Transcript Dementia Boot Camp Part 1 & 2 - Duke Center of Geriatric Nursing

Dementia Boot Camp
Melanie Bunn, RN, MS, GNP
[email protected]
Geriatric Grand Challenge Institute: Dementia Care
Duke University School of Nursing
March, 2013
What are the current
issues/systems of care?
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Risk based dementia prevention
Diagnosis (Medicare wellness visit)
Public awareness/community engagement
Care coordination & transitions
Safety issues
Managing & preventing comorbidity
Behavioral management/skills
End of Life Care
Non-compliance
• Acute illness 20% to 40%
• Chronic illness 30% to 60%
• Prevention 80%
• See the pattern? Why?
Christensen AJ. Patient adherence to medical treatment regimens: bridging the
gap between behavioral science and biomedicine. New Haven: Yale University
Press; 2004. Current perspectives in psychology.
Risk Based Dementia
Prevention
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Nutrition
Mental exercise
Physical activities
Stress management
Other lifestyle choices
http://www.alzprevention.org/
Alternative Approach:
Motivational Interviewing
Diagnosis:
Previous Approaches
• “Screening” at health fairs
• Evaluation when symptoms are noticed
– Lack of insight/cooperation with assessment
– Absence of baseline
• Attitudes as a barrier to screening
– Untreatable
– Part of aging
– Something to be hidden
Medicare Annual Wellness Visit
• Normalizes cognitive assessment and
screening
• Sets individual baseline
• Identify early changes
• Standardizes & simplifies approach
• Research into tools, phone screening
Medicare Annual Wellness Visit
http://www.alz.org/professionals_and_researchers_14899.asp
• Cordell CB, Borson S, Boustani M, Chodosh J, Reuben D, Verghese
J, et al. Alzheimer's Association recommendations for
operationalizing the detection of cognitive impairment during the
Medicare Annual Wellness Visit in a primary care setting.
Alzheimer's & Dementia: The Journal of the Alzheimer's
Association. 2012. In Press.
• Alzheimer's Association Medicare Annual Wellness Visit Algorithm
for the Assessment of Cognition
• Tools highlighted in the recommendations
• Medical Learning Network article on the Annual Wellness Visit
(billing information on pages 4-6)
• Medicare Annual Wellness Visit Fact Sheet
Dementia update
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Prevalence
Biology
Genetics
Risk factors
Detection
• Developing
treatments
• Testing therapies
• Caregiving
• Health disparities
http://www.nia.nih.gov/alzheimers/publication/2011-2012alzheimers-disease-progress-report/
Diagnosis
• Physical exam
(Especially neurological & cardiac)
• Lab studies
• Imaging study
• Cognitive evaluation & emotional screen
(What works & what doesn’t work)
• Functional assessment
• Review medications
What could it be?
Identifying underlying issue
Possibilities
• Normal aging
• Mild cognitive impairment
• Acute confusion or delirium
• Dementia
DEMENTIA
Lewy Body
Dementia
Alzheimer’s
Disease
Vascular
(Multiinfarct)
Dementia
FrontoTemporal
Lobe
Dementia
70-80
Other
Dementias
AD: Basic info
• Changes happen over months and years,
not hours or days
• Usually, changes happen in a slow,
steady, predictable manner
• STRUCTURAL and CHEMICAL changes:
– Structural: Plaques & tangles
– Chemical: Neurotransmitters drop
• Medications impact chemical changes,
NOT structural changes
AD: Memory
• Early on: Storage, not retrieval problem
• Later on: Storage and retrieval
• Retained: Emotional and motor memory
AD: Common changes
• MOOD
– Blame others: defensive
– Blame self: depressed
– Impulsive or indecisive
• MOBILITY
– Not impacted until later in disease
• COMMON ISSUES
– Getting lost
– Making mistakes: words, finances, decisions
– Can be explained…but pattern immerges
Alzheimer’s
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New info lost
Recent memory worse
Problems finding words
Mis-speaks
More impulsive or indecisive
Gets lost
2 major types: YOUNG or TYPICAL onset
Notice changes over 6 months – 1 year
Vascular disease
• Changes depend on where in the brain
damage occurs so…
– Each person and each disease is different
– Changes are often sudden, inconsistent and less
predicable
• Not a brain disease: a circulation disease
– Big change, improvement, plateau, big change
(swelling then absorbed or revascularization)
– Associated with diabetes, heart disease, high blood
pressure
Vascular Dementia
• Can have bounce back & bad days
• Judgment and behavior ‘not the same’
• Spotty loss (memory, mobility)
• Emotional & energy shifts
• Memory, mood & mobility can all be impaired…or not!
