Transcript Dementia

Dementia/ Delirium an
Overview
October 2011
Introduction to Harvest
Healthcare
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Experience. Education. Excellence.
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Harvest is a leading full-service behavioral health provider,
specializing in the delivery of progressive and innovative
consultative behavioral health services for patients and residents
residing in skilled nursing, rehabilitation, and assisted living
facilities. Our multidisciplinary team of highly skilled
professionals work together to offer a broad menu of services
including but not limited to 24-hour prescriber on-call services
and hospitalization support, comprehensive cognitive
assessments, documentation review, OBRA compliance support
and customized educational programs designed for the
individual needs of your facility.
Objectives
This presentation was developed for the
continuing education of health care
providers
 At the conclusion of this presentation the
audience will have a basic understanding of
dementia and delirium, symptoms and
management.
 Mental health care professionals should be
consulted for the treatment of patients with
dementia or delirium.
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Dementia (taken from Latin, originally meaning "madness", from
de- "without" + ment, the root of mens "mind")
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Is a serious loss of cognitive ability in a previously
unimpaired person, beyond what might be
expected from normal aging.
It may be static, the result of a unique global brain
injury, or progressive, resulting in long-term
decline due to damage or disease in the body.
Although dementia is far more common in the
geriatric population, it may occur in any stage of
adulthood.
Dementia
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Is a non-specific illness syndrome (set of signs
and symptoms) in which affected areas of
cognition may be memory, attention, language,
and problem solving.
It is normally required to be present for at least 6
months to be diagnosed; cognitive dysfunction
that has been seen only over shorter times, in
particular less than weeks, must be termed
delirium.
In all types of general cognitive dysfunction,
higher mental functions are affected first in the
process.
Diagnosis of Dementia
The earlier the better as there are
medications that slow the process of
cognitive loss.
 Diagnosis is made through the review of
medical history, review of medical record,
medical evaluation and cognitive testing
with multiple measures.
 MMSE is no longer the standard for
detection as it is unreliable.
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Orientation concerns
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Especially in the later stages of the condition,
affected persons may be:
 disoriented in time (not knowing what day of the week,
day of the month, or even what year it is),
 in place (not knowing where they are),
 and in person (not knowing who they are or others
around them).
Behavioral and psychological
symptoms of dementia (BPSD)
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Dementia is a condition in which individuals
progressively lose cognitive function and, as a
result, often develop difficult behaviors that cause
stress for both patients and their caregivers. These
behaviors, are collectively known as behavioral
and psychological symptoms of dementia (BPSD).
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BPSD include screaming, wandering, resisting
care, hitting, and psychological symptoms such as
depression, psychosis, and sexual disinhibition.
BPSD
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BPSD is prevalent in nursing homes where
67-78 percent of patients have dementia
and, of them, 76 percent exhibit BPSD.
In fact, it is common for patients to be
institutionalized because of BPSD, so
clinicians must become proficient in
assessing and managing these symptoms.
Medications
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Acetylcholinesterase inhibitors: Tacrine (Cognex),
donepezil (Aricept), galantamine (Razadyne), and rivastigmine
(Exelon) are approved by the United States Food and Drug
Administration (FDA) for treatment of dementia induced
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by Alzheimer's disease. They may be useful for
other similar diseases causing dementia such as
Parkinson's or vascular dementia.
N-methyl-D-aspartate Blockers. Memantine
(Namenda) is a drug representative of this class. It
can be used in combination with
acetylcholinesterase inhibitors.
Off-Label Medications
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Antidepressant drugs: Depression is frequently
associated with dementia and generally worsens
the degree of cognitive and behavioral
impairment. Antidepressants effectively treat the
cognitive and behavioral symptoms of depression
in patients with Alzheimer's disease, but evidence
for their use in other forms of dementia is weak.
Anxiolytic drugs: Many patients with dementia
experience anxiety symptoms.
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Although benzodiazepines like diazepam (Valium)
have been used for treating anxiety in other
situations, they are often avoided because they
may increase agitation in persons with dementia
and are likely to worsen cognitive problems or are
too sedating. Buspirone (Buspar) is often initially
tried for mild-to-moderate anxiety. There is little
evidence for the effectiveness of benzodiazepines
in dementia, whereas there is evidence for the
effectiveness of antipsychotics (at low doses).
Antipsychotic drugs: Both typical
antipsychotics (such as Haloperidol) and atypical
antipsychotics such as (risperidone) increase the risk of death
in dementia-associated psychosis.
