Transcript Dr. Mark P. Tyrrell, Specialist Consultant in Dementia

UNDERSTANDING AND
MANAGING THE SYMPTOMS OF
DEMENTIA
DR. MARK P. TYRRELL PHD
NURSE CONSULTANT IN DEMENTIA CARE
THE NATIONAL DEMENTIA CARE CONFERENCE
RADISSON BLU ST HELENS HOTEL, STILLORGAN ROAD, BLACKROCK, CO. DUBLIN
2ND MARCH, 2016
DIAGNOSIS OF DEMENTING PROCESSES
The three critical questions that are posed during the
diagnostic process:
• Is memory loss present?
• What could be causing it?
• Are the symptoms and course of the disease consistent
with what we know as Alzheimer’s disease?
THE ANSWER TO THE FIRST QUESTION COMES FROM:
A.
History from the patient and their family
• Changes in memory and function from previous abilities
• Changes in behavior patterns
• Other symptoms such as becoming unstable on their feet, “spells”, or
tremor
• Medical history and medications
• Social history such as degree and/or changes in social interaction, and
supportive family
• How the person functions on a usual day
• Onset and duration of the symptoms
• Waxing and waning of symptoms (good days and bad days)
B. A MENTAL STATUS SCREEN
• Mini-Mental Status Examination
• Clock Drawing
• Figure copying
C. OBSERVATION OF BEHAVIOR AND
INTERACTION WITH OTHERS
-Language Function
-Ability to cope with noise or groups
-Motor Functions
-Evidence of paranoia or psychosis
-Ability to navigate the environment and to see
-The person’s insight into their memory
WHAT COULD BE CAUSING IT?
The goal is to rule out all other potential
causes of presenting symptoms.
ARE THE SYMPTOMS AND COURSE OF THE DISEASE
CONSISTENT WITH WHAT WE KNOW AS ALZHEIMER’S
DISEASE?
• The history and neuropsychological tests will reflect losses in
cognition
• Imaging studies and laboratory tests will be negative.
• The symptoms and behavioral presentation will be consistent
with AD
• Slow onset, insidious progression
• Global losses in cognition, planning, language, memory, and
visual-spatial perception
• Changes in short-term auditory and/or visual memory
-Subtle intensification of negative personality
characteristics
-Decreased ability to inhibit
-Increased self-absorption
-Decreased tolerance for noise, crowds, change
-Increased symptoms with fatigue
-Uneven symptoms presentation
-Episodes of depression
-Gradual loss of functional abilities because of
problems with planning and sequencing
THREE MAIN CATEGORIES OF SYMPTOME EXIST
• Cognitive Losses
• Skills deficits
• Behaviours
BEHAVIOUR
• Patient behaviour problems have consistently
been shown to have the greatest negative
effects on caregiver outcomes, especially
burden (Sorensen et al., 2006, Michon et al,
2005; Hart et al., 2003; Arai et al., 1999;
Dunkin and Anderson-Hanley, 1998).
THE BIOLOGICAL BASIS OF BEHAVIOURAL
SYMPTOMS IN DEMENTIA
RELATIONSHIP BETWEEN
NEUROTRANSMITTERS AND
BEHAVIOUR IN DEMENTIA
CHOLINERGIC/ACETYLCHOLINE
Anatomical Origin
Dysfunction and Behaviour
•
•
Synthesised by choline acetyltransferase in the
nucleus basalis of Meynert of the basal
forebrain.
Function
•
Promotes proper hippocampal and cerebral
cortex function. Necessary for selective
attention, learning, memory, and sleep-wake
cycle
Diminished levels of Ach leads to amnesia,
agitation, and psychotic symptoms. Possible
direct relationship to disease severity.
NORADRENERGIC/ NORADRENALINE (NE)
Anatomical Origin
Dysfunction and Behaviour
•
•
The locus ceruleus located in the rostal
pons of the brain (brain stem)
Function
•
Modulates mood and stress response.
Produces psychotic symproms
High levels of NE leads to
hypervigilance, decreased appetite,
insomnia, anxiety, agitation and
psychosis. Low levels of NE leads to
depressed mood.
