Different Strokes for Different Folks: Variable Approaches to Different Forms of Dementia

1
Different Strokes for Different Folks Variable
Approaches to Different Forms of Dementia

• Julie Feil, MSW, LCSW
• The Memory Center
• Affinity Health System

2
The Goals of The Memory Center

• We see individuals of all ages with all forms of
  memory loss in various stages.
• To identify and provide treatment options for
  those with memory disorders
• To advocate for early detection!

3
Why is the Diagnosis Important?

• It allows us to identify what form of memory
  problem we are dealing with. This results in
• More focused education and support- appropriate
  to family and individual
• More accurate and effective pharmaceutical
  treatment modality choice
• Increased awareness for families and individual
• Rule out treatable causes of dementia

4
It is like Stopping a Rolling Truck!
5
Barriers to Obtaining a Diagnosis

• Belief that it is Just normal aging
• Stigma attached to Alzheimers Disease
• Fear
• Lack of Insight into Problem
• Denial
• Embarrassment

6
Determining the Diagnosis

• Appointment includes
• The Neurological or Medical Examination
• The Neuropsychological Testing
• The Psychosocial Evaluation

7
Possible Diagnosis

• Alzheimers Disease
• Mild Cognitive Impairment
• Probable Lewy Body Dementia
• Vascular Dementia
• Frontotemporal Dementia
• Normal Pressure Hydrocephelus
• Sleep Apnea
• Pseudodementia- Depression
• Epilepsy
• Parkinsons Disease Plus
• Alcohol Related Dementia

8
Imaging Studies

• Extremely helpful tool in diagnosing which
  particular type of memory disorder is likely
  present. A trained physician can now identify
  classic Alzheimers Disease with 98 certainty.

9
Alzheimers Disease
10
What is Alzheimers Disease?

• The most common cause of dementia
• Irreversible, progressive disease
• Affects the brain by destroying neurons first
  in the hippocampus (memory area of the brain)
  then spreading to other areas
• Neuron degeneration is felt to be from plaques
  consisting of beta amyloid proteins that are
  deposited and tangles in nerve cells

11
Is it in the Water?

• Why are so many people getting it is a
  common question.
• We do not know the exact cause nor do we have a
  cure. Latest research is focusing on diet and
  lipids.
• This is a disease that, predominantly affects
  those gt 65.
• As we are living longer, the prevalence is thus
  higher.

12
Neuropsychological Testing

• Following testing, individuals with MCI show an
  isolated memory loss. Those with Alzheimers
  Disease show a pattern of increased difficulty
  with memory, categorical fluency, orientation,
  and emerging problems in construction and
  calculations.

13
Exercise

• Name as many animals as you can in 1 minute
• Measures catagorical fluency
• Individuals with some form of progressive memory
  disorder will score less than 12 and should be
  evaluated.
• A better predictor of Alzheimers disease or MCI
  than the Mini Mental and can easily be used
  quickly as a screen in doctors offices

14
Mild Cognitive Impairment

• Being researched as a likely pre-cursor to
  Alzheimers Disease- consists of mild memory loss
  that appears progressive in nature
• It is crucial that these individuals are assessed
  as early preventative interventions are showing
  promise in delaying the onset or conversion to
  Alzheimers Disease!

15
Assessment Questions

• Short term memory loss?
• Financial management
• Repetitive questions?
• Depression? Anxiety?
• Misplacing items or hiding items?
• Orientation to person, place and time
• Change in ability to perform hobbies or household
  tasks?
• Occupational issues?

16
Depression Screen

• It is also important to address depression using
  a depression screening tool such as the Geriatric
  Depression Scale or Beck Depression Inventory.
• Why? Studies suggest between 20 and 30 of
  dementia patients in early stages develop Major
  Depressive Disorder and between 30-40 in middle
  stages. Not uncommon, depressive symptoms need
  to be monitored closely on a frequent basis and
  treated appropriately.

17
Characteristics - Early

• Short term memory loss and asking questions
  repeatedly are often the first signs
• Inability to complete familiar tasks
• Difficulty learning and retaining new information
• Misplacing items, often in inappropriate places
• A growing awareness of subtle changes may cause
  depression and frustration.

