Download Care of the Dementia Patient Presentation

Basic Care of the Dementia Patient
Assisted Living Association of
Alabama
Hyatt Regency Wynfrey Hotel
September 28, 2016
Andrew S. Duxbury MD FACP – Professor
Division of Gerontology and Geriatric Medicine
University of Alabama at Birmingham
Who Are The Elderly?
 They are not a single
population
 What is true for one
subpopulation may not be
true for another
 Aging concerns are
universal
 The process of aging hasn’t
changed over time –
attitudes have
The Age Wave Approaches
The Rise Of The Oldest Old
Changing Social Attitudes
Towards Aging
 Denial of realities of
aging
 Disappearance of aging
from public space
 Removal of aged from
family life
 Lack of aging role
models in pop culture
Defining Elder Populations
 The Chronologic
Definition of Age
 The Functional
Definition of Age
 The Fifteen Year
Definition of Age
The Older Adult and the Health Care
System: A Critical Intersection
 Older adults will
increase from 14% to
22% of the population
 Older adults use
roughly 1/3 health
services and this is
expected to increase
 Older adults are the
heaviest consumers of
medication and
medical equipment
 Older adults wish to
age in place – the
system often has other
ideas
Basic Human Ecology
 Humans, like other species, adapt their environment
to suit their needs
 In turn, individuals are shaped by their
environments and are changed by experience
 Maintaining an independent existence depends
upon the individual’s abilities to adapt to both
internal and external change
 Function is a measure of the ‘fit’ between an
individual and their environment of choice
Function In Graphic Terms
Function
Person
Environment
Function in the Face of Change
Environment
Person
Internal
Change
External Change
Restoration
Balance
Changed Person
Changed Environment
Acute vs. Chronic Disease
ACUTE
 Rapid onset
 Amenable to quick
diagnosis and
restorative measures
 Can be completely
removed from the body
CHRONIC
 Insidious onset
 Often easily diagnosed,
can be ameliorated but
effects cannot
necessarily be removed
 Usually a long term or
life long condition
Top Twelve Health Conditions
of the Older American
 Atherosclerosis
(Coronary disease and
stroke)
 Cancer
 Hypertension
 Diabetes
 Arthritis







Sensory impairment
Chronic lung disease
Kidney failure
Dementing illness
Depression
Incontinence
Osteoporosis/Fracture
Dementia – Arcs of the Disease
Function
Alzheimer’s
Ischemic Vascular
Frontal Lobe
Time
How Should We Approach
Dementia?
 As a society – how do we want to take care of
dementia patients?
 Do we want to regard dementia patients as worthy
of our attention or do we want to make them
invisible?
 Is dementia a disease where we wish to expend
shrinking medical resources?
 Given the complexity of the human brain, is
dementia a disease that we can even begin to
understand?
Is Dementia Inevitable?
 Have we become too successful at eliminating other
diseases?
 If we could remove dementia, what would arise to
take it’s place?
 Evidence that dementia may be a life long process –
The Nun’s Study
Dementia
 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
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
Dementia: 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
Dementia: 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
Dementia: Essential Features
 Impairments in . . .




Abstract thinking
Ability to reason
Judgement
Impulse control
 Personality changes

Not “him/herself”
Dementia: Essential Features
 Lost abilities result in
CHANGES . . .



Personality
Behavior
Emotion
Get away from
me, you big fat
slob!! You
#@!!!#*!!!
“My mother would never say such a thing!”
Types of Dementing Illness
 Alzheimer’s Disease
 Ischemic Vascular Dementia
 Frontal Lobe Dementia
 Lewy Body Dementia
 Pick’s Disease
 Creutzfeld-Jakob Disease
 Parkinson’s Disease
Stages of Disease: The FAST
(Functional Assessment Staging)
Scale
 Seven Stage Scale
often used in
clinical practice and
research to assess
the abilities of a
patient with
Alzheimer’s disease
Stage 1 - Normalcy
 No impairments
 No memory
problems evident to
individuals, families
or medical
professionals on
examination
Stage 2 – Very Mild Cognitive
Decline
 May be normal age
related changes
(Mild Cognitive
Impairment or MCI)
 Individuals may
notice memory
lapses in terms of
forgetting words,
names, where they
Stage 3 – Mild Cognitive
Decline
 Friends, family or
coworkers may start to
notice memory issues.
 Word finding or memory
difficulties may become
apparent on clinical testing.
 Occupational tasks may
suffer from inability to
remember steps
 Difficulty remembering
names of new people
 Problems with retaining
read material
 Loss of ability to plan
 Losing of valuables
Stage 4 – Moderate Cognitive
Decline
 Decreased
knowledge of
current events
 Loss of ability to
perform mental
arithmetic or handle
change
 Inability to perform
complex tasks such
 Loss of memory of
personal history
 Withdrawl in
complex or socially
challenging
situations
 Less likely to enjoy
gatherings or
crowds
Stage 5 – Moderately Severe
Cognitive Decline
 Major cognitive
gaps emerge.
Patients require
assistance with day
to day activities
such as choosing
clothing
 Cannot recall
important details
 Confusion about
where they are or
about time such as
date
 Retain strong sense
of self and
autonomy
 Recognize familiar
individuals such as
Stage 6 – Severe Cognitive
Decline
 Personality changes
emerge
 Require assistance with
basic activities of daily
living such as bathing or
using the toilet – often
incontinent
 Lose awareness of recent
experiences and
surroundings
 Forget names of familiar
people but can usually
distinguish faces
 Disruptions in normal
sleep/wake cycles
 May be delusional,
hallucinate, be paranoid
 Wander and become lost
easily
Stage 7 – Very Severe
Cognitive Decline
 Cannot respond to
environment or
stimuli
 Cannot control own
body, lose
ambulatory ability
and are bed bound
 Cannot speak
recognizably with
 Cannot eat without
assistance
 Reflexes become
abnormal and
muscles become
rigid and contract
Alzheimer’s Disease –
The Cholinergic Hypothesis
 The neurons most destroyed by Alzheimer’s
use acetylcholine as their primary
neurotransmitter
 Difficult to directly raise levels of
acetylcholine in the brain
 Indirect raising of levels by preventing
breakdown into individual components more
successful
Acetylcholinesterase Inhibitors
 Block the enzyme that
breaks acetylcholine
down to component parts
 Four varieties:




