions
Impulsive
Hyperorality
Other Dementia Types



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Wernicke-Korsakoff Syndrome
Cognitive problems after
chemotherapy
Normal pressure hydrocephalus
Jakob-Creutzfeld
Head Injury
Dementia Diagnostic
Process
Referrals to a memory
program
 You suspect or know that a dementia
problem exists
AND
 you are concerned about patient
independence or ability to manage ADL’s at
home,
OR
 you are concerned about a caregiver’s
ability to manage a patient at home.
Clinical Pearl
Normal motor examination
Cognition worse than behavior.......
Think Alzheimer’s
Behavior worse than cognition.......
Think frontal lobe (Pick’s)
Parkinsonian signs on examination
No hallucinations early in illness
Think vascular dementia
Detailed visual hallucinations early
Think Lewy Body dementia
Key points regarding diagnosis




The MMSE is a disorganized, fair quality
screening tool.
The Clock Drawing test has drawbacks
and limitations.
90% of the diagnosis is based upon
collateral history, which may be
inaccurate.
A physical and neurological exam is
mandatory.
Key points regarding diagnosis



History and examination findings
should not be interpreted in a clinical
vacuum.
Few text book situations occur and
overlap conditions are common.
Not everyone with dementia has
Alzheimer’s disease and some have
protracted delirium.
Benefits of Medical
Assessment


Diagnostic clarification
Identify medical conditions affecting
capacity

Identify means to enhance capacity

Identify less restrictive alternatives

Preemptive planning
What the health care team
must do for the patient

Give a clear diagnosis and prognosis

Exude optimism

Lessen fear and the stigma of
dementia

Prescribe cognition stabilizer(s)

Inform where resources are located
What the health care team
must do for the caregivers

Provide closure

Exude confidence

Relieve guilt

Provide reassurance

Provide support resources

Set care giving limits
Diagnostic challenges



Less than half of all Alzheimer’s
patients know that they have the
disease.
2/3 are not diagnosed until they reach
the moderate stage.
Published clinical guidelines to
facilitate diagnosis are infrequently
used.
Diagnostic challenges




No blood or imaging test can reliably
diagnose any type of dementia.
Most diagnoses are made by
neurologists and neuropsychologists.
Demand will soon exceed their supply.
Primary physicians will become more
responsible for diagnosing dementia by
necessity.
Misperceptions Clarified



Alzheimer’s disease can be accurately
diagnosed in up to 97% of cases using
simple assessment techniques in the
office.
New advancements in treatment will
make a real impact in the lives of
dementia patients.
It is terrible to have Alzheimer’s
disease and not know it.
Dementia Diagnostic
Process

Review of symptom onset and
progression

Memory testing

Physical and neurological examinations

Blood tests

Brain imaging
Mental Status Testing


–

–

–

–

–

–
Orientation
Learning and memory
Three word item recall
Naming ability
Name parts of objects
Gnosis
Describe function of objects
Tempoparietal function
Language comprehension, ideomotor praxis, left-right
discrimination
Visual constructions
Clock drawing, cube copying
Working memory
Add coins
Mental Status Testing

Abstraction
– Explain similarities

Attention and concentration
– Digit span
– Months of the year reversed

Language
– Fluency, repetition, reading

Spatial and object memory
– Recall where an item was hidden

Remote memory
– Details about significant past events
Common Screening Tools

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Folstein Mini-Mental State Examination
Montreal Cognitive Assessment
Screening (MOCA)
Mini-Cog
Functional Activities Questionnaire
The Seven Minute Screen
Clock Drawing Test
Lab Testing





CBC, CMP
B-12
TSH
Syphilis testing
CSF analysis
Brain Imaging



CT Scanning
MRI
PET Scanning
Treatment Modalities



Pharmacological
Behavioral
Palliative; not curable
Realistic Goals of Dementia
Treatment


Attenuate cognitive and functional
decline.
Prevent / decrease behavioral and
psychiatric symptoms.

Delay nursing home placement.

Lengthen period of self-sufficiency.

