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DEMENTIA CARE UPDATE
Introduction to Dementia Care
2
42%
of residents in assisted
living have Alzheimer’s
disease or another form
of dementia
3
Alzheimer's disease is
the sixth leading
cause of death in the
United States.
More than 5 million
Americans are living
with the disease.
1 in 3 seniors dies
with Alzheimer's or
another dementia.
In 2012, 15.4 million
caregivers provided
more than 17.5 billion
hours of unpaid care
valued at $216 billion.
Nearly 15% of caregivers
for people with
Alzheimer's or another
dementia are longdistance caregivers.
In 2013, Alzheimer's will
cost the nation $203
billion. This number is
expected to rise to $1.2
trillion by 2050.
Source: Alzheimer’s Association, www.alz.org
4
WHAT IS DEMENTIA?
•
Not a specific disease
•
A general term that describes a wide range of
symptoms associated with a decline in memory or
other thinking skills severe enough to reduce a
person's ability to perform everyday activities
•
Alzheimer's disease accounts for 60 to 80 percent
of cases
•
Vascular dementia, which occurs after a stroke, is
the second most common dementia type
Source: Alzheimer’s Association, www.alz.org
5
DEMENTIA
Alzheimer’s Disease
Vascular Dementia
Lewy Body
Frontotemporal
Mixed Dementia
Parkinson’s
Disease
6
SYMPTOMS OF DEMENTIA
At least two of the following core mental functions
must be significantly impaired to be considered
dementia:
•
Memory
•
Communication and language
•
Ability to focus and pay attention
•
Reasoning and judgment
•
Visual perception
7
CAUSES OF DEMENTIA
#1: Alzheimer’s disease
#2: Vascular dementia
•
Dementia with Lewy bodies
•
Mixed dementia
•
•
Normal pressure
hydrocephalus
Parkinson’s disease
•
Huntington’s disease
•
Frontotemporal dementia
•
•
Creutzfeldt-Jakob disease
Wernicke-Korsakoff
Syndrom
8
ALZHEIMER’S DISEASE
Symptoms:
•
Difficulty remembering names and recent events
•
Apathy and depression
•
Impaired judgment
•
Disorientation
•
Confusion
•
Behavior changes
•
Difficulty speaking, swallowing and walking
Source: Alzheimer’s Association
9
ALZHEIMER’S DISEASE
Brain changes:
•
Deposits of the protein
fragment beta-amyloid
(plaques) that build up
between brain cells
•
Twisted strands of the
protein tau (tangles) that
build up inside cells
•
Evidence of nerve cell
damage and death in the
brain
Source: Alzheimer’s Association
10
ALZHEIMER’S DISEASE
11
ALZHEIMER’S DISEASE
Source: Alzheimer’s Association
12
STAGES
Stage 1
No impairment
The person does not experience any memory problems. An interview
with a medical professional does not show any evidence of symptoms
of dementia.
Stage 2
Very mild cognitive decline
The person may feel as if he or she is having memory lapses —
forgetting familiar words or the location of everyday objects. But no
symptoms of dementia can be detected during a medical examination
or by friends, family or co-workers.
Stage 3
Mild cognitive decline
Friends, family or co-workers begin to notice difficulties. During a
detailed medical interview, doctors may be able to detect problems in
memory or concentration.
Source: Alzheimer’s Association
13
STAGES
Stage 4
Moderate cognitive decline
At this point, a careful medical interview should be able to detect
clear-cut symptoms in several areas: forgetfulness of recent events,
greater difficulty performing complex tasks, such as planning dinner.
Stage 5
Moderately severe cognitive decline
Gaps in memory and thinking are noticeable, and individuals begin to