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This means that any use of antipsychotic
medication for dementia-associated psychosis is
off-label and should only be considered after
discussing the risks and benefits of treatment with
these drugs, and after other treatment modalities
have failed.
In the UK around 144,000 dementia sufferers are
unnecessarily prescribed antipsychotic drugs,
around 2000 patients die as a result of taking the
drugs each year.
Agitation
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One of the greatest impacts on quality of life for
patients with dementia is the presence of agitation
behavior in the middle stages of the disease
process.
More than half of patients with dementia exhibit
some type of "agitation" behavior over the course
of a year, in addition to depression or psychosis.
Experts suggest that the best way to manage
agitation is through environmental and atmosphere
changes rather than medications. Medications are
a last resort.
Agitation
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Behavior management experts define "agitation
behavior" as "inappropriate verbal or motor
activity.”
Non-aggressive Verbal Behavior: Incoherent
babbling, screaming or repetitive questions is
frustrating to the caregiver and family members,
especially as a sign that the person with dementia
is "losing it."
Agitation
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Non-aggressive Physical Behavior: Pacing,
wandering, repetitive body motions,
hoarding or shadowing represent ways for
the person with dementia to communicate
boredom, fear, confusion, search for safety
or inability to verbalize a request for help or
a feeling of pain.
Agitation
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Aggressive Verbal Behavior: Cursing and abusive
language can be shocking when the person with
dementia was previously upright and proper.
Aggressive Physical Behavior: Clearly, physically
aggressive behavior such as hitting, scratching or
kicking can be dangerous or life-threatening to the
caregiver and care recipient.
Agitation
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Men are twice as likely to exhibit
aggressive behavior, especially in the
middle to late stages of the disease, or if
they have major depression.
The degradation of different parts of the
brain causes aberrant behavior. Other
conditions, such as pain, can also lead to it.
Agitation
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Some caregivers cope by ignoring agitation
behaviors. This is one of the worst things to do
since it ultimately makes things worse for both the
caregiver and the person with dementia.
The stress placed on the caregiver at home by
these agitation behaviors often forces premature
placement in a nursing facility, health problems
for the caregiver and lessened quality of life for
both.
Understanding Agitation
Behavior
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Experts say that all types of behavior are forms of
communication. The patient is trying to tell you
something even though the disease has robbed
them of other ways (i.e., talking) of telling you.
They may be expressing depression or pain and
the person does not know how to express it in
words.
Some experts believe that agitation behavior is
"the inability the deal with stress."
Sundowning
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Refers to a state of confusion at the end of
the day and into the night. The cause isn't
known. But factors that may aggravate lateday confusion include:
* Fatigue
* Low lighting
* Increased shadows
Some tips for reducing sundowning:
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Plan for activities and exposure to light during the
day to encourage nighttime sleepiness.
Limit caffeine and sugar to morning hours.
Serve dinner early and offer a light snack before
bedtime.
Keep a night light on to reduce agitation that
occurs when surroundings are dark or unfamiliar.
In a strange or unfamiliar setting such as a
hospital, bring familiar items such as photographs
or a radio from home.
Sundowning
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When sundowning occurs in a care facility, it may
be related to the flurry of activity during staff shift
changes. Staff arriving and leaving may cue some
people with dementia to want to go home or to
check on their children — or other behaviors that
were appropriate in the late afternoon in their past.
It may help to occupy their time during that
period.
Is Behavior Event-Related?
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Organization by the caregiver will help a great
deal in beginning to combat these behaviors:
 Modify the environment to reduce known stressors
(e.g., shadowy lighting, mirrors, loud noises);
 Note patterns of behavior and subtle (and not so subtle)
clues that tension and anxiety are increasing (i.e.,
pacing, incoherent vocalization);
 Dysfunctional behavior often increases at the end of the
day as stress builds as the person becomes tired.
Certain stressors can trigger
agitation behaviors.
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As the caregiver, you have to use all of your
senses to understand the environment and the
behaviors.
Fatigue
Change of Environment, Routine or Caregiver
Affective Responses to Perception of Loss
Responses to Overwhelming or Misleading
Stimuli.
Excessive Demand
Delirium
Fatigue:
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If confusion and agitation increase late in
the day, suspect that fatigue may be a
factor.
Encourage rest or have quiet periods for up
to two times a day.
Change of Environment, Routine
or Caregiver:
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Sameness and routine help to minimize
stress in the patient with Alzheimer’s
Disease.
Affective Responses to Perception
of Loss:
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This means that persons with dementia still
have memories and perceptions of activities
that they used to enjoy. They miss being
able to drive a car, cook or care for children.