SEROTONERGIC/SEROTONIN
Anatomical Origin
•
The raphe nuclei in the brain stem
Function
•
Regulation of body temperature,
Cardiovascular system, respiratory
system, sleep/alertness, mood,
aggression, sensory perception, sexual
behaviour, and feeding behaviour.
Dysfunction and Behaviour
•
Low levels of Serotonin leads to
anxiety, agitation, increased
psychomotor activity, insomnia,
psychosis and depressed mood.
DOPAMINERGIC/DOPAMINE
Anatomical Origin
Dysfunction and Behaviour
•
•
The substantia nigra in the brain stem
with projections directly communicating
with the frontal lobe, limbic system, and
motor areas.
Function
•
Regulated emotional response (limbic
system), executive functions (frontal
lobe) and complex movements (motor
striatum)
Decreased levels of Dopamine leads to
difficulty initiating movement, rigidity,
postural abnormalities, parkinsonian
tremor (akinesia or bradykinesia),
blunted affect and apathy.
ASSOCIATION OF AREAS OF BRAIN
PATHOLOGY TO BEHAVIOURAL
CHANGES IN DEMENTIA
LIMBIC SYSTEM
Function
Dysfunction
• Emotions
• Memory dysfunction, no
affective dimension to memory,
apathy, unstable affect, and
personality changes
HIPPOCAMPUS
Function
Dysfunction
• Storage of short-term memory
• Poor learning ability, memory loss
OCCIPITAL LOBE
Function
Dysfunction
• Visual Processing
• Blindness, loss of depth
perception, colour agnosia (lack of
recognition) and persistent after
images
FRONTAL LOBE
Function
Dysfunction
• Organize words into fluent
• Difficulty using little words (in,
speech.
on, he, she, or).
• Changes in personality,
judgment and behaviour
PARIETAL LOBE
Function
Dysfunction
• Association area for
• Alexia (inability to read),
integrating sensory input
agraphia (inability to write),
neglect syndrome, inability to
perceive pain. Agnosia,
apraxia, aphasia, visualspatial disturbances, loss of
executive functions, psychosis.
TEMPORAL LOBE
Function
Dysfunction
• Recognition and comprehension • Agnosia, apraxia, aphasia,
of sensory input, hearing
memory consolidation,
association of memory, thought,
perception and emotion.
visual-spatial disturbances, loss
of executive functions,
disorientation in space and
time, psychosis
A NUMBER OF CONCEPTUAL CARE MODELS EXIST
WHICH HELP ONE UNDERSTAND KEY ASPECTS OF
DEMENTIA FROM A PSYCHODYNAMIC PERSPECTIVE
AND WHICH ASSIST THE NURSE OR CAREGIVER TO
ENSURE THAT THE CARE OF THE PERSON WITH
DEMENTIA IS PERSON-CENTRED. IN PARTICULAR,
THESE MODELS HELP EXPLAIN MANY OF THE
BEHAVIOURS IN DEMENTIA EMPHASISING THAT
THESE BEHAVIOURS ARE NOT JUST A PRODUCT
OF THE PERSON’S NEUROLOGICAL IMPAIRMENT.
KITWOOD’S ENRICHED MODEL OF DEMENTIA
• While Kitwood’s (1997) Enriched Model of Dementia
acknowledges that the primary cause of problems for the person
with dementia stems from their neurological impairment, it also
recognises that other factors play a role in determining how the
person with dementia lives with their illness. Hence the model also
takes into account factors such as the person’s level of health and
physical fitness; their life history and personality, and their social
psychology, suggesting that it is the complex interplay between
these factors plus the persons degree of neurological impairment
that determines how their dementia affects the way they live.