need help with day-to-day activities.
Stage 6
Severe cognitive decline
Memory continues to worsen, personality changes may take place
and individuals need extensive help with daily activities.
Source: Alzheimer’s Association
14
STAGES
Stage 7
Very severe cognitive decline
In the final stage of this disease, individuals lose the ability to respond
to their environment, to carry on a conversation and, eventually, to
control movement.
Source: Alzheimer’s Association
15
VASCULAR DEMENTIA
Symptoms:
•
Impaired judgment or ability to plan steps needed
to complete a task is more likely to be the initial
symptom, as opposed to the memory loss often
associated with the initial symptoms of Alzheimer's
•
Occurs because of brain injuries such as
microscopic bleeding and blood vessel blockage
•
The location of the brain injury determines how the
individual's thinking and physical functioning are
affected
Source: Alzheimer’s Association
16
VASCULAR DEMENTIA
Brain changes:
•
Brain imaging can often detect blood vessel
problems implicated in vascular dementia
•
In the past, evidence for vascular dementia was
used to exclude a diagnosis of Alzheimer's disease
(and vice versa)
•
That practice is no longer considered consistent
with pathologic evidence, which shows that the
brain changes of several types of dementia can be
present simultaneously
Source: Alzheimer’s Association
17
DELIRIUM
•
An acute confusional state
•
Medical condition that results in confusion and
other disruptions in thinking and behavior, including
changes in perception, attention, mood and activity
level
•
Individuals living with dementia are highly
susceptible to delirium
•
Can easily go unrecognized
18
Regulatory Requirements
for Dementia Care
19
CARE OF PERSONS WITH DEMENTIA
•
Applicability
•
Mild Cognitive Impairment
•
•
Wrist bands and egress
alert devices
Fire clearance
•
Exit alarms
•
Training
•
Delayed egress
•
Adequate staffing
•
Locked doors
•
Medical assessments and
appraisals
•
Safety modifications
Applicable Regulations
•
Personal grooming and
hygiene items
• 87705
20
ADVERTISING DEMENTIA SPECIAL CARE…
•
Plan of operations
•
Changes in condition
•
Philosophy
•
Success indicators
•
Assessments
•
Admission agreement
•
Admission procedures
•
Advertisements
•
Activity programming
•
Staff qualifications
•
Staff training
•
Physical environment
Applicable Regulations
• 87706
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TRAINING REQUIREMENTS IF ADVERTISING…
•
Direct care staff: 6 hours of orientation within the
first four weeks
•
Various methods of instruction allowed
•
8 hours of inservice training every 12-months
•
Require topics
•
Documentation
•
Trainer requirements
Applicable Regulations
• 87707
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2016 CAREGIVER ORIENTATION TRAINING
•
40 hours total orientation
•
20 hours before working independently
• 6 hours dementia
• 4 hours postural supports, hospice
•
20 hours within first 4 weeks of employment
• 6 hours dementia
23
2016 CAREGIVER ONGOING TRAINING
•
20 hours annually
•
8 hours dementia
•
4 hours postural supports, hospice
24
CCG CAN HELP
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Co-Morbidities
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CO-MORBIDITIES IN DEMENTIA CARE
•
Complications related to the disease
•
Significant concern for safety and quality of life
•
Often related to eventual cause of death
•
Creates risk management issues for the provider
27
Swallowing Disorders
SWALLOWING DISORDERS
