Slide 1

Interventions to Minimize Behavioral Symptoms of Dementia: Moving Beyond RedirectionPart I

Margaret Hoberg MSN, GNP-BCSiobhan McMahon MSN MPH GNP-BCThe title of this module is Behavioral symtpoms of dementia: moving beyond redirection as an intervention. It was developed as a collaborative effort of Esther Gieschen of the Alzheimers association, Debra Laine of the Arrowhead agency on Aging, Margaret Hoberg a geriatric nurse practitioner who works in the Elder Care department and St. Marys Duluth clinic and Siobhan McMahon, also a geriatric nurse practitioner who works in the Elder Care department and teaches at the College of St. Scholastica.

The impetus for the creation of the module was that caregivers in our Arrowhead region commonly shared concerns that their attempts to re-direct persons with dementia related behavior changes were not successful and at times were even met with resistance and anger. Thus, we explored the literature, and had conversations with experts in the field and discovered information that may help families and caregivers to better understand redirection as an intervention and to consider additional more effective interventions. 1Learning ObjectivesExplain the effects of dementia on thinking, emotions and communicationUse a theory to help explain behavioral and communication changes associated with dementia and to guide interventionsRespond to behavioral changes with a calm, validating approachComprehensively assess verbal and nonverbal messages, including those that are associated with stressDevelop a plan whose non-pharmacological interventions reflect an understanding of and respect for the person and their preferences.Objectives

The learning objectives of this module I will focus on the first four objectives listed here.

The last objective, Developing a plan whose non , will be presented in module II of this dementia presentation. 2Clara91-year-old woman AD (recent MMSE score 12) Severe agitation per LPN who is passing meds A few hours ago she hit another resident. CNA adds she has been irritable and pacing. The night CNA also notes she has been having trouble sleeping and has expressed feelings that othersShe has heart disease and mild COPD. She has a history of recurrent UTIs .Clara cooperates at times, but when left in her room, she wanders the hall, seeming confused. When redirected to her room, she insists that she had to go home and would refuses assistance with care.

3Throughout the presentations we will share a few brief cases to help demonstrate the application of the concepts discussed within the modules. To get started, we want to share a scenario and ask you to consider how you might approach/ treat this situation. Throughout the presentation you may gather additional ideas and reflect on your own practice regarding successful interventions you have employed; that may lead you to change your approach or perspective. But to just get started, lets review this case and consider our options as we think of them now.

What is the most appropriate next step in the care of Clara?(A) Administer prn lorazepam .5mg-1 mg intramuscularly, sublingual or po(B) Administer haloperidol 1 mg intramuscularly or po(C) Ask family member, nurse or CNA to spend one-on-one time with her; begin a thorough assessment for acute illness and unmet physical need. (D ) Restrain Clara to obtain a blood and urine work-up

4Consider these options. What would you do now. What is the most appropriate next step in the care of Clara?(A) Administer lorazepam 1 mg intramuscularly, sublingual or po(B) Administer haloperidol 1 mg intramuscularly or po(C) Ask family member, nurse or CNA to spend one-on-one time with her; begin a thorough assessment for acute illness and unmet physical emotional or social needs. (D) Restrain the patient to obtain a blood and urine work-up

5Answer: C is the preferred answer and throughout this presentation, we will discuss the reasons for this choice. The primary differential diagnoses are agitation related to an underlying medical problem (hence, delirium) and a psychotic disturbance related to AD. Clarifying this differential requires a more careful mental status examination and a laboratory work-up. However, this cannot be accomplished until the patient has been calmed.Given the time course, full work-up can probably wait, so restraining the patient is too aggressive in this case. If the patient appeared obviously medically ill or in distress and did not cooperate with the necessary evaluation, then restraint might be necessary. However, the ED team can try to de-escalate the situation; the best first approach is nonpharmacologic. Since this patient was cooperative on arrival, she may be calmed with careful individual attention and re-orientation. This strategy should be allowed sufficient time to succeed. If it fails, pharmacologic intervention may be needed.Dementia Statistics

5.3 million 7th leading cause of deathRisk >65: 9.1 % men/ 17.2% womenRisk: Over age 85 12.1% men20.3% womenLong term careAL 45-67 % with some dementia41 % with moderate to severe cognitive impairment

Dementia is a common condition, but really an umbrella term for many different conditions, the most common being Alzheimers dementia. Vascular dementia, dementia of lewy bodies, and frontotemporal dementia also occur with some frequency. The diagnosis of dementia of any type involves ruling out other medical, metabolic or nut

There pathophysiology varied6

Memory / Cognitive ChangesNormal agingMild cognitive impairmentDelirium (e.g. acute infection)Other medical / health causes (B12 deficiency; thyroid dysfunction)DepressionAlzheimers diseaseVascular (multi-infarct) dementiaDementia associated with Lewy bodiesOther (alcohol, frontotemporal dementia, Parkinsons Disease, Neurosyphilis)

TopicSlide 7Cognitive changes, including dementia, may be caused by numerous pathological changes changes. And the degree of memory change, or changes in thinking, can vary from minor such as those changes associated with normal aging, to severe, such as those changes associated with the late stages of dementia.