Reduce caregiver burden.
Pharmacologic Arsenal
FDA Approved Medications for
Treatment of Alzheimer’s Dementia


Cholinesterase Inhibitors: Prevent the
breakdown of acetylcholine
– Donepezil (Aricept), Galantamine
(Razadyne), Rivastigmine (Exelon)
Glutamate Regulator:
– Memantine (Namenda)
Pharmacologic Arsenal
Medications for the treatment of mood
disorders and behaviors



Antidepressants
– fluoxetine, citalopram, mirtazepine, sertraline,
venlaxafine
Antipsychotics
– haloperidol, risperidone, quetiapine,
zasperidone
Anxiolytics
– buspirone, lorazepam
Prevention of Dementia

Stay mentally and physically active

Socialize

Live a healthy lifestyle

Eat a balanced diet
Working with clients
who have dementia
Behaviors of Dementia
Behavior Management
Cognitive changes


These are changes in memory,
thinking, and learning.
Involve a variety of mental skills such
as attention, problem-solving,
memory, language , visual-perceptual
skills, and other aspects of reasoning
and intellect.
Dementia can cause difficult
behaviors


Changes in the brain can cause
problems with a person’s ability to
think, understand, and respond
appropriately.
The behaviors result from the disease
itself, not because the person is trying
intentionally to be mean or
uncooperative.
Dementia Behaviors






Repetitive questioning or
hoarding/obsessive behavior
Poor judgment
Disinhibition
Impulsiveness
Wandering
Insomnia or somnolence
Dementia Behaviors
– Irritability, agitation, restlessness, aggression
– Social withdrawal, apathy, depression, suicidal
ideation
– Hallucinations-sensory
 An object or event is believed to be
perceived
– Delusions-thoughts
 Untrue beliefs based on pathology
 Paranoia and unfounded accusations
Prevalence of dementia


The reported dementia prevalence in
Assisted Living and Special Care Units
ranges from 40-67%.
Dementia afflicts a substantial portion
of elderly patients on the medicalsurgical units of general hospitals.
ALFA (2006); Lyketos, Sheppard, Rabins (2000)
Prevalence of behavioral
symptoms


56% of residents in AL settings had
behavioral symptoms related to
dementia.
Current management methods are
insufficient to respond to the needs
of residents.
Boustani and associates (2005)
Challenges of dementia







Functional challenges
Personality changes
Mood changes
Resistance
Lack of Insight
Apathy
Shadowing







Repeating
Agitation
Aggression
Paranoia
Wandering
Delusions
Hallucinations
Framework for care




Provides for person-centered planning.
Organizes the many theories,
approaches, strategies, and
techniques.
Comprehensive assessment.
Maximize functional independence and
morale of individuals with dementia.
The Habilitation Domains

The top 3:
– Physical
– Functional
– Emotional
The Habilitation Domains



Social
Sensory
Communication
The Five Tenets
Tenet #1:
Make the physical environment work.
Tenet #2:
Know that communication remains
possible.
Tenet #3: Focus on remaining skills.
The Five Tenets
Tenet #4:
Live in the patient’s world: behavioral
changes.
Tenet #5: Enrich the patient’s life.
Link behavior to an
unmet need.

Link the behavior to one of three
human needs:
– Love
– Usefulness
– Expression of raw emotions
Look at behavior as a
means of
communication.
– What is the person trying to communicate?
– Is it worth responding to or is it simply
annoying?
– Pick your battles.
What happened before?

To help determine reasons for a
patient’s behavior, look at its
antecedents.
Sudden behavior changes



May indicate relationship issues.
May indicate medical or physical
problem.
May indicate environmental change.
Assess for delirium

Abrupt state of confusion

Disturbance of consciousness



Impairment of cognition and
perception
One or more underlying causes
May be associated with hyperactivity
or lethargy
Symptoms of delirium


Many types of cognitive - behavioral
symptoms can occur including visual
hallucinations, delusions, paranoia,
manic behavior, aggression, apathy,
and impaired memory.
“Sun-downing” is not specific to
delirium.
Risk factors for delirium







Severe illness
Hypo perfusion
Hypoxia
Infection
Drug toxicity
Fractures
Alcoholism
Risk factors for delirium







Dementia (25-50% of all cases)
Impaired ADLs
Sensory impairment
Urinary retention
Fecal impaction
Physical restraint use
Sleep deprivation
Assess for pain




Ask the resident.
Interview the caregivers.
Review the medical record for painrelated diagnoses.
Physical examination and lab studies.
Assess for pain
Use a validated pain rating system:
 Facial expression
 Posture
 Vocalizations
 Appetite
 Interactivity
Pain Rating Scales






Verbal 0-10 scale
Abbey pain scale
Pain assessment for the dementing
elderly
Faces Pain scale
Pain assessment in advanced
dementia (PAINAD)
Checklist of nonverbal pain indicators
CNPI)
Evaluate the
consequences


Do the behaviors need to change for
the comfort and the safety of the
patient or the caregiver?
Some behaviors do not bother the
patient—do they need to be modified?
Set the tone





Relax. Center.
Use a clear, low, loving tone of voice.
Calm, gentle, matter-of-fact approach.
Humor.
Cheerful.
Set the tone



Use the mirroring technique.
Chat about a happy topic before
starting a task.
Use short, simple sentences, familiar
words.
Build trust


