Transcript Alzheimer’s Disease for Emergency Personnel

Alzheimer’s Disease for
Emergency Personnel
Helle Brand, PA
Banner Alzheimer’s Institute
Objectives
Describe Alzheimer’s disease
 Outline the impact of coexisting diseases
on dementia and discuss delirium
 Identify the challenges of providing care
to patients with dementia
 Discuss specific strategies to enhance
care and outcomes for patients with
dementia
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Demographics of Dementia
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5.3 million Americans have dementia
By 2050, numbers will more than triple
About 10% of age 65+; nearly half of
those 85+ are affected
 Average life expectancy following
diagnosis is 8 – 10 years
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6th leading cause of death among older
Americans
About Dementia…
Dementia is not a specific diagnosis
 Each type of dementia has unique
features and is progressive
 Most common types of dementia include:
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Alzheimer’s disease (AD)
Lewy body dementia (LWD)
Vascular dementia (VaD)
Frontotemporal dementia (FTD)
Mild
I
N
Impaired
D
memory;
E
P Personality
changes;
E
N
Spatial
D disorientatio
E
n
N
C
E
Moderate
Severe
Confusion; Resistivenes
Bedfast;
s
Agitation;
Mute;
Insomnia; Incontinence Intercurrent
;
Aphasia;
infections;
Eating
Apraxia
Dysphagia
difficulties;
Motor
impairment
TIME
Progression of Dementia
Reference: Hurley & Volicer, 1998
Terminal
Clinical Presentation of Dementia
Function
Cognition
Behavior
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Insidious onset with progressive decline
Impaired social or occupational
functioning
Memory loss
Cognitive loss in at least 1 other domain
◦ Language
◦ Calculations
◦ Orientation
◦ Judgment
Deficits not due to other systemic disease
Deficits NOT in the setting of a delirium
DSM IV Criteria for
Alzheimer’s Dementia
Early (MILD) Stage
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Features
Short term memory loss
Problems with language
and abstract thinking
Misplacing things
Disorientation of time
Poor/ decreased judgment
Changes in mood/behavior
and/or personality
Treatment
Loss of initiative
• Cholinesterase Inhibitor
May have difficulty in a
• Manage depression and
crowd
other co-existing health
problems
Maintaining Independence
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may get lost driving or be unsure of self
in new surroundings
Forget appointments, family events
Lists may not make sense
May compensate for weaknesses
GRADUAL DECLINE IADLs
Early changes in AD, continued
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Medication management
Driving
Weight loss
Mood, especially depression
Changing awareness and concern for
safety
Need for life planning: financial, legal
Balancing autonomy vs supervision
Special concerns early on
Memory loss, confusion and attention worsen
over a 2-10 year span
 Judgment and problem solving a problem
Can’t think logically, organize thoughts
Loss of ability to handle complex tasks and
technology, gradual problems with taking care of
self
 Personality and behavior changes
 Increasing dependence
 Increasing language difficulties
 Vulnerable adults, cannot live alone
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Moderate Stage Alzheimer’s
Middle (MODERATE) Stage
.
Living with help
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Behaviors: suspiciousness, irritability,
restless, impulsivity, seeing or hearing
things not present, agitation,
wandering, sleep disturbance,
disinhibition
Changing communication/expectations
Increasing dependence, behaviors cause
increasing caregiver burden/stress
Safety: need 24 hour supervision
Recognizing delirium
Concerns with mid stage AD
Memory loss is severe, including long term
Loss of recognition of others beyond self
Problems controlling bowel/bladder
Fully dependent for care needs
Minimal to no speech
Changes in posture/walking, may not walk
and/or become bed bound
 Neurologic changes: myoclonic jerks,
seizures, dysphagia
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Late to End Stage Alzheimer’s
Late stage AD
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Risk for falls
May be prone to infection or skin
breakdown
Weight loss
Potential for seizures
Increasing sleep
Planning for death and dying
Comfort in terms of mood and pain
TIMELY HOSPICE REFERRAL
Issues in advanced Alzheimer’s
Dementia + Comorbidities
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Large numbers have chronic medical
issues
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Acute medical issues associated with
advanced dementia
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Medications can hasten decline
◦ Antihistamine, anticholinergics, corticosteroids,
anti-parkinson, hypnotics, sedatives, opioids,
ETOH
Maslow, Nur Cl N Am, 2004; 39: 561-579; Feil et al. JAGS 2007; 55:S293-301.