Though there is not test or picture that will clearly and definitively diagnose the presence of dementia, a comprehensive history and physical will help to determine its presence. To start, many medical conditions are ruled out such as thyroid problems, vitamin deficits, and acute illness. These conditions often create symptoms that mimic dementia. A history and physical that pays close attention to neurological, mental health and cognitive assessments, is obtained. Only by ruling out other causes and gathering information about symptoms combined with the aforementioned exam-- can a diagnosis of dementia be made. It is essentially a diagnosis of exclusion. persistent and progressiveDementia

Dementia is a persistent and, progressively changes a persons memory, abiliity to problem solve, ability to speak and use language, ability to interpret messages and other stimuli, and the ability to express and understand emotions. Combined together, all of these changes impair a persons ability to function as they once did; on physical, social and emotional levels. 8Alzheimers diseaseAlzheimers disease (AD) is an irreversible, progressive brain disease that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks of daily living. In most people with AD, symptoms first appear after age 60.AD is the most common cause of dementia among older people, but it is not a normal part of aging.Alzheimers disease is one type of dementia; it is the most common cause of dementia. 9Cause of Alzheimers DementiaAmyloid plaques and neurofibrillary tangles which start in area of brain affecting memory and spread to other areasGradual loss of connections between nerve cells (neurons) in the brain. This loss leads to diminished cell function and cell death. Read more about Alzheimers Disease by connecting to this link: Alzheimer's Association Web Page with Description of Alzheimer's DementiaThe pathophysiology behind Alzheimers dementia is thought to be from the development of amyloid plaques and neurofibrillary tangles. These changes typically are first seen in an area of the brain called the hippocampus and therefore typically cause changes in memory and orientation. These changes then spread to areas throughout the brain, causing additional changes in normal thought processes. 10Causes of Vascular DementiaComplete blockage of blood vessels in the brain. The complete blockage of an artery in the brain usually causes a stroke, but some blockages don't produce stroke. These "silent brain infarctions" increase a person's risk of vascular dementia. The risk increases with the number of infarctions experienced over time. One variety of vascular dementia is called multi-infarct dementia. Heart disease and irregular heart rhythms, such as atrial fibrillation, can increase your risk of stroke.

Narrowing of the blood vessels in the brain. Vascular dementia also can occur without a complete blockage of an artery. Portions of the brain can be starved for oxygen and food by reduced blood flow from arteries narrowed by vascular disease.

Vascular dementia can also be caused by: very low blood pressure, bleeding brain, blood vessel damage from such disorders as lupus erythematosus or temporal arteritis

Vascular dementia, sometimes referred to as multi-infarct dementia, is another common cause of cognitive impairment. Changes in blood vessels, including small capillaries, from any systemic disease such as atherosclerosis, diabetes, irregular heart rhythms, changes circulation effectiveness to all parts of the body, including the brain. 11Other conditions that cause memory loss or dementia medication side effects chronic alcoholism certain tumors and infections in the brain blood clots in the brain vitamin B12 deficiency dehydration high fever some thyroid, kidney, or liver disorders

Other common types of dementia include Dementia of Lewy Body and Frontotemperal dementia.

In addition to primary dementia types, certain medical conditions contribute to dementia symtpoms. Examples of those medical conditions include Vitamin B 12 deficiency, Hypothyroidism, and medication side effects. 12Dementia symptomsMemory impairment- getting lost in familiar settings, forgetting previous conversations, names, facesLanguage impairment- difficulty finding words or following conversation, inability to communicate needs and preferences through verbal meansApraxia-unable to perform previously learned tasks such as not knowing how to drink from a cup even though person may have sensory and physical ability intactAgnosia-unable to recognize objects or other sensory stimuliImpaired executive function- poor planning and judgement, difficulty solving problemsThere are common primary symptoms of dementia. Many times people refer to memory loss as the primary symptom of dementia. Think back to the effects of dementia we talked about on many parts of the brain over time understand the multiple effects that dementia has on thinking, emotions and function.

In addition to changes in memory, persons with dementia typically also have difficulty finding words, expressing thoughts and interpreting messages. Apraxia, ore the inablity to perform a well known task such as buttoning a button, is common.

Other symptoms you will commonly see include the inability to recognize familiar objects. Impaired executive function refers to the inability to solve problems that occur throughout the course of a normal day. 13MildModerateMemory problemsGetting lostDifficulty handling money or medicationsTaking a longer time than usual completing a taskPoor judgmentLosing thingsMood changesIncreased memory lossProblems recognizing family and friendsInability to learn new thingsDifficulty carrying out routine multi-step tasksProblems coping with new situationsImpulsiveDelusions and paranoiaProgressive Symptoms of ADThe next two slides briefly review common symptoms of dementia in early, mid and late stages. In early stages symptoms include memory problems, getting lost or confused, having difficulty handling money or medications, taking a longer time than usual to complete every day tasks such as getting ready in the morning, poor judgment, having more frequent or more sever mood change, and losing things.

In middle stages of progressive dementia, memory impairment worsens, individuals begin to have difficulty recognizing family and friends, have difficulty carrying out routine multi step tasks, more difficulty coping with new situations, and becoming more impulsive14SevereDifficulty recognizing one self or familyInability to verbally communicateWeight lossSeizures Difficulty swallowingGroaningMoaningIncreased sleepingLoss of bladder and bowel controlProgressive Symptoms of ADThe next two slides briefly review common symptoms of dementia in early, mid and late stages. In early stages symptoms include memory problems, getting lost or confused, having difficulty handling money or medications, taking a longer time than usual to complete every day tasks such as getting ready in the morning, poor judgment, having more frequent or more sever mood change, and losing things.

In middle stages of progressive dementia, memory impairment worsens, individuals begin to have difficulty recognizing family and friends, have difficulty carrying out routine multi step tasks, more difficulty coping with new situations, and becoming more impulsive15