Use non-threatening, factual words:
who, what, when, where, and how.
Avoid asking why something happened
or why they did something.
Do not attempt to reason


People with dementia lose their ability
to reason.
Insight is often impaired.
Rephrasing



The individual is validated/comforted
when their own words are
acknowledged by another.
Repeat the gist of what the person has
said, using the same key words.
Use a similar tone and cadence.
Use redirection to stop
undesired behavior


Can the patient be distracted with
another activity, treat, topic of
conversation?
You may have to say, “Now we are
going to…” rather than asking or
suggesting a task or activity.
Reminiscing


Exploring the past can help reestablish familiar coping methods and
ways of handling stress.
Use “always” and “never” to trigger
earlier memories.
Easier to change the
environment

Under stimulation
– Restlessness, pacing, wandering, or
calling out.

Over stimulation
– Nervousness, agitation, physical
aggression.
Progressively Lowered
Stress Threshold Concept
(PLST)



A proactive intervention to reduce
likelihood of challenging behaviors.
Based on premise that those with
dementia have a decreased ability to
respond to stressors.
The cumulative effect of stressors
prompts behaviors.
Stabilize the environment



Routine; daily schedule.
Create a level of quiet and peace.
Make sure the patient is comfortable.
Maximize sensory input





Validate the patient’s reality without
exacerbating anxiety
Keep simple, but provide multisensorial opportunities
Music
Fabrics, pets
Touch
Identify and Use the
Preferred Sense


Enables caregiver to speak the
person’s language and improve
communication.
Builds trust.
–
–
–
–
Vision
Hearing
Touch
Smell
Touch



Confused individuals often need to feel
the presence of another human being.
Pleasant memories are often evoked.
Personal space must be respected.
Music




When words are gone, melodies
return.
Comforts, reduces agitation and
stress.
Provides channel for expression of
emotion.
Enhances communication.
Consider life experiences


Former life experiences can play a
major role in behavior.
At times, thinking of the person’s
former role may help in the
development of activities.
Need for staff training is
critical.
Staff who are trained in dementia and
its management are better prepared to
care for residents.
But, nearly 88% of resident assistants
thought that confusion was a normal
consequence of aging.
Hawes and Phillips (2000); Luxenberg (2003), Alzheimer’s Association (2005).
Education and training
will be key




Growing elderly population.
Projected nursing workforce shortage.
Rates of staff turnover are likely to
increase.
Retention of adequate staff will
become even more difficult in the
future.
Callahan, 2001; General Accounting Office [GAO], 2001; Noelker, 2001, Stone, 2001.
Awareness of Abuse
A closer look at
agitation/aggression
Abuse
Physical, psychological, sexual, and/or
financial maltreatment, that may be
the result of the actions of others or
may result from neglect by others or
by self.
(Dyer et al., 2000).
Prevalence of elder abuse



All forms are under-reported
1% to 4% all elders
5.4% to 11.9 % for demented elderly
Risk factors for elder abuse




Excessive physical and psychological
demands associated with care giving
Advanced age
Poor health and physical frailty
Impaired activities of daily living
Risk factors for elder abuse




Alcohol and substance abuse
Psychopathology
History of abusive behavior
Poor pre-morbid relationships
Risk factors for elder abuse
Families caring for relatives with
Alzheimer’s Disease in the community
are particularly vulnerable to
episodes of violent behavior.


Caregiver depression
Living arrangement with immediate
family member, but not spouse
Paveza, Cohen, et al. The Gerontologist, 1992
Abuse from care recipients



57-67% of dementia patients manifest
some form of aggressive behavior.
Nearly 16% patient to caregiver
violence.
In one study, 66.2% of nursing home
assistants reported minor physical
injuries on a daily basis, with 58.2%
experiencing more serious injury in
last 12 months.
Neuroanatomy of Aggression
Many areas of the brain are involved
 Prefrontal cortices (trouble thinking)
 Left temporal lobe (short fuse)
 Limbic system (anxiety; moodiness)
– Hypothalamus
– Amygdala

Brainstem
Neurophysiology of Aggression




Complex interplay of neurotransmitters
and hormones
Serotonin
Norepinephrine
Testosterone
Diagnose the cause of agitation








Infection
Injury
Pain or discomfort
Illness: physical, psychiatric
Sleep disorders
Medication side effects or interactions
Environmental triggers
People triggers
Prevention of agitation or
aggressive behavior






Address the causes or antecedents
Provide a structured environment
Provide appropriate activity
Address emotional needs
Modify caregiver communication
techniques and approaches
Provide sunlight
Treatment of agitation and
aggression