THE INSPIRATION FOR THE MODEL AROSE FROM
KITWOOD’S OBSERVATION THAT SOME PEOPLE
WITH DEMENTIA WHO HAD CONSIDERABLE
NEUROLOGICAL IMPAIRMENT SEEMED TO
FUNCTION BETTER AND HAVE A BETTER QUALITY OF
LIFE THAN OTHERS WHO HAD A LESSER DEGREE OF
NEUROLOGICAL IMPAIRMENT. KITWOOD
HYPOTHESISED THAT THE SOCIAL AND
PSYCHOLOGICAL ENVIRONMENT IN WHICH THE
PERSON WITH DEMENTIA LIVES COULD BE
SUPPORTIVE OR DAMAGING TO THEIR WELLBEING.
HE USED THE TERM “MALIGNANT SOCIAL PSYCHOLOGY”
(MSP) TO DESCRIBE THE DAMAGING EFFECTS OF THE
NEGATIVE ATTITUDES AND PREJUDICES OF OTHER PEOPLE
ON SOMEONE’S PERSONHOOD, AND THE OPPOSITE
TERM “POSITIVE PERSON WORK” (PPW) TO DESCRIBE
HOW ONE COULD UPHOLD THE PERSONHOOD OF AN
INDIVIDUAL WITH DEMENTIA. THE GOAL THEREFORE IS TO
MAXIMISE INTERVENTIONS THAT INCORPORATE ASPECTS
OF PPW, AND MINIMISE THOSE THAT LEAD TO MSP. IN
OTHER WORDS TO MAINTAIN A SUPPORTIVE SOCIAL
ENVIRONMENT (KITWOOD, 1997).
THE NEED-DRIVEN DEMENTIA-COMPROMISED
BEHAVIOUR MODEL (NDB)
• The model suggests that these behaviours are in fact an
attempt by the individual to communicate their unmet
needs and hence, caregivers can explore these behaviours
to develop interventions that may enhance the quality of
life of the person with dementia.
IN THIS MODEL BEHVIOURS ARE SEEN AS AN
INTERACTION BETWEEN “BACKGROUND” AND
“PROXIMAL” FACTORS (MITTY & FLORES, 2007). THE
FORMER ARE RELATIVELY SET AND HENCE NOT
AMENABLE TO MODIFICATION. THESE INCLUDE
NEUROLOGICAL PATHOLOGY; PHYSICAL HEALTH
STATUS; PRE-MORBID PERSONALITY; AND BOTH
LANGUAGE AND FUNCTIONAL ABILITY
PROXIMAL FACTORS ON THE OTHER HAND ARE
LESS FIXED AND HENCE CAN BE USED TO TARGET
INTERVENTIONS. THESE FACTORS INCLUDE UNMET
PSYCHOSOCIAL NEEDS (E.G. THE NEED FOR
INCLUSION, COMPANIONSHIP, ATTACHMENT);
UNMET PHYSIOLOGICAL NEEDS (E.G. THE NEED
FOR COMFORT RELIEF FROM PAIN); AND QUALITY
OF THE PHYSICAL AND SOCIAL ENVIRONMENT
(E.G. NOISE, OVER OR UNDER STIMULATION).
THE INTERACTION BETWEEN THESE FACTORS
RESULTS IN NEED-DRIVEN DEMENTIACOMPROMISED BEHAVIOURS. THE MODEL POSITS
THAT THIS IS PERHAPS THE MOST INTEGRATED
RESPONSE THAT A PERSON WITH DEMENTIA CAN
MAKE GIVEN THE NATURE AND LIMITATIONS OF
THEIR ILLNESS (KOLANOWSKI, LITAKER AND
BAUMANN, 2002).
UNFORTUNATELY HOWEVER, MANY OF THESE
NON-VERBAL BEHAVIOURS ARE SEEN AS NEGATIVE
AND HENCE ALL TOO OFTEN, INTERVENTIONS
FOCUS ON TRYING TO ELIMINATE THEM RATHER
THAN TO UNDERSTAND WHAT THEY MIGHT MEAN,
OR WHAT THE PERSON IS TRYING TO
COMMUNICATE.
