Alzheimer

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Alzheimers Disease and Dementia Care for
Health Plan Case Managers

• Karen Bugg RN LMSW
• Institute for Health Care Studies
• Michigan State University
• August 16th 17th 2010

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What does dementia mean?
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Dementia and the Brain

• Injury to brain cells causes dementia.
• Dementia causes a decline in a persons ability
  to think, understand, and remember and affects a
  persons function.
• Dementia gets worse over time.

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Dementia

• Because of memory loss
• no longer self-sufficient
• requires ongoing help or supervision
• functional dependency

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Activities of Daily Living

• Bathing
• Dressing
• Feeding Self
• Toileting
• Transferring

• Telephone
• Driving
• Shopping
• Meal Preparation
• Managing Finances
• Managing Medications

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Causes of Dementia

• Alzheimers disease is the most common cause of
  dementia.
• Other common causes are
• Vascular dementia
• Dementia with Lewy bodies

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Alzheimers definition

• A progressive degenerative neurological disease.
• Most common form of dementia in the elderly.
• Nearly 75 of all dementia cases.

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Alzheimers in the United States

• 5.3 million people
• One person is newly diagnosed every 70 seconds
• 7th leading cause of death
• Rates are expected to double every 20 years

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Alzheimers Disease - Statistics

• 6-8 of all persons age 65 and older
• 30-50 of all persons age 85 and older
• By 2029, all baby boomers will be at least 65
  years old
• 5.3 million cases currently, will increase to 18
  million by 2040

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Race Ethnicity

• Older African Americans and Hispanics are much
  more likely than older whites to have Alzheimers
  disease and other dementias.

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Michigan

• In 2008, sixty-eight percent of nursing home
  residents were cognitively impaired.

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Current Dilemmas in Dementia Care

• Alzheimers disease is under diagnosed,
  particularly among patients who do not speak
  English as their primary language.
• Pre-Alzheimers impairments are often attributed
  to normal aging.
• Denial and fear often delay evaluation.
• Typical lag time between symptom onset and
  diagnosis is two years.
• Most patients are not diagnosed by their primary
  care physicians.

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Impact on health care

• Today, there are about 4,700 providers, up from
  about 3,300 five years ago.   
• Alzheimer's disease now accounts for 10.1 percent
  of hospice admissions nationwide, up from 5.5
  percent in 2000.   
• ALHs beds have tripled over the decade from
  600,000 to 2,000,000..   

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The Future of Alzheimers Disease

• Treatment with current FDA approved drugs
• Disease modifying drugs to induce remission
• Medications to reverse memory loss
• Cure

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Investigational Treatments

• Passive immunotherapy
• Active immunization
• Secretase inhibitors
• Gene therapies
• Neurotrophics

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Brain Anatomy Function

• Related to Memory

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Healthy Brain Cells

• Billions of neurons
• Axons message transmitters
• Dendrites message receivers
• Groups of neurons have special functions

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Healthy Brain Processes

• Communication
• Metabolism
• Repair

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Brain Communication

• Neurotransmitters
• A chemical messenger between neurons that excite
  or inhibit.

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Brain Metabolism

• Brain needs lots of blood to nourish cells with
  oxygen and glucose.
• Or death to cells.

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Brain Repair

• Neurons can live 100 years or more.
• They must maintain and repair.
• Injury and illness can destroy.
• New neurons can be generated in some areas.

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The Frontal Lobes

• Help you to do more than one thing at once.
• Prioritize what to focus on.
• Sense how much time is passing.

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When dementia affects the frontal lobes, you may

• Have difficulty focusing on a task and paying
  attention to what is going on.
• Be overwhelmed when a caregiver talks and touches
  at the same time.
• Have difficulty following the logic of an
  argument.
• Need the most important words said first in a
  sentence.

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You may also

• Need short and simple words and sentences.
• Refuse a bath because you cant think of how to
  do it.
• Be unable to stop striking or grabbing someone
  because you cant control impulses.

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Temporal Lobes

• The temporal lobes help you
• Understand language
• Speak
• Read and write.

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When dementia affects the temporal lobes, you
may

• Make non-sense words.
• Use the wrong sounds when talking.
• Substitute words or use fewer words.
• Say yes when you mean no.
• Not understand what someone tells you.
• Not understand what you read.
• Use swear words without realizing it.