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Those with some form of dementia are at
increased risk for developing delirium
Delirium is a risk factor for future delirium
and for developing a permanent dementia
Age contributes to both
Medications play a role
Recognition of symptoms and treatment is
critical
What we need to know about
delirium and dementia
Incidence of Delirium
At least 25% >70 are admitted with
delirium
◦ Occurs in about half of elderly patients during
or after acute hospitalization
◦ More than half of these are found to have
permanent dementia, previously undiagnosed
◦ Up to 70% of ICU patients develop delirium
◦ Delirium occurs in 28 – 83% of patients near
the end of life (terminal agitation, restlessness)
Girad, Crit Care. 2008;12 Suppl 3:S3. Epub 2008 May 14; Waszynski, AJN, 2007,
107:12, 50-59
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D: dementia
E: electrolytes, dehydration
L: lung, liver, heart, kidney, brain
I: infection
R: Rx drugs
I: injury/pain/stress
U: unfamiliar environment
M: metabolic
Causes of Delirium
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Delirium
◦ Abrupt onset (hours –
days)
◦ Duration days to
weeks
◦ Symptoms include
confusion, forgetfulness,
altered sleep-wake
cycle, high frequency of
delusions, hallucinations
and illusions
◦ Causes include acute
medical conditions,
meds, ETOH abuse,
acute psychosis
◦ Treatment of
underlying condition;
supportive techniques
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Dementia
◦ Insidious onset
(months – years)
◦ Duration 2-20 years
◦ Symptoms include
decline in memory,
speech/ language
difficulty, loss of selfcare abilities and a
variety of behavior
problems
◦ Causes depends of
etiology of disease
◦ Treatment limited to
managing symptoms
and behaviors
In summary, how to differentiate
Delirium vs. Dementia
Your challenges with confused
patient
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Assessing confusion: Delirium v. Dementia
or Delirium Superimposed on Dementia
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Safety
Identification and treatment of pain
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Health Care Decisions
 Family Caregivers
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Confusion Assessment Method
◦ Feature 1: Acute Onset or Fluctuating Course
 Is there any evidence of an acute ∆ in MS from
baseline? Did the behavior fluctuate during the day,
increase/decrease in severity?
◦ Feature 2: Inattention
 Did the patient have difficulty focusing attention, being
easily distracted, or have difficulty tracking
conversation?
◦ Feature 3: Disorganized thinking
 Was the patient’s thinking disorganized or incoherent,
unclear, rambling or switching topics?
◦ Feature 4: Altered Level of Consciousness
 Overall, how would you rate the patient’s level of
consciousness? Alert - Vigilant – Lethargic – Stupor Coma
Inouye, S. (1990) Annals of Internal Med 113(12) 941-948.
Clock Drawing
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Simple screening tool:
◦ Ask the patient to draw a clock
◦ Place all the numbers on the clock
◦ Set the time at 11:10
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Scoring: 5 points totals
◦ 1 point for
◦ 1 point for
◦ 1 point for
order
◦ 1 point for
◦ 1 point for
the clock circle
the numbers in correct order
numbers being in proper special
two hands of the clock
the correct time
1. What are the date,
month, and year?
2. What is the day of the
week?
3. What is the name of this
place?
4. What is your phone
number?
5. How old are you?
6. When were you born?
7. Who is the current
president?
8. Who was the president
before him?
9. What was your mother's
maiden name?
10. Can you count backward
from 20 by 3's?
SPMSQ
SCORING:*
 0-2 errors: normal mental
functioning
3-4 errors: mild cognitive
impairment
5-7 errors: moderate cognitive
impairment
8 or more errors: severe
cognitive impairment
*One more error is allowed in
the scoring if a patient has
had a grade school education
or less.