Cognex (tacrine)
Aricept (donepezil)
Exelon (rivastigmine)
Razadyne (galantamine)
 Each has slightly different
effects and side effects
A New Idea:
Fighting Cell Death
 The chemical glutamate involved in telling
cells when to die
 Does so by activating receptors that speed up
cell function (NMDA receptors)
 Blockage of this effect saves neurons and
function
How Glutamate Functions
Memantine – A New
Medication
 Different mechanism
of action than previous
 May be used in
conjunction with
acetylcholinesterase
inhibitors
 Active at later stages of
disease
 Brand name Namenda
Medications Proven Not To
Work For Alzheimer’s Disease
 Gingko Biloba
 Vitamin C
supplements
 Vitamin E
supplements
Other Medications: Treatment
of Behavioral Symptoms
 Tranquilizers
 Sleep aids
 Antipsychotics
 Antidepressants
 Neural pathway
inhibitors
Tranquilizers
 Short acting
benzodiazepines


Ativan (lorazepam)
Xanax (alprazolam)
 Long acting
benzodiazepines


Valium (diazepam)
Konopin
(clonazepam)
Sleep Aids
 Desyrel (trazodone)
 Ambien (zolpidem)
 Lunesta
(eszopiclone)
 Restoril
(temazepam)
 Rozerem
(ramelteon)
Antipsychotics
 Risperdal
(risperidone)
 Zyprexa (olanzapine)
 Geodon (ziprasidone)
 Abilify (aripriprazole)
 Seroquel (quetiapine)
 Haldol (haloperidol)
Antidepressants
 SSRIs
 Prozac (fluoxetine)
 Zoloft (sertraline)
 Celexa (citalopram)
 Lexapro (escitalopram)
 Paxil (paroxetine)
 SNRIs
 Effexor (venlafaxine)
 Pristiq (desvenlafaxine)
 Cymbalta (duloxetine)
 Other
 Remeron (mirtazapine)
 Pamelor (nortriptyline)
Neural Pathway Inhibitors
 Tegretol
(carbemazepine)
 Depakote (valproic
acid)
 Neurontin
(gabapentin)
 Lyrica (pregabalin)
The Next Step?
 Bapineuzumab


Monoclonal
antibody against
amyloid plaques
Some preliminary
studies suggest
‘clearing’ of plaque
possible
Medications Proven Not To
Work For Alzheimer’s Disease
 Gingko Biloba
 Vitamin C
supplements
 Vitamin E
supplements
 ?Prevagen
Dementia Treatment:
More Than Medication
 Dementia involves social context and family
systems
 Dementia must be approached as a chronic illness
 The behavioral issues in dementia require
behavioral interventions
Dementia Treatment: A Model
Functional life
Disease
Acute
Treatment
Dysfunction
Functional Balance
Restored
Case Mgmt.
Techniques
Designing Environments
 Appropriate for reverse developmental stages
 Safe and secure
 Uphold autonomy and dignity wherever
possible
 Take other conditions of aging such as visual
or hearing problems into account
 Put the ‘home’ before the ‘nurse’
Environmental Needs
 Touch gardens and plants
 Generationally appropriate
music
 Fresh air and sunshine
 Children
 Pets
 Sensory stimulation
 Art
Behavioral Treatment
 Behavioral problems should be treated
behaviorally, not medically
 Some behaviors are normal in dementia and
need not be treated
 Caregivers and families need to educate
themselves in what is normal and what
requires intervention
The Use of Hospice in
Dementia
 Limited by Medicare rules to patients in
FASS stage 7 or in rapid decline.
 In general, for patients who cannot walk,
feed themselves or make their needs known
verbally.
 Assistance to patients and family systems to
cope with inevitable decline and death.
Dementia:
Some Uncomfortable Realities
 Dementia tends to be
medicalized as strictly a
brain disorder
 Dementia care regarded as
a personal rather than a
public responsibility
 Reductions in public funds
available for elder
programs
The Over Medicalization of
Dementia
 Emphasis on medication rather than
behavioral modification
 The reliance on the nursing home as a
provider
 Resistance to therapeutic modalities as ‘nonmedical’
 Lack of interest from providers as ‘incurable’
The Problem of Medicare
 Medicare not designed for treatment of
chronic diseases like dementia
 Most things needed by dementia patients
outside of Medicare’s benefits
 Costs of long term care cannot be borne by
Medicare with current design
Social Disinterest in
Dementia
 Scary to individuals on a
very personal level
 Invisibility of dementia
patients
 Competition for resources
 Youth oriented society
 Tilt of public away from
social programs to private
gain
Societal Choices
 What should our policies be regarding dementia and
Elder Care?
 How should we divide the necessary resources
between public and private?
 These are not abstract notions – This is our future.
25-50% of us will have dementing illness before we
die
A Thought To Take Home
 When the problems are
obvious, ask the
obvious questions
 We are the system –
nothing will change
unless we want it to