18
Moderate

• Forgetting to turn off stoves, appliances
• Emerging safety concerns
• Problems with calculations and financial
  management
• Inappropriate in public
• More problems communicating, reading, writing

19
Severe

• Severe loss of memory
• May be unable to recognize loved ones
• More hallucinations or delusions
• Void of emotion
• Needs assistance with all personal cares
• Difficulty chewing or swallowing.

20
Treatments

• Cholinesterase Inhibitors are being used to slow
  the progression with good success
• Aricept
• Razadyne
• Exelon
• Other medication often used in conjunction with
  cholinesterase inhibitors (NMDA receptor
  antagonist)
• Namenda

21
Key Psychosocial Issues

• Individuals and families coping with Alzheimers
  Disease require ongoing support as the disease
  progresses.
• A referral to the local Alzheimers Association
  is recommended for ongoing needs
• Although there is staging documented and many
  follow the pattern loosely, everyone has a
  unique, individual experience.

22
Supportive Approaches

• Care partners have various thresholds in terms of
  their ability to manage the care of someone with
  progressive Alzheimers Disease.
• Goal is to tackle each symptom as it emerges and
  seek manageable solutions
• Behavior issues are often signs of unmet,
  unexpressed needs.
• Important to increase activity level and provide
  cognitive exercise as well as physical and
  social activity.

23
The Alzheimers Association

• Excellent organization for all types of memory
  disorders
• Provide support, education, advocacy and
  programming encompassing all aspects of the
  disease to individuals and their care partners.

24
Other Resources for Individuals and Care Partners

• Adult Day Centers
• Home health agencies
• Respite care
• Transportation resources
• Care consultants
• Assisted living options
• County Departments on Aging / Benefit Specialists
• Aging and Disability Resource Centers
• Elder Law Attorney

25
Support Groups

• Support groups are very valuable and take many
  forms. Groups exist for
• MCI patients
• Early onset Alzheimers disease
• Care partners (spouses, family, etc)
• Adult Children of people with Alzheimers Disease
• Early stage Alzheimers Disease

26
Key Resources

• Books and Magazines
• The 36 Hour Day Mace and Rabins
• A Dignified Life The Best Friends Approach to
  Alzheimers Care Bell and Troxel
• Reminiscence magazine (Reiman Public.)
• Aging with Grace - Snowdon
• Learning to Speak Alzheimers - Coste
• Mayo Clinic on Alzheimers Disease - Peterson

27
Resources continued

• Websites
• www.alz.org The Alzheimers Assoc.
• www.alzheimers.org - Alzheimers Disease
  Education and Referral Center
• www.alzstore.com The Alzheimers Store
• www.cwag.org Coalition of WI Aging Groups
• www.dhfs.state.wi.us/aging/dementia - WI Bureau
  of Aging Long Term Care Resources
• www.mayoclinic.com Mayo Clinic Health Info

28
Lewy Body Dementia
29
Lewy Body Dementia

• A progressive brain disease and second leading
  cause of dementia in elderly. (20 of all
  dementia cases)
• Appears to affect men more than women
• Consists of protein deposits or lewy bodies
  that are widespread throughout the brain. Often
  the memory area looks fine on imaging.
• Cognitive decline occurs prior to or concurrent
  with parkinsonian features
• Earlier age of onset than Alzheimers

30
Characteristics

• A probable Lewy Body Disease is defined when one
  meets 2 out of the 3 symptoms
• Fluctuating Cognition with clear variations in
  alertness.
• Recurrent visual hallucinations that are very
  detailed
• Parkinsonism muscle stiffness and rigid, slowed
  movements

31
Other Suggestive Features

• REM sleep disorders vivid dreams, purposeful
  and sometimes violent movements
• Severe sensitivity to neuroleptics (medications
  for psychiatric symptoms)
• Abnormal depth perception problems in
  visuospatial skills
• Mood lability, depression, aggression

32
Neuropsychological Testing

• Individuals with LBD have difficulty in the
  following areas of cognitive thinking
• Orientation
• Construction
• Perception
• Memory

33
Hooper Visual Organization Test

• 30 puzzle pictures
• Indicator of visuospatial skills and posterior
  functioning.
• Shows how we perceive and make sense of the world
  around us.
• Often a good predictor of whether or not someone
  should be retested for driving abilities.