LBD
• Fine motor changes
– Using hands
– Swallowing
• Mobility problems
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Rigidity
Tremor
Falls
Periodic limb
movements
• Fluctuations in abilities
& function (fine one
day, impaired the next)
• Other changes
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Syncope
Hallucinations
Delusions
Nightmares
Insomnia
Memory inconsistent
(temporary loss of LT)
– Attention/executive
function
– Visual spatial changes
– REM sleep BD
LBD diagnosis (LBDA website)
DEMENTIA plus
• 3 core symptoms:
– fluctuating cognition (bad days & good days)
– vivid visual hallucinations and/or delusions
– motor dysfunction
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• 3 suggestive symptoms
– REM sleep behavior disorder with acting out of
dreams or excessive daytime sleepiness
– abnormal brain CT/MRI
– extreme sensitivity to antipsychotics/other
psychotrophic medications
LBD: Medications
Reactions can be extreme & unpredictable or
opposite than expected
• Parkinson’s Disease (tremors)
– Don’t always help
– Make thinking and hallucinations worse
• Antipsychotics (hallucinations)
– Don’t always help
– Make mobility worse
• AChEI/NMDA (thinking & behaviors)
• Antidepressants
Fronto-Temporal Dementias
• Many types
• Frontal – impulse and behavior control
loss (not memory issues)
– Says unexpected, rude, mean, odd things to
others
– Dis-inhibited – food, drink, sex, emotions, actions
– OCD type behaviors
– Hyperorality
• Temporal – language loss
– Can’t speak or get words out
– Can’t understand what is said, sound fluent –
nonsense words
Public awareness/
community engagement
• TV/magazine/health care offices public
service ads
• Research/conference blips
• Non-profit local efforts (fund raising/public
awareness)
Public awareness/
community engagement
• These are your communities and why you
are here!!!
• Here’s what I’m doing: community
education programs through ANC, law
enforcement education through CIT,
profession education through ANC, Duke
SON, AHEC sessions
• ANC, AA, AFA are all reaching out
• You have potential to make more impact!!!
Public awareness/
community engagement
• Alternative approaches
• Going to where people are
• Using informal opinion leaders
– Prostate cancer screening in African
American communities
– Churches, barber shops, hair salons
Brain Failure
Structural brain failure
Chemical brain failure
Structural Brain Failure
• One way street
• Depending on type of dementia, changes
happen in different areas resulting in
different changes
Memories
• Losses
– Where & when you are
– What is going on
– Where you want to go
– What you want to do
• Preserved abilities
– Confabulation!
– Emotional memories
– Motor memories
Issues of Understanding
• Losses
– Can’t interpret information
– Can’t make sense of words
– Gets off target
• Preserved abilities
– picks up on facial expression
– picks up on tone of voice
Language Issues
• Losses
– Can’t find the right words
– Not able to say what you mean
– Can’t make needs known
• Preserved abilities – automatic speech
– singing
– swearing
– turn taking
Sensory Changes
• Losses
– Awareness of body and position
– Ability to locate and express pain
– Awareness of feeling in most of body
• Preserved Abilities
– 4 areas can be sensitive
– Any of these areas can be hypersensitive
– Need for sensation can become extreme
Self-Care Changes
• Losses
– initiation & termination
– tool manipulation
– sequencing
• Preserved Abilities
– motions and actions
– the doing part
– cued activity
Issues of Impulses & Emotions
• Losses
– becomes labile & extreme
– think it - say it
– want it - do it
– see it - use it
• Preserved
– desire to be respected
– desire to be in control
– regret after action
Chemical failure
• Fluctuations
• Extremely good moments and…
Extremely bad moments
The 3 major problems
(as I see it)
• Current systems of care are set up BY
logical people FOR logical people
• Reimbursement is based on procedures &
acute care models & doesn’t recognize the
complexity of people with dementia
• Efforts to improve systems of care aren’t
keeping up with the focus on prevention
and treatment
NAPA
• Research – developing new and targeted
approaches to prevention and treatment.
• Tools for Clinicians
• Easier access to information to support
caregivers www.alzheimers.gov,
• Awareness campaign
Alternative Approaches
• Geriatric Grand Challenge Institute:
Dementia Care
• Turning around system care views (insideout? bottom-top?)
• Better communication b/t systems
• Better communication b/t families/informal
and formal
• Smaller group settings
• Adult day programs/PACE
Suggested Next Steps
• Go to the Alzheimer’s Association site and
familiarize yourself with the Medicare
Annual Wellness Visit algorithm and
screening tools
• Download the 2011-2012 Alzheimer’s
Disease Progress Report from the
NIA/NIH Alzheimer’s site
• Review prevention recommendations on
the AFA site