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Parietal Lobes

• The parietal lobes
• Help you locate and arrange objects in space.
• Tell your brain to pay attention to everything
  that is in the space you see.

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When dementia affects the parietal lobes, you may

• Use excessive energy putting an arm into a shirt
  sleeve.
• Put a glass down on the edge of a plate, rather
  than beyond it.
• Have difficulty responding to objects on the left
  side of your visual field.
• Have difficulty tolerating clutter, many objects,
  and movement in the room.

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You may also

• Feel angry, frustrated, and tired from all of the
  confusing objects and sounds in the environment.
• Respond better when a caregiver approaches from
  the front.
• Resist stepping into a tub or shower because you
  cant see the side of the tub, where your feet
  or hands should go, or how deep the water is.

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Hippocampus

• The hippocampus creates your memory of recent
  events such as
• What someone just said.
• What you had for lunch.
• Who just visited you an hour ago.
• Where you parked your car.

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When dementia affects the hippocampus, you may

• Repeat a question over and over again.
• Forget that a family member just visited.
• Be surprised or angry when a caregiver begins to
  remove clothing when you just agreed to take a
  shower.
• Lose items repeatedly or store them in the wrong
  place.

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The Aging Brain

• And Memory

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Namenesia

Hi. Im, Im, Im. Youll have to forgive me,
Im terrible with names.
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Roomnesia
Now why did I come in here?
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Fleeting thought syndrome
A.K.A. the senior moment
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Memory loss is not a normal part of aging
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Decline in mental ability is not inevitable as
people age

• Neuroplasticity
• Cognitive reserve

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Cognitive Reserve

• Relationship between brain pathology and
  cognitive effect moderated by CR
• CR markers education, occupation, leisure
  interests
• Greater CR causes less impact on function with
  similar level of pathology
• Greater CR leads to steeper decline once
  pathology overwhelms

Yaakov Stern
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Types of Memory

• Episodic memory
• Semantic memory
• Working memory
• Procedural memory

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The Aging Brain

• Brain tissue volume decreases with age due to
  white matter loss.
• Regional loss may be gender specific.
• Frontal regions are more vulnerable to decline.
• Neurogenesis growth of new brain cells.

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Aging Vulnerable Processes

• Processing speed
• Working memory
• Divided attention
• Complex visual processing
• Long term memory
• Episodic memory
• Source recall

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Preserved Abilities with Aging

• Priming - an unconscious influence of past
  experience on current performance or behavior.

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Visual Priming

• C H _ _ M _ _ K
• O _ T _ _ U S
• D _ N O _ _ U R
• P R _ _ T I _ _ _ I T _ _ _

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Preserved Abilities with Aging

• Priming - an unconscious influence of past
  experience on current performance or behavior.
• Inhibition of stimulus-bound responding.

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Stroop test
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Common Causes of Poor Memory

• Insomnia and impaired sleep (apnea)
• Drug side effects (antihistamines)
• Menopause
• Depression
• Attention Deficit Disorder
• Head injury
• Chemotherapy

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Problem Medications

• Antiarrythmics
• Antiemetics
• Antihistamines
• Antiparkinson Agents
• Antipsychotics
• Antispasmotics
• Skeletal Muscle Relaxants
• Tricyclic Antidepressants

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Uncommon Causes of Poor Memory

• Young onset Alzheimers disease
• Mosquito and tick born disease
• Brain tumors
• Toxin and heavy metal exposure
• Anesthesia
• Seizures

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Early Warning Signs of Dementia

• Frequent repeating / defensive answers
• Word finding difficulty
• Mistakes with bills / checkbook
• Changes in hygiene / grooming
• Mistakes with medications
• Geographic disorientation

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Alzheimers Disease

• And related disorders

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Alois Alzheimer 1864-1915
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Risk Factors

• Advancing age
• 65 or older
• Mild cognitive impairment (MCI)
• Family history
• Genetics
• Young onset
• Downs Syndrome

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DSM-IV Diagnosis

• Decreased cognitive functioning including
• Memory impairment
• One or more of
• Aphasia
• Apraxia
• Agnosia
• Inability to plan, organize, sequence
• Inability to comprehend abstract concepts

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DSM-IV Diagnosis

• These deficits cause significant impairment in
  daily functioning.
• Gradual onset and continued decline.
• Not due to other physical or mental medical
  conditions or during the course of a delirium.