*One less error is allowed if
the patient has had education
beyond the high school level.
Describe actual behaviors or symptoms
demonstrated and the frequency which
they occur
 Determine if the behavior is new or has
increased in frequency
 Obtain from family any successful
interventions for identified behaviors
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Assessment of Behavior(s)
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Moderate Dementia:
◦ Resisting/fighting
hands-on caregivers
◦ Assaultive toward
caregivers/peers
◦ Wandering and
rummaging
◦ Physical restlessness
◦ Sundowning
◦ Eating problems
◦ Sleeping problems
◦ Yelling
◦ Sexual behaviors
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Advanced Dementia:
◦ Resisting/fighting
hands-on caregivers
◦ Fall risk (wanting to
walk when unable to)
◦ Physical restlessness
◦ Resisting/refusing to
eat/drink
◦ Disruptive sleep
patterns
◦ Disruptive yelling
Common behaviors
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Decreased ability to recognize familiar
places and faces
Can forget names, addresses
Become disoriented
Decreased reasoning and judgment
Behavioral changes
Increasing confusion
All worse with any stressors
concrete thinking
Let’s remember!
Approach Strategies
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Introduce yourself at each encounter
Use touch as appropriate
Start with the “Soft Approach”
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Smile, warm demeanor
Remain calm, reassuring, RESPECTFUL
Pleasant voice and tones
Go slow
Talk in short, simple sentences; rephrase
Avoid correcting/confrontation
aka CONNECT NOT CORRECT
◦ Actions help when communication may fail: use
gestures, demonstrate, touch affected areas
Comfort Techniques
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Anticipate and meet basic comfort needs
such as continence care, food/fluids,
positioning, room temperature
Give the patient something to hold on to such
as a washcloth, stuffed animal, doll, your
hand, etc.
Food is ultimate distractor
Touch
Sing or play music
Read a prayer, poem, scripture verse
Pharmacological Interventions
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Antipsychotics to manage psychosis
(delusions, paranoia, hallucinations)
Mood stabilizers (for aggression/mania)
Trazadone for sleep
Avoid benzodiazepines to manage
psychosis or agitation
Avoid medications with anticholinergic
properties
Maintaining Safety
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Falls due to impulsivity, confusion
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Compliance with care, may pull at tubes,
resist medications
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Psychosis: hallucinations, misperceptions,
paranoia, delusions
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Home situation: weapons
Identification & Treatment of Pain
Patients with moderate to severe
dementia cannot reliably report pain
 Pain is often under recognized and under
treated in dementia patients
 Pain tolerance does NOT change due to
dementia
 Pain left untreated will lead to challenging
behaviors such as striking out and yelling
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How to Measure Pain?
PAINAD
0
1
2
Breathing
Independent of
vocalization
Normal
Occasional labored
breathing.
Short period of
hyperventilation.
Negative
Vocalization
None
Facial
Expression
Smiling, or
inexpressive
.
Occasional moan or
groan.
Low level speech with
a
negative or
disapproving quality.
Sad. Frightened.
Frown.
Noisy labored breathing.
Long period of
hyperventilation.
Cheyne-stokes
respirations.
Repeated troubled
calling out.
Loud moaning or
groaning.
Crying.
Body
Language
Relaxed.
Tense.
Distressed pacing.
Fidgeting.
Rigid. Fists clenched,
knees pulled up.
Pulling or pushing away.
Striking out.
No need to
console.
Distracted or
reassured by voice or
touch.
Unable to console,
distract or reassure.
Consolability
Warden et al. J Am Med Dir Assoc 2003, 4: 9-15.
Facial grimacing.
Score
Pharmacological Interventions
for Pain
Routine administration of acetaminophen
up to 3 grams daily for mild to moderate
pain
 Use small doses of opioids for moderate
to severe pain
 If pain medications are effective,
they should be ordered routinely NOT
prn
 Use other strategies as well!
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Use the family as appropriate: identify
baseline, changes; effective strategies
 Medic Alert bracelets:
 Other technologies: GPS, radio
transmitters for repeat wanderers
 Community education
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Other considerations