Dementia Specialist Training

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Dementia Specialist Training

• Linda L. Buettner, Ph.D.,CTRS
• Florida Gulf Coast University

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Four parts in todays program

• Basic information about diseases causing dementia
• Communication skills needed by the Dementia
  Specialist
• Behavior management skills needed by the Dementia
  Specialist
• Using activities to help.

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What is dementia anyway?

• Syndrome a group of signs and symptoms that
  cluster together without one specific cause
• Over 70 different diseases cause it
• Alzheimers disease is the most prevalent cause
• Alzheimers disease makes up about 50

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What is Alzheimers disease???

• Progressive, neurological illness in which brain
  cells are destroyed
• The destruction results in structural and
  chemical changes in the brain
• There is no single cause
• There is no cure
• Treatments are limited

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What are the early warning signs

• Recent memory loss that effects job performance
• Difficulty performing familiar tasks
• Problems with language
• Disorientation to time and place
• Poor judgment
• Problems with abstract thinking
• Misplacing things
• Changes in mood or behavior
• Personality changes
• Loss of initiative

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Symptoms two distinct types

• Psychiatric/behavioral
• Depression (mood)
• Psychosis (delusions and hallucinations)
• Major personality and behavioral changes
• Restlessness and agitation
• Apathy

• Cognitive
• Amnesia
• Aphasia
• Agnosia
• Apraxia

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AD does not come on suddenly!

• Insidious onset
• Gradual decline
• Recent memory impaired first
• Often 1-2 years before seeking medical attention

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Stage 1- Early stage

• 2-5 years
• decreased ability to learn new things
• difficulty concentrating
• may not be able to manage checkbook
• may repeat things
• may get lost in familiar surroundings
• knows there is a problem

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Stage 2- Confusional Stage

• Shows poor judgment
• Often disoriented and withdrawn
• May not seem interested in past hobbies or social
  contacts
• Appears paranoid and may accuse others of
  stealing or hiding things.
• Sometimes restless (or) and aggressive
• Lasts 3-12 years

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Stage 3 - Dependent stage

• Most difficult for caregivers
• Communication becomes a serious problem
• Understanding others is difficult
• Significant loss in daily living skills
• Needs help with personal care yet is angry,
  confused, embarrassed, and sometimes aggressive
• Lasts 2-5 years

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Stage 4 - Terminal stage

• Lasts a year or more
• Substantial physiological decline
• Requires skilled nursing care
• Unable to walk, talk, or move around safely
• At high risk for aspiration

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How big is the problem?

• Four-Five million Americans
• 110 over 65
• 12 over 85
• 13 families
• 60-70 nursing home residents
• Cost to families is enormous

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How is it diagnosed?

• Memory Clinics - diagnostic centers
• Physical exam
• Routine lab tests and EKG
• Brain imaging studies
• Personal and family history
• History of medication use and alcohol use
• Neurological exam
• Assessment for depression and cognitive
  functioning (Scales Geriatric depression scale -
  MMSE)
• Sort out type of dementia, depression, delirium
  and establish baseline.

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Other common forms of dementia

• Vascular dementia (small strokes)
• AD and vascular dementia
• Lewy body dementia (proteins)
• Parkinsons dementia
• Alcohol related dementia (Korsakoffs)
• Dementia related to advanced cancer or AIDS
• Diabetes and dementia
• Chronic disease to manage

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Depression

• Defined as depressed mood, loss of interest or
  pleasure in usual activities and at least 4 of
  the following changes in weight or appetite,
  disturbed sleep, motor retardation or agitation,
  lack of energy, feelings of worthlessness,
  suicidal thoughts, difficulty thinking or
  concentrating
• Must occur for at least 2 weeks

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Delirium in the elderly

• Defined as acute or sub-acute alteration in
  mental status, that comes on fast, caused by a
  reversible or temporary condition.
• The longer the individual has delirium the more
  likely there will be serious complications.
• With appropriate treatment most get better.