34
Hooper Visual Organization Example
35
Answer

• LIGHTHOUSE

36
Clock Draw Example

• Goal- To draw the face of a clock, put the
  numbers in the correct positions, and indicate
  the time at 1110.

37
Key Psychosocial Issues

• Families and affected person may be dealing early
  on with safety issues involving the physical
  issues, hallucinations, and misperceptions
  (often leading to trouble with driving).
• Also, the inconsistency of symptoms and
  confusion, creates stress as the family never
  quite knows what is coming next.
• Loved one may not recognize family or home at an
  earlier stage.

38
Assessment Questions

• Sleep disturbance?
• Gait disturbance / Falls?
• Appears socially withdrawn at times
• Variable symptoms?
• Hallucinations?
• Disorientation?
• Suspiciousness?
• Wandering?
• Apparent slowed processing verbally and
  physically
• Other behavior problems or aggression?

39
Supportive Approaches

• Families struggle with misperceptions- benefit
  from support of others in same situation (support
  groups). Care partners need respite!
• Often occurs at a younger age- grieve loss of
  retirement plans, etc.
• Individual often very insecure without loved one
• More rapid course than AD
• Physical and communication issues in addition to
  cognitive

40
Common Interventions

• Due to Parkinsonism, individual is at a higher
  fall risk. Need to adapt environment and consider
  a Physical therapy evaluation
• Misperceptions! Eg. May perceive that a black rug
  is a hole, or texture change represents a
  different height/level. Occupational therapist
  evaluation, adjusting home environment, adjusting
  lighting and visual cues
• Wandering Risk easily disorientated- Obtain
  Safe Return
• Driving Issues becomes lost or does not
  recognize once familiar landmarks. Driver
  evaluation and subsequent referral to
  transportation resources suggested

41
Treatments for LBD

• Cholinesterase inhibitors (medications approved
  for Alzheimers Disease) tend to work even better
  for people with LBD
• Parkinsons Disease medications often help with
  the symptoms related to movement
• It is important to diagnose LBD as some
  antipsychotic medications given for
  hallucinations can cause severe reactions in
  patients with this disease. (eg. Haldol)

42
Key Resources

• The Alzheimers Association
• The Lewy Body Dementia Association
• Websites
• www.lewybodydementia.org LBD Assoc.
• www.zarcrom.com/users/alzheimers/odem/od-d.html
  Directory of other Dementias
• www.alz.org The Alzheimers Assoc.

43
The Frontotemporal Dementias
44
Frontotemporal Dementias

• Neurodegenerative changes in the frontal and
  temporal lobes of the brain
• Several types depending on which areas show
  damage eg. Picks disease (involves only frontal
  lobes)
• Occurs between the ages of 35 and 75 years
  (younger than AD and LBD) Some forms are genetic.
• Many early research programs are focusing on the
  frontotemporal dementias and possible
  reversible causes

45
Characteristics

• There is generally an early loss of personal
  awareness and sometimes an increase in social
  disinhibition and mood swings.
• Depression is common
• Often diagnosed at an earlier age, therefore
  occupational problems may exist.
• Family members are usually quite frustrated and
  require special counseling or support
• More rapid progression

46
The Frontal Lobe - the Gatekeeper

• People who suffer from the FTDs may exhibit
  inappropriate behaviors in public, be less
  inhibited, may show mood swings, or may become
  quite the opposite- more depressed, apathetic
  and socially withdrawn.

47
Neuropsychological Testing

• Frontal area involves the doing part of the
  brain- executive functioning thus testing shows
  difficulties in the areas of
• Behavior
• Reasoning and Judgment
• Planning
• Initiation

48
Neuropsychological testing continued

• Temporal Area involves speech and language thus
  testing reveals difficulty with
• Naming
• Comprehension
• Word finding
• Speech (aphasia often noted)

49
Example Boston Naming Test
50
Key Psychosocial Issues

• Loss of Insight Often people with frontotemporal
  dementias do not have insight into their
  difficulties. This makes it more challenging for
  families to provide care and that care is
  occasionally met with resistance
• Compulsive behaviors
• Lack of empathy for others- Often the care
  partner desires an acknowledgement for their hard
  work that never comes.