Behavioral
Pharmacological
Behavioral treatment of
agitation and aggression
Identify the level of agitation and
respond accordingly.
Mild: validate and talk.
Moderate: structure environment;
distract.
Severe: establish understandable limits;
decrease stimuli.
Behavioral treatment of
aggression
Panic Phase
 Intervention is needed to prevent
injury.
 Get away (pre-planned exit strategy).
 Obtain assistance.
Rescue


911
Facility code-response team
Psychiatric Hospitalization



Careful consideration.
Behavioral and pharmacological
treatment first.
Goal is to eliminate aggressive
symptoms and return to his/her
environment.
Medications to treat agitation
and aggression


No medications are approved by the
FDA for the specific treatment of
aggression.
Medications that are used must be
monitored to determine effectiveness.
Medications

SSRI Antidepressants
– Used to treat lowered serotonin levels.
– sertraline, fluoxetine, citalopram,
escitalopram, etc.
– Some effect can be noted in 3 to 5 days,
but can take two weeks for full effect.
Medications




Beta-blockers: propranolol, metropolol
Antipsychotics: Risperdal, Haldol,
quetiapine
Anti-convulsants: valproate, Tegretol,
Neurontin, Lamictal
Combination therapy, such as
– buspirone + propranolol
– valproate + anti-psychotic medication
About those benzodiazepines




Medications, such as Ativan and
Xanax, are used for anxiety in nondemented patients
When used with demented patients,
they can increase confusion, falls, and
agitation.
Limit to an as needed basis only.
Avoid gels.
When to report to APS


When the caregiver is unable to
protect self and/or the care recipient
from elder abuse.
Other interventions have been
unsuccessful.
Recommendations




The likelihood of aggressive behaviors
needs to be an expectation among the
demented and mentally ill population.
Improved recognition and assessment.
Education and training.
Improved reporting.
Case Management and
Care Coordination



Each case is unique.
It is never just about the patient.
Case management interventions must be
directed at the patient and his/her
caregiver(s).
Outpatient Case and
Disease Management

Case Management Process
– Engagement
– Assessment
– Plan of Care Collaboration
– Intervention
– Evaluation
Assessment for
Intervention


Due to changes in the brain from
dementia, a person needs the
environment and the caregiver to
compensate for impaired memory
functions.
The more we know about how a person’s
memory ability has changed, the more we
can target successful strategies to
improve their quality of life.
Engagement






With whom will you be working?
Size up family dynamics.
Capacity/insight issues.
Medical decision-making.
Recognizing and responding to
caregiver stress.
Empathetic approach.
Assessment

Biopsychosocial
– Active listening
approach
– Assess
ability/stress of
care provider
Assessment


Patient Goals
Caregiver Goals
– Long term care plans?



Existing Strengths and Resources
Medical Record
Reassess at 6 months
Tools for Assessment




Case management organizations
Biopsychosocial assessment tools via
internet
Katz activities of daily living
Create a short form
Plan of Care Collaboration




Patient
Caregiver(s)
Medical providers
Community resources
Interventions




What is needed to keep patient safe?
What will provide for patient’s dignity?
What will improve patient’s quality of
life?
What offers least restrictive
environment?
Interventions


What communication techniques and
behavioral approaches will be most
effective?
What is needed to support the
caregiver?
Interventions








Medication management
Financial security
Environmental adjustments
Personal care assistance
Nutrition/hydration
Physical exercise
Social activities
Caregiver support
Interventions

Identify key agencies
– Alzheimer’s Association & others
– Area Agency or Commission on Aging
– Senior Neighbor Centers and Service
– Social Security Administration
– Veteran’s Administration
– Secretary of State
– MDCH
– Medicare & Medicaid
Interventions

Identify Home Supports
– Adult day programs
– Home delivered meals
– Home helper services
– Respite care
– Transportation
Interventions

Assist with long-term care planning
– DPOA or guardianship
– Housing advisors
– Long term care facilities
PACE
 AL
 AL dementia
 Skilled nursing facilities


Hospice
The Alzheimer’s Disease
Bill of Rights





To be informed of one’s diagnosis.
To have appropriate medical care.
To be productive in work and play for
as long as possible.
To be treated like an adult, not a child.
To have expressed feelings taken
seriously.
The Alzheimer’s Disease
Bill of Rights




To be free from psychotropic
medications, if possible.
To live in a safe, structured, and
predictable environment.
To enjoy meaningful activities that fill
each day.
To be outdoors on a regular basis.
The Alzheimer’s Disease
Bill of Rights



To have physical contact, including hugging,
caressing, and hand-holding.
To be with individuals who know one’s life
story, including cultural and religious
traditions.
To be cared for by individuals who are well
trained in dementia care.
The Best Friends Approach to Alzheimer’s Care, by Virginia Bell and David Troxel; 1997:
Health Professions Press, Inc., Baltimore
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Memory and Aging - Michigan State University