* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Memory and Aging - Michigan State University
Neurophilosophy wikipedia , lookup
Haemodynamic response wikipedia , lookup
State-dependent memory wikipedia , lookup
Neuroplasticity wikipedia , lookup
Metastability in the brain wikipedia , lookup
Environmental enrichment wikipedia , lookup
Neuroeconomics wikipedia , lookup
Perivascular space wikipedia , lookup
Brain Rules wikipedia , lookup
Cognitive neuroscience wikipedia , lookup
Embodied cognitive science wikipedia , lookup
Abnormal psychology wikipedia , lookup
Neuropsychology wikipedia , lookup
Holonomic brain theory wikipedia , lookup
Sports-related traumatic brain injury wikipedia , lookup
Memory and aging wikipedia , lookup
Clinical neurochemistry wikipedia , lookup
Visual selective attention in dementia wikipedia , lookup
Impact of health on intelligence wikipedia , lookup
Neuroanatomy of memory wikipedia , lookup
Aging brain wikipedia , lookup
Biochemistry of Alzheimer's disease wikipedia , lookup
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 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 CH__M__K O_T_ _US D_NO__UR PR__TI___IT___ Preserved Abilities with Aging Priming - an unconscious influence of past experience on current performance or behavior. Inhibition of stimulus-bound responding. red brown white blue white blue green brown red brown red green white blue green white brown blue Stroop test green red Common Causes of Poor Memory Insomnia and impaired sleep (apnea) Drug side effects (antihistamines) Menopause Depression Attention Deficit Disorder Head injury Chemotherapy Problem Medications Antiarrythmics Antiemetics Antihistamines Antiparkinson Agents Antipsychotics Antispasmotics Skeletal Muscle Relaxants Tricyclic Antidepressants Uncommon Causes of Poor Memory 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 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 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 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