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Normal Aging Brain Images
Whole brain atlas, 2003
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Vascular Dementia Images
Whole brain atlas, 2003
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Alzheimers Image
Whole brain atlas, 2003
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Pathological hallmarks of AD

• Brain atrophies
• Plaques form
• Tangles develop
• Cells with memories are lost
• Anatomical drawings
• Temporal lobe
• Cerebral cortex (handout)

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Brain Atrophy
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Senile Plaques
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Neurofibrillary Tangles
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Lewy bodies
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Who gets AD?

• Usually between 40-90
• 70 of nursing home residents have dementia
• Majority are women
• 2/3 are cared for at home
• live 8-10 years after diagnosis
• Most will have a combination of the
• 3 Ds (dementia, depression, delirium) over the
  course of disease

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Treatments

• Five approved medications
• Tacrine (rarely used)
• Aricept,
• Reminyl,
• Exelon,
• Namenda
• Roughly cost the same but vary in side effects

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How do you protect yourself?

• Head injuries
• Toxins
• Brain Health work out (brain body) and eat
  brain healthy diet
• New link with Diabetes and glucose in the brain
• Prevention is the best approach

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How can you help?

• Activity to stimulate the use of the brain and
  the body.
• Activity to encourage movement.
• Activity for social connections.
• Activity to provide joy.

Pop quiz 1
Jot down your ideas for each (stimulate mind
body, movement, social connections, joy) What
little thing can you do?
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• Communication and the Four As

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Communication

• A process by which information is exchanged
  between individuals through a common system of
  symbols, signs, or behaviors.
• The areas of the brain used for communication
  are often affected early in the disease process
  of Alzheimers.

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Understanding what is heard .
Dr. Richard Powers, www.Alzbrain.org
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Verbal communication

• Organizing the message
• Sending the message
• Receiving the information
• Processing the information
• Organizing a response
• Responding

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Non-Verbal Communication

• Body language
• Show the person take 2-3 minutes
• Facial expression
• Gestures
• Touch
• Tone of voice (you are on a schedule but you have
  to take your time)

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Team Project

• Describing and Drawing Activity

Pop Quiz 2
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Why problems occur
Early
cant remember
Amnesia
cant understand words
Aphasia
cant recognize objects/faces
Agnosia
cant do familiar motor tasks
Apraxia
Late
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Memories
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Talking using words
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Temper and emotions...
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Alzheimers kills brain cells
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Because of these symptoms the person cannot
always

• Express needs
• Cooperate with your wishes
• Recognize familiar objects or people
• Understand what an object is used for
• Respond to reason
• Learn new things
• Make complex decisions

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The individual can

• feel pain and not always be able to express it
• experience emotions (sadness, fear, loneliness)
• enjoy hobbies, recreational interests, favorite
  foods, and music (you might need to adapt)
• respond to voice and eye contact
• Understand human kindness and compassion.

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What you need to understand

• And use the proper techniques
• Based on the 4 As

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Amnesia

• Memory
• Recent
• Short term
• Remote

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Aphasia

• Understanding words language
• Receptive
• Expressive

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Agnosia

• Recognizing objects faces

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Apraxia

• Familiar motor skills

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Tips for good communication

• Do a 3 second assessment
• Eliminate noise and distractions
• Approach the person from the front
• Establish and maintain eye contact
• Keep things simple and manageable
• Allow for choices
• Allow plenty of time for response
• Use familiar words and cues
• Put up signs or give cues in writing
• Communication board (individualize) or wallets
• Demonstrate actions

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Violet
Anna
Three second assessment
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Key images to point out needs
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Practice
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Grooming TipsRemember we want to do things for
ourselvesDressing, Bathing, Eating, Toileting,
Moving, Recreation
Reminders
Amnesia
Set up supplies and show
Aphasia
Demonstrate use - start movement
Agnosia
Physically assist
Apraxia
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How do you know how much the individual
understands?

• Do the 6 Point Communication Assessment
• tell her to raise her arm (1 pt.)
• ask what day it is (1 pt.)
• ask what year it is (1 pt.)
• ask her to identify a pen and a watch (1 pt.)
• tell her to pick up the spoon (1 pt.)
• repeat today is a pretty day (1 pt.)
• Less than 3 points use a hand mirror to see if
  the individual recognizes herself

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What you can do to relieve disturbing behaviors

• First Describe them accurately

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Agitated Behaviors

• We want to prevent these from occurring
• If they do we want to calm those who are agitated
• DOES THIS TELL YOU ENOUGH?