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The Alzheimer Brain

• Massive cell loss changes the entire brain during
  Alzheimers progression.
• The cortex shrivels. This damages the brains
  ability to think, plan, and remember.
• The hippocampus shrivels, which affects the
  ability to form new memories.
• Ventricles (fluid-filled spaces) grow larger.

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The Alzheimer Brain

• Underneath the microscope
• Alzheimer tissue has less nerve cells and
  synapses.
• Plaques (abnormal clusters of protein fragments)
  build up between nerves.
• Dead and dying nerve cells remain in the brain.
• Plaques and tangles are the prime suspects of
  cell death and tissue loss.

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Alzheimers progression

• The early stages of Alzheimers may begin up to
  20 years before a diagnosis is made.
• Mild to moderate stages last 2-10 years.
• Severe Alzheimers lasts 1-5 years.

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Stages of Alzheimers

• http//www.nia.nih.gov/Alzheimers/Publications/sta
  ges.htm

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Vascular Dementia

• Second most common form of dementia.
• Caused by problems with the supply of blood to,
  or within the brain.

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Risk Factors

• Hypertension
• Diabetes
• Genetic

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Symptoms of vascular dementia

• May develop suddenly then decline in steps.
• Memory loss may not be the first symptom.
• Concentration problems.
• Changes in mood.
• Physical weakness.
• Difficulty communicating or conversing.

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Types of vascular dementia

• Large stroke (cortical) associated with physical
  impairments.
• Small stroke (lacune) in the basal ganglia or
  thalamus strategic.
• Small vessel disease (sub-cortical).
• Intracranial bleed (intracerebral subdural).

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Dementia with Lewy Bodies

• Discovered in 1912 by Frederich Lewy.
• Common cause of dementia in the elderly.
• Dopaminergic, cholinergic, noradrenergic,
  serotonergic, and glutaminergic systems affected,
  decreased dopamine D2 receptors.
• Over 50 of Parkinsons patients develop PDD
  dementiaa Lewy Body dementia.

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Dementia with Lewy Bodies

• May coexist with AD
• 10 to 30 of AD cases have LBs.
• 32 to 89 of DLB cases have AD changes.
• AD pathology in DLB is different, less severe,
  more diffuse plaques, rare tangles.
• Familial form of DLB associated with triplication
  of SNCA gene.

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Symptoms of Lewy Body Dementia

• Episodes of altered consciousness
• Fluctuating cognition
• Recurrent visual hallucinations
• Parkinsonism
• Extreme sensitivity to anitpsychotics
• Sleep disorders

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Frontotemporal Dementia

• Frontal temporal areas of the cortex are
  affectedPicks bodies form and impair neuronal
  function.
• Fairly common10 to 15 of cases.
• Onsetage 40-65 60 average.
• Can last longer than Alzheimers.
• May be hereditary in 38-60 of cases.

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The Frontal Lobes

• Help you to do more than one thing at once.
• Prioritize what to focus on.
• Sense how much time is passing.

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Temporal Lobes

• The temporal lobes help you
• Understand language
• Speak
• Read and write

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Symptoms of FTD

• Behavior and personality changes
• Personal and social awareness impaired
• Disinhibition
• Repetitive behaviors
• Fixations/obsessions
• Impulsive
• Hyperorality

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Other Dementia Types

• Wernicke-Korsakoff Syndrome
• Cognitive problems after chemotherapy
• Normal pressure hydrocephalus
• Jakob-Creutzfeld
• Head Injury

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Dementia Diagnostic Process
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Referrals to a memory program

• You suspect or know that a dementia problem
  exists
• AND
• you are concerned about patient independence or
  ability to manage ADLs at home,
• OR
• you are concerned about a caregivers ability to
  manage a patient at home.

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Clinical Pearl

• Normal motor examination
• Cognition worse than behavior....... Think
  Alzheimers
• Behavior worse than cognition....... Think
  frontal lobe (Picks)
• Parkinsonian signs on examination
• No hallucinations early in illness Think
  vascular dementia
• Detailed visual hallucinations early
• Think Lewy Body dementia

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Key points regarding diagnosis

• The MMSE is a disorganized, fair quality
  screening tool.
• The Clock Drawing test has drawbacks and
  limitations.
• 90 of the diagnosis is based upon collateral
  history, which may be inaccurate.
• A physical and neurological exam is mandatory.