51
Assessment Questions

• Judgment and Insight
• Decision making, impulsivity
• Mood changes depression, apathy
• Alteration in planning and initiation
• Susceptible to sweepstakes
• Compulsive behaviors
• Speech and language issues
• Socially or sexually inappropriateness
• Work related problems

52
Supportive Approaches

• Often the disinhibition and behavior changes
  combined with the lack of insight put care
  partners in very difficult situations. Families
  benefit greatly by connecting with others.
• Examine behaviors and look at underlying needs
  that are unexpressed or the emotions behind the
  behaviors. Document approaches and redirections
  that work.
• Compulsive behaviors can be draining on loved
  ones.
• Need to choose battles wisely!

53
Communication

• As the temporal lobes become damaged, one will
  often will see changes in ability to express self
  and converse with others.
• A referral to a speech therapist and
  communication books may be helpful

54
Treatments

• The cholinesterase inhibitors (Alzheimers
  medications) work in approximately 1 in 3
  patients with FTD. We are not sure why.
• SSRIs or specific anti-depressants are being
  investigated as chemically beneficial and also
  help control behavior symptoms and accompanying
  depression

55
Key Resources

• Books
• The 36 Hour Day Mace and Rabins
• What if its Not Alzheimers? A Caregivers Guide
  to Dementia Radin and Radin
• Websites
• www.alz.org The Alzheimers Assoc.
• www.ftd-picks.org The Assoc. for Frontotemporal
  Dementias

56
Vascular Dementia
57
Vascular Dementiaor Multi Infarct Dementia

• Caused by hardening of the arteries or mini
  silent strokes in the brain
• The blockages of the small arteries of the brain
  caused by poor blood flow. Can be prevented by a
  heart healthy diet and other stroke prevention
  techniques (controlled blood pressure and
  cholesterol)
• More common in those with Alzheimers Disease as
  a co-existing problem.

58
Characteristics

• Early on there may be changes in
• Memory and cognition
• Decision-making
• Sleep disturbance
• Apathy
• Sensory Loss
• More physical limitations
• Language problems

59
Assessment and Approaches

• Any or all of the above symptoms or approaches
  mentioned may apply dependent on where the damage
  has occurred in the brain.
• A clear differentiation of diagnosis is thus
  important.

60
Treatments

• Goal is to prevent further strokes through diet
  and exercise.
• Generally speaking, what is good for the heart is
  good for the brain
• Anticoagulants such as Aspirin, Aggrenox, Plavix,
  or Vit. E are often used.
• Cholinesterase inhibitors are utilized Razadyne
  has been approved for use and has shown benefit
  in those with Vascular Dementia

61
Summary

• There are many kinds of dementia it is
  inaccurate to assume Alzheimers Disease prior
  to a complete diagnostic assessment.
• It is important to determine which type of memory
  loss one has as there are various treatments,
  prognosis, and expectations related to each.
  Some are also preventable!
• Each form has its own unique effects on family
  and care partners. It is important to tailor our
  approach to that individuals needs.

62
What Comes First?
Alzheimers Disease Memory, repetition, confusion
Lewy Body Dementia Hallucinations, variability, movement problems
Frontotemporal Dementias Behavior changes, apathy, language problems
Vascular Dementia Depends on area of damage
63
QUESTIONS?
64
FOR YOUR REFERENCE
65
Comprehensive Psychosocial Interventions

• Should include
• Assessment of psychosocial needs of the
  individual with the memory loss and their family.
• Ruling out other possible contributing causes of
  dementia such as depression and alcoholism
• Providing support and counseling as they journey
  through the various stages of the disease
• Providing education and resources to meet ongoing
  needs.
• Advocating for the individual and family.
• Promotion of healthy lifestyle and non-
  pharmaceutical interventions if possible

66
Continued

• Assessments of
• Family History of Memory Loss
• Family Dynamics and Support Systems
• Social and Occupational implications
• Safety and Potential Environmental Barriers
• Communication Issues

67
Continued

• Mental health history
• Activities of Daily Living grooming, dressing,
  and bathing (The Functional Activity
  Questionnaire is often given)
• IADLs- meal preparation, cleaning, shopping,
  money management
• Medication compliance

68
Continued

• Driving
• Financial Planning
• Emerging Behavioral Issues
• Advanced Directives and Financial Planning
• End of Life Care