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Passive Behaviors

• To prevent passive behaviors
• To alert those who are passive
• WHAT DOES THIS TELL YOU?

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Apathy or Passivity

• Lack of interest
• Lack of motivation,
• Withdrawal
• Social isolation
• Depression
• Loss of function
• WHAT DOES THIS TELL YOU?

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Psychiatric

• Depression
• Anxiety
• Psychosis
• Paranoia
• Delusions
• Hallucinations

Psychiatric evaluation and 11
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Physically non-aggressive

• Motor-restlessness
• Repetitive movements
• Wandering
• Rummaging, hoarding
• Hiding things
• Intrusive
• Spitting
• Pacing
• Picking,scrubbing, and rubbing

Crave sensory motor activity
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Physically aggressive

•   Hitting
• Biting
• Kicking
• Pushing
• Destroying things
• Self-injurious.

Space-Pain-Threatened
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Verbally Non-aggressive

• Vocalizing
• Repetitive questioning
• Complaining
• Screaming
• Weepy, crying
• Moaning

Assess for pain depression --Need to feel needed
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Verbal aggressive

•   Arguing
• Yelling
• Threatening
• Irritability
• Cursing
• Angry outburst.

Past personality-chronic mental health
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Other behaviors

• Refusing care
• Refusing medications
• Refusing foods or liquids
• Socially inappropriate
• Disrobing
• Urinating in public or somewhere other than a
  toilet

• Gluttony
• Pica (eating non-edibles)
• Sleep-wake disturbance
• Late day restlessness
• Sexually inappropriate
• Disinhibition

Now that you described the behavior....
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Second thing Look for an unmet need

• Lonely
• Afraid
• In Pain
• Thirsty or hungry
• Craving activity or stimulation
• Need to go to the bathroom
• Need to change position
• Need to get away from...

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2a. Needs related to health

• Acute illness (cant tell you)
• Effects of medicines (more confused)
• Changes in hearing or vision
• Dehydration (dry lips)
• Constipation (abdominal symptoms)
• Pain (rubbing)
• Depression (crying or screaming)

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2 b. Needs related to the environment

• Too much noise or clutter
• Excessive stimulation
• Poor sensory environment
• No orientation or cues
• Environment too large or unfamiliar
• Unstructured environment

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2c. Needs related to the task

• Task is too complicated
• Too many steps at a time
• Not modified for increasing impairment
• Task unfamiliar
• Too boring, childlike,
• or useless

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2d. Needs related to communication

• No communication
• Failed to get attention-startled
• Too much verbal information
• Too fast or too loud or too soft
• No cues or gestures or demonstration used
• Complicated language

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Third thing Do some problem solving

• When did the problem occur?
• What triggered it?
• Look at time of day?
• Did you make an error in your approach?
  (Caregiver technique)
• Develop a list of alternative strategies to try

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Re-set the schedule
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Time of Day of the Problem

• Morning
• Afternoon
• Evening
• Night
• MIXED Behaviors

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Simple methods to manage the daily routine

• Individualize (see handout about Marjorie)
• Use a large clock, calendar, and schedule
• Find out the residents prior routines interests
• Stick with the same routine each day
• Simplify activities and encourage self-care
• Supervise with dignity-use system of least
  restrictive prompts (more details later)
• Structure activities - use planned lists for
  ideas
• Do NOT make the mistake of sterilizing the
  environment - stimulation activity are vital!

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Always do a 3-second assessment

• Stop 5-6 feet away
• Greet the resident and observe body language
  (feet, legs, hands, and face)
• Decide on your best approach based on what you see

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Use the 5 Rs for responding...

• Reassess
• Reconsider your approach plan
• Redirect if possible
• Routine and structure
• Reassure the confused individual

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Balance the day
Things for survival
Time to socialize
Interesting activities
Family
Rest
Helping others
Choices
Kovach, 2003