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Key points regarding diagnosis

• History and examination findings should not be
  interpreted in a clinical vacuum.
• Few text book situations occur and overlap
  conditions are common.
• Not everyone with dementia has Alzheimers
  disease and some have protracted delirium.

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Benefits of Medical Assessment

• Diagnostic clarification
• Identify medical conditions affecting capacity
• Identify means to enhance capacity
• Identify less restrictive alternatives
• Preemptive planning

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What the health care team must do for the patient

• Give a clear diagnosis and prognosis
• Exude optimism
• Lessen fear and the stigma of dementia
• Prescribe cognition stabilizer(s)
• Inform where resources are located

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What the health care team must do for the
caregivers

• Provide closure
• Exude confidence
• Relieve guilt
• Provide reassurance
• Provide support resources
• Set care giving limits

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Diagnostic challenges

• Less than half of all Alzheimers patients know
  that they have the disease.
• 2/3 are not diagnosed until they reach the
  moderate stage.
• Published clinical guidelines to facilitate
  diagnosis are infrequently used.

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Diagnostic challenges

• No blood or imaging test can reliably diagnose
  any type of dementia.
• Most diagnoses are made by neurologists and
  neuropsychologists.
• Demand will soon exceed their supply.
• Primary physicians will become more responsible
  for diagnosing dementia by necessity.

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Misperceptions Clarified

• Alzheimers disease can be accurately diagnosed
  in up to 97 of cases using simple assessment
  techniques in the office.
• New advancements in treatment will make a real
  impact in the lives of dementia patients.
• It is terrible to have Alzheimers disease and
  not know it.

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LTC Rules of Thumb

• AD can be diagnosed in LTC setting.
• Imaging is less important.
• Careful medication review is critical (any
  antihistamine, bladder drug, sleeping pill, TCA,
  potent analgesic, and measurable drug can
  worsen memory and behavior).

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Dementia Diagnostic Process

• Review of symptom onset and progression
• Memory testing
• Physical and neurological examinations
• Blood tests
• Brain imaging

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Mental Status Testing

• Orientation
• Learning and memory
• Three word item recall
• Naming ability
• Name parts of objects
• Gnosis
• Describe function of objects
• Tempoparietal function
• Language comprehension, ideomotor praxis,
  left-right discrimination
• Visual constructions
• Clock drawing, cube copying
• Working memory
• Add coins

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Mental Status Testing

• Abstraction
• Explain similarities
• Attention and concentration
• Digit span
• Months of the year reversed
• Language
• Fluency, repetition, reading
• Spatial and object memory
• Recall where an item was hidden
• Remote memory
• Details about significant past events

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Common Screening Tools

• Folstein Mini-Mental State Examination
• Montreal Cognitive Assessment Screening (MOCA)
• Mini-Cog
• Functional Activities Questionnaire
• The Seven Minute Screen
• Clock Drawing Test

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Lab Testing

• CBC, CMP
• B-12
• TSH
• Syphilis testing
• CSF analysis

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Brain Imaging

• CT Scanning
• MRI
• PET Scanning

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Treatment Modalities

• Pharmacological
• Behavioral
• Palliative not curable

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Realistic Goals of Dementia Treatment

• Attenuate cognitive and functional decline.
• Prevent / decrease behavioral and psychiatric
  symptoms.
• Delay nursing home placement.
• Lengthen period of self-sufficiency.
• Reduce caregiver burden.

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Pharmacologic Arsenal

• FDA Approved Medications for Treatment of
  Alzheimers Dementia
• Cholinesterase Inhibitors Prevent the breakdown
  of acetylcholine
• Donepezil (Aricept), Galantamine (Razadyne),
  Rivastigmine (Exelon)
• Glutamate Regulator
• Memantine (Namenda)

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Pharmacologic Arsenal

• Medications for the treatment of mood disorders
  and behaviors
• Antidepressants
• fluoxetine, citalopram, mirtazepine, sertraline,
  venlaxafine
• Antipsychotics
• haloperidol, risperidone, quetiapine,
  zasperidone
• Anxiolytics
• buspirone, lorazepam

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Other Therapies

• Dynamic psychotherapy
• Aromatherapy
• Music therapy
• Phototherapy
• Electroconvulsive therapy

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Prevention of Dementia

• Stay mentally and physically active
• Socialize
• Live a healthy lifestyle
• Eat a balanced diet

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Working with clients who have dementia

• Behaviors of Dementia
• Behavior Management

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Cognitive changes

• These are changes in memory, thinking, and
  learning.
• Involve a variety of mental skills such as
  attention, problem-solving, memory, language ,
  visual-perceptual skills, and other aspects of
  reasoning and intellect.