Safe activities should be substituted to deal
with grief and loss.
Depression should be treated.
Responses to Overwhelming or
Misleading Stimuli:
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Excessive, noise, commotion or people can trigger
agitation behavior. Researchers have found that
more than 23 people in a group (e.g., dining room
or holiday party) can cause undue stress in a
person with dementia. The television, mirror
image, dolls or figurines may represent extra
people in the environment.
Before medicating with anti-psychotic drugs, the
health care team should consider these
environmental factors.
Excessive Demand:
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Caregivers and families must accept that the
individual has lost (and continues to lose) mental
functions. No amount of quizzing, reality
orientation, "brain exercises," retraining or
pushing them to try harder will improve their
mental capabilities. Indeed, it can cause stress and
a sense of futility.
The best a caregiver can do is provide positive
support and understanding, encourage
independence and assist the individual when they
are unable to perform a task.
Delirium:
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Illnesses such as infections, pain,
constipation, trauma or drug interactions
may cause dementia-like symptoms.
Preventive measures such as good oral care,
nutrition, simplified medication regimens
and adequate fluid intake play an important
role in well-being.
Some Specific "Problem"
Behaviors
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Wandering: Caregivers should understand that
individuals wanders for a reason. The exact reason
may be hard to determine. Nevertheless, locking
him/her in a room or restraining in a chair is
inappropriate. Implement activities and adjust the
environment to relieve agitation if possible.
Minimize all safety risks.
Specific problem behaviors
(BPSD)
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Screaming: Consider medical causes for
screaming that the person cannot verbalize such as
pain, depression or hearing loss.
Gathering/Shopping: An individual with dementia
who rearranges objects around the residence,
hoards or appropriates other’s possessions can be
a disruptive nuisance. Provide the individual with
a "safe" place where s/he can store items (and you
can retrieve them). You may provide the
individual with a canvas "shopping bag."
BPSD
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Pacing: An individual with dementia who
paces incessantly can burn off too many
calories. High-calorie finger foods may help
the problem. You can try to reduce pacing
by providing inviting places for the
individual to sit and relax.
BPSD
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Sexual Aggression: Try to determine whether the
sexual gesture is indeed sexual in nature and not
an expression of the need to go to the bathroom.
Refer to psychiatry to determine treatment
options. Medications may not be useful in treating
sexual symptoms.
Symptoms may indicate an atypical dementia such
as Lewy Body Dementia or Pick’s Disease. These
may require different types of psychiatric and
behavioral interventions.
BPSD
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Hallucinations/Illusions: After you have removed
confusing stimuli (e.g., shadowy lighting,
televisions, dolls), refer to psychiatry to assess for
signs of an atypical dementia such as Lewy Body
Dementia or Pick’s Disease.
These may require different types of psychiatric
and behavioral interventions.
What can be done:
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A simplified approach to managing
agitation behaviors can be summed up as:
"Modify the environment, modify the
behavior and medicate as a last resort."
Recent research is starting to show that
some relatively basic interventions can be
used to ease agitation behaviors.
Music Therapy:
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Some studies show that playing calming music or
a favorite type of music can lead to a decrease in
agitation. When used during meals, soothing
music can increase food consumption; when used
during bathing, relaxing or favorite music can
make it easier to give a bath. Experiment with
relaxing, soothing, classical, religious or period
(e.g., 1920’s or Big Band) music.
Exercise and Movement:
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Light exercise, such as chair exercises as directed
by a physical therapist or activities coordinator
each day can help to maintain function of limbs
and decrease problem behaviors. Walking after
dinner several times each week may help reduce
aggression.
When small groups of 3-4 people go on walks, it
may lead to beneficial social interactions such as
singing and talking.
Activities:
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Safe activities are a good way to get back in
touch with their earlier life and find
meaning throughout the disease process.
Activities can reflect either things the
person enjoyed in the past or can reflect
what they did for work.
Socialization:
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Human interaction is essential for people
with dementia. As mentioned, large groups
and most strangers are definitely out. But
you can introduce new individuals as a
"new friend" or companion to spend time
with the person who has dementia.
They can reminisce, converse, walk or
perform activities together.
What can you do?
Help to identify dementia early by
documenting memory loss and confusion.
 Request a cognitive assessment from the
Cognitive Assessment Program at Harvest.
 Practice patience.
 Be a detective and work toward finding the
cause of agitation in an effort to resolve it.
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Thought Provoking Questions:
Can you describe sundowning and name
some potential causes?
 Can you identify some potential causes of
agitation?
 Can you describe the difference between
delirium and dementia?
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