Dysphagia:
Occurs when there is a
problem with any part of
the swallowing process.
SWALLOWING DISORDERS
Aspiration:
Occurs when liquids or
solids are breathed into
the respiratory system
instead of properly being
swallowed I into the
stomach.
SWALLOWING DISORDERS
Monitoring Residents for Dysphagia and Aspiration
•
Choking on foods, liquids or medication
•
Coughing during or after eating
•
Wet sounding voice
SWALLOWING DISORDERS
Monitoring Residents for
Dysphagia and Aspiration
(cont.)
•Extra
effort to chew or
swallow
•
“Pocketing” food
SWALLOWING DISORDERS
Interventions for Residents
With Swallowing Difficulties
INTERVENTIONS/SWALLOWING DISORDERS
1.
Have Resident sit upright when eating.
2.
Tilt the resident’s head slightly forward when
eating.
3.
Ensure the resident remains sitting or standing
upright for at least 15-20 minutes after finishing a
meal.
4.
Minimize distractions in dining area.
INTERVENTIONS/SWALLOWING DISORDERS
(cont.)
5.
Do not encourage residents to talk until he/she
has swallowed his/her food.
6.
Cut food into small pieces.
7.
Encourage swallowing more than once after each
bite or drink.
INTERVENTIONS/SWALLOWING DISORDERS
(cont.)
8.
Modified diets if physician ordered.
9.
Request a speech therapy evaluation from the
physician to evaluate swallowing.
SWALLOWING DISORDERS
Examples of Modified Diets for
Residents with Cognitive
Impairment and Swallowing
Disorders
MODIFIED DIETS/ SWALLOWING DISORDERS
•
Thick liquids
•
Soft foods
•
Pureed
•
Minced, ground and
chopped
Pneumonia
PNEUMONIA
Causes of
Pneumonia
CAUSES OF PNEUMONIA
Bacteria
•
Bacteria enters through inhalation or the
bloodstream.
•
Bacteria infect the alveoli.
•
Immune system responds by releasing white blood
cells to attack bacterium.
•
Release of white blood cells also triggers body to
respond with fever, chills and fatigue.
CAUSES OF PNEUMONIA
Virus
•
Virus enters body through droplets that enter the
mouth or nose.
•
Virus invades cells around the alveoli and airways.
•
Attacked cells die which leads to swift response
from body’s immune system
•
Fluid leaks into alveoli which affects the
transportation of oxygen into bloodstream.
CAUSES OF PNEUMONIA
Fungus
•
Least common cause of pneumonia
•
Fungi enters body through inhalation of spores, or
through the bloodstream
•
Fungi travel to alveoli and surrounding cells.
•
White blood cells are released to destroy the fungi,
which also triggers the body to respond with fever,
chills and fatigue.
PNEUMONIA
Signs and Symptoms
to Monitor:
•
Drowsiness
•
High Fever
•
Rapid Breathing
•
Chills
PNEUMONIA
Signs and Symptoms to
Monitor (cont.):
•
Cough
•
Chest Pain
•
Blue tint to lips or nails
•
Flu like symptoms
•
Inability to clear throat
PNEUMONIA
Complications of Pneumonia
Especially in Residents with
Cognitive Impairment
COMPLICATIONS OF PNEUMONIA
1. Septic Shock
Untreated bacteria growth
in the bloodstream can
cause normal circulation
to shut down. In some
cases, body tissues can
swell uncontrollably and
cause organ failure.
COMPLICATIONS OF PNEUMONIA
2. Lung Abscess
In some cases of
pneumonia, a cavity forms
within the affected area
and fills with puss.
COMPLICATION OF PNEUMONIA
3. Acute Respiratory Distress Syndrome (ARDS)
Sometimes pneumonia becomes so widespread
in the lungs breathing becomes increasingly
difficult. As a result, the body does not receive
enough oxygen to function properly.
COMPLICATIONS OF PNEUMONIA
4. Pleural Effusion
This condition occurs when fluid accumulates in
the membrane that surrounds the lungs. When