THE KEY TO USING THIS MODEL THEREFORE IS TO
EXPLORE THE PROXIMAL FACTORS IN DEPTH IN
ORDER TO GAIN AN UNDERSTANDING OF THE
PROCESSES THAT UNDERPIN THEM AS THIS WILL
ASSIST IN THE IDENTIFICATION OF INTERVENTIONS
TO MEET THE PERSON’S UNMET NEEDS
(KOLANOWSKI, LITAKER AND BAUMANN, 2002).
THE PROGRESSIVELY LOWERED STRESS THRESHOLD
MODEL (PLST)
• The PLST model proposes that a person has a stress
threshold that is firmly established by adulthood but which
can be temporarily altered during times of illness, or
permanently during episodes of brain damage as is the
case in dementia.
NORMALLY, ADULTS HAVE A RELATIVELY HIGH THRESHOLD
TO STRESS. PEOPLE WITH DEMENTIA HOWEVER, HAVE A
DIMINISHED ABILITY TO INTERACT WITH THEIR
ENVIRONMENT. THEY FIND THINGS IN THEIR
ENVIRONMENT CONFUSING BECAUSE THEIR BRAIN IS NO
LONGER ABLE TO PROCESS INFORMATION ACCURATELY.
CONSEQUENTLY, THEY HAVE A HEIGHTENED POTENTIAL
FOR ANXIETY AND DYSFUNCTIONAL BEHAVIOUR- THEIR
STRESS THRESHOLD IS LOWER (HALL AND BUCKWALTER,
1987).
EFFECTS OF STRESS DURING A 24-HOUR DAY IN
THE PERSON WITH DEMENTIA
Dysfunctional behavior
Stress threshold
Anxious behavior
AM
Noon
PM
Night
Normative behavior
PLST SOURCES OF STRESS
• Fatigue.
• Many competing stimuli:
-Noise.
-Television; radio; public address.
-Too many people.
-Too many things going on at
once:
Eating dinner + being given medicines + background music playing +
visitors calling.
PLANNED ACTIVITY LEVELS FOR THE PERSON WITH
DEMENTIA TO MINIMIZE THE EFFECTS OF STRESS.
Dysfunctional
behavior
Stress threshold
Anxious behavior
Normative behavior
AM
Noon
PM
Night
PLST SOURCES OF STRESS
• Physical stress:
-Illness; side effects of medicines.
-Hunger; thirst; discomfort.
• Changes:
-Different caregiver.
-Change in routine.
-Change in environment.
PLST SOURCES OF STRESS
• Change in environment:
Internal: Hunger; pain; constipation.
External: Noise; Stimulation; change in decoration.
PLST SOURCES OF STRESS
• Demands that exceed abilities:
-Decisions that are too complex.
-Tasks that are beyond abilities.
• Negative & Punitive feedback:
“Don’t do that!”
“Your parents are dead.”
“But this IS your house!”
“No, you are not going to work.”
• The model recommends that caregivers establish simple routines
and stick to them, that they assess stressors in the person’s
environment on an on-going basis, and that they eliminate or
modify these in order to make the world appear less stressful.
PLST: CARE PLANNING
•
Reduce ENVIRONMENTAL STRESS:
-Caffeine.
-Misleading stimuli.
-Unending spaces.
-Unnecessary noise.
-Extra people.
-Large rooms.
PLST: CARE PLANNING
• Compensate for the person’s lost abilities by adjusting your APPROACH.
-Use calm consistent approach and routine.
-Do not try to reason.
-Do not ask to “try harder.”
-Do not try to teach new routines/skills.
-Do not try to get the person to recover lost skills.
PLST: CARE PLANNING
-Eliminate “you are wrong” messages.
-Distract rather than confront.
-Simplify your communication.
-Use Validation rather than Reality Orientation.
VALIDATION APPROACHES
• Do:
-Distract them to a different subject or activity.
-Accept the blame for misunderstandings (even when its not
your fault):
“I’m sorry, I didn’t mean to frighten you.”
“I’m sorry if that hurt.”
REMEMBER!
Dementia is INCURABLE but not UNTREATABLE!
• Preserve remaining abilities.
• Avoid unnecessary stress.
• Treat overlapping illnesses- may make symptoms worse.
Thank You!