this membrane becomes inflamed form
pneumonia, it is more susceptible to fluid
retention and infection.
PNEUMONIA
Interventions to
Avoid Pneumonia
INTERVENTIONS TO AVOID PNEUMONIA
•
Good nutrition and
hydration
•
Regular physical
activities
•
Monitor for aspiration
INTERVENTIONS TO AVOID PNEUMONIA
•
Manage Dysphagia
•
Report symptoms to
physician immediately
Pressure Ulcers
PRESSURE ULCERS
Factors that Contribute to Skin Problems:
•
Poor nutrition
•
Dehydration
•
Lack of ability to ambulate or move about easily
•
Inability to turn in bed or from side to side in chair
PRESSURE ULCERS
Factors That Contribute to Skin Problems (cont.)
•
Decreased sensation
•
Poor circulation
•
Shearing
•
Loss of bladder and/or bowel control
•
Decreased activity
•
Poor cognitive function (especially residents with
dementia)
PRESSURE ULCERS
Strategies to Keep the
Resident’s Skin Healthy
STRATEGIES FOR HEALTHY SKIN
•
Turn and reposition
minimally every 2 hours
•
Hydrate skin with topical
application of lotions/creams
STRATEGIES FOR HEALTHY SKIN
•
Utilization of a barrier
cream/ointment for
incontinence
•
Meticulous incontinent
care
•
Adequate hydration and
nutrition
PRESSURE ULCERS
Complications with
Pressure Ulcers
COMPLICATIONS WITH PRESSURE ULCERS
1. Blood Poisoning – condition when bacteria
enters the blood stream. Requires immediate
medication attention, or could progress to sepsis
which is life threatening.
2. Infection in the Bone – also known as
“Osteomyelitis”. Infection enters bone through
outside wound or from the bloodstream. If left
untreated may cause permanent bone damage.
COMPLICATIONS WITH PRESSURE ULCERS
3.
Infection with Antibiotic – Resistant Bacteria:
a bacteria that is not killed or controlled by
antibiotics. This is a serious health problem for
the resident and everyone in the facility.
4.
Pain and Associated Depression –
Persistent and chronic pain from pressure ulcers
can cause emotional distress and depression.
5.
Amputation – severe ulcers can lead to
amputation of infected extremity.
PRESSURE ULCERS
Four Stages of Pressure Ulcer:
Stage 1: The initial sign of a pressure ulcer is
reddening of the skin. At this point, the wound is only
superficial and the skin is typically unbroken. A
Stage 1 pressure ulcer will heal quickly when the
pressure point is relieved on the area.
PRESSURE ULCERS
Stage 2 – This stage is
characterized by a blister
on the surface of the skin.
The blister can be broken
or unbroken. There are
now layers of the skin that
have become injured, so
the wound is no longer
superficial.
PRESSURE ULCER
Stage 3 – In this stage, the wound has progressed
through all layers of the skin. The affected area is at
high risk for contracting a serious infection. Relieving
the pressured area is essential, along with additional
padding or coverings to protect the wound and
promote healing. Surgery may be needed to remove
dead tissue.
PRESSURE ULCER
Stage 4: This is the final and most severe stage of a
pressure ulcer. The wound has now progressed
through the skin layers and has reached underlying
muscle, tendons, and bone. The wound itself may
not appear large in diameter when observing the
skin, but the depth of the wound is very severe.
PRESSURE ULCERS
PRESSURE ULCERS
Preventing Pressure Ulcers
Urinary Tract Infections
URINARY TRACT INFECTIONS (UTI’S)
Types of Infections Associated with Urination:
•
Bladder Infection
•
Kidney Infection
•
Urethra Infection
URINARY TRACT INFECTIONS (UTI’S)
Causes and Risk Factors of UTI’s

Escherichia Coli Bacteria (E. Coli)

Chlamydia and Mycoplasma

Bowel Incontinence

Kidney Stones

Immobility

Dehydration

Lack of Nutrition
URINARY TRACT INFECTIONS (UTI’S)
Common Symptoms:

Burning pain while urinating

Frequent/Urgent urination

Abdominal or pelvic pain

Itching or tenderness in lower
abdomen

Fever and chills
URINARY TRACT INFECTIONS (UTI’S)
Common Symptoms (Cont.)

Fatigue

Blood in urine or cloudy urine

Foul or strong odor

Back or side pain

Confusion or rapid cognitive decline

Nausea and vomiting
URINARY TRACT INFECTIONS (UTI’S)
Monitoring Residents
for UTI’s
MONITORING RESIDENTS FOR UTI’S
•
Observe for change in
condition
•
Changes in behavior
•
Resident is holding
his/her abdominal
area
•
Increased urgency in
the need to void
MONITORING RESIDENTS FOR UTI’S
•
Resident complains of
pain
•
Smaller amounts of
urine when voiding
•
Urine may smell foul,
and look cloudy and
dark in color
•
Low grade fever
URINARY TRACT INFECTION (UTI’S)
Interventions to Avoid UTI’s
•
Encourage/assist the resident to stay hydrated and
have balanced nutrition.
•
Good incontinence care as well as proper hygiene
for the continent resident.
•
Encourage/assist using the bathroom throughout
the day.
Falls
FALLS
•
More than 1/3 of adults 65 and older fall each year
in the US.
•
Men are more likely to die from a fall. However,
women are 67% more likely than men to have a
nonfatal fall injury.
•
When an older adult falls, the effects go beyond
physical injury.
FALLS
Resident Risk Factors
of Falls:
•
Effects of Medications
•
Eyesight problems
•
Hip, leg and foot
disorders
•
Disease and illness
FALLS
Environmental Risk
Factors
•
Elevated Bed Heights
•
Low-seated chairs
•
Poor lighting
•
Slippery floors or nonsecured rugs
FALLS
Environmental Risk
Factors (Cont.)
•
Clutter
•
Poorly maintained
walking aids
•
Lack of safety
equipment
FALLS
Fall Risk Reduction
Strategies
FALL RISK REDUCTION STRATEGIES
Fall risk assessment
Condition of resident, medications used by resident,
history of falls, gait and balance assessment,
walking aid assessment, medical history, evaluation
by physical therapist, etc.
FALL RISK REDUCTION STRATEGIES
General strategies
•
Observe environment for potentially unsafe
conditions.
•
Identify residents who are “at risk” for falling and
implement specific fall risk reduction strategies for
that resident.
•
Many others
FALLS
Other Factors in Risk Reduction

Medications

Footwear

Exercise

Assistive Devices
FALL RISK REDUCTION STRATEGIES
General Strategies
•
Remind resident to request assistance as needed.
•
Ensure all pathways are free from obstacles.
•
Provide adequate lighting
•
Provide appropriate chairs with arms that are solid
and secure.
FALLS
How to
Properly
Respond to a
Fall
Treating Alzheimer’s Disease
89
CURRENTLY APPROVED TREATMENTS
Name
Brand name
Approved For
FDA Approved
1. donepezil
Aricept
All stages
1996
2. galantamine
Razadyne
Mild to moderate
2001
3. memantine
Namenda
Moderate to
severe
2003
4. rivastigmine
Exelon
All stages
2000
90
CURRENT TREATMENTS
•
Target key chemicals in the brain
(neurotransmitters) that are disrupted by
Alzheimer’s
•
Do not cure the disease
•
Do not treat the underlying cause
•
May help to improve symptoms
91
TREATMENT HORIZON
•
New drugs in development are trying to modify the
disease process itself
•
Impacting one or more of the many brain changing
caused by Alzheimer’s disease
•
Researchers believe effective treatment will require
a “cocktail” of medications
•
Obstacles to progress: not enough volunteers, not
enough federal funding for research
92
TARGETS FOR FUTURE DRUGS
•
Beta-amyloid
•
Tau protein
•
Inflammation
•
Insulin resistance
•
Brain imaging and biomarkers
93
BETA-AMYLOID
Click on the link to view the video.
Make sure you’re connected to the internet.
http://www.alz.org/research/video/video_
pages/understanding_attacking_alz.html
94
INFLAMMATION
Click on the link to view the video.
Make sure you’re connected to the internet.
http://www.alz.org/research/video/video_pages
/inflammation.html
95
INSULIN RESISTANCE
Click on the link to view the video.
Make sure you’re connected to the internet.
http://www.alz.org/research/video/video_pages
/insulin_and_alz.html
96
BRAIN IMAGING AND BIOMARKERS
Click on the link to view the video.
Make sure you’re connected to the internet.
http://www.alz.org/research/video/video_pages
/quest_for_biomarkers.html
97