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Dementia can cause difficult behaviors

• Changes in the brain can cause problems with a
  persons ability to think, understand, and
  respond appropriately.
• The behaviors result from the disease itself, not
  because the person is trying intentionally to be
  mean or uncooperative.

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Dementia Behaviors

• Repetitive questioning or hoarding/obsessive
  behavior
• Poor judgment
• Disinhibition
• Impulsiveness
• Wandering
• Insomnia or somnolence

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Dementia Behaviors

• Irritability, agitation, restlessness, aggression
• Social withdrawal, apathy, depression, suicidal
  ideation
• Hallucinations-sensory
• An object or event is believed to be perceived
• Delusions-thoughts
• Untrue beliefs based on pathology
• Paranoia and unfounded accusations

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Prevalence of dementia

• The reported dementia prevalence in Assisted
  Living and Special Care Units ranges from 40-67.
• Dementia afflicts a substantial portion of
  elderly patients on the medical-surgical units of
  general hospitals.
• ALFA (2006) Lyketos, Sheppard, Rabins (2000)

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Prevalence of behavioral symptoms

• 56 of residents in AL settings had behavioral
  symptoms related to dementia.
• Current management methods are insufficient to
  respond to the needs of residents.
• Boustani and associates (2005)

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Challenges of dementia

• Functional challenges
• Personality changes
• Mood changes
• Resistance
• Lack of Insight
• Apathy
• Shadowing

• Repeating
• Agitation
• Aggression
• Paranoia
• Wandering
• Delusions
• Hallucinations

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Framework for care

• Provides for person-centered planning.
• Organizes the many theories, approaches,
  strategies, and techniques.
• Comprehensive assessment.
• Maximize functional independence and morale of
  individuals with dementia.

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The Habilitation Domains

• The top 3
• Physical
• Functional
• Emotional

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The Habilitation Domains

• Social
• Sensory
• Communication

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The Five Tenets

• Tenet 1
• Make the physical environment work.
• Tenet 2
• Know that communication remains possible.
• Tenet 3 Focus on remaining skills.

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The Five Tenets

• Tenet 4
• Live in the patients world behavioral changes.
• Tenet 5 Enrich the patients life.

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Link behavior to an unmet need.

• Link the behavior to one of three human needs
• Love
• Usefulness
• Expression of raw emotions

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Look at behavior as a means of communication.

• What is the person trying to communicate?
• Is it worth responding to or is it simply
  annoying?
• Pick your battles.

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What happened before?

• To help determine reasons for a patients
  behavior, look at its antecedents.

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Sudden behavior changes

• May indicate relationship issues.
• May indicate medical or physical problem.
• May indicate environmental change.

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Assess for delirium

• Abrupt state of confusion
• Disturbance of consciousness
• Impairment of cognition and perception
• One or more underlying causes
• May be associated with hyperactivity or lethargy

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Symptoms of delirium

• Many types of cognitive - behavioral symptoms can
  occur including visual hallucinations, delusions,
  paranoia, manic behavior, aggression, apathy, and
  impaired memory.
• Sun-downing is not specific to delirium.

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Risk factors for delirium

• Severe illness
• Hypo perfusion
• Hypoxia
• Infection
• Drug toxicity
• Fractures
• Alcoholism

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Risk factors for delirium

• Dementia (25-50 of all cases)
• Impaired ADLs
• Sensory impairment
• Urinary retention
• Fecal impaction
• Physical restraint use
• Sleep deprivation

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Assess for pain

• Ask the resident.
• Interview the caregivers.
• Review the medical record for pain-related
  diagnoses.
• Physical examination and lab studies.

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Assess for pain

• Use a validated pain rating system
• Facial expression
• Posture
• Vocalizations
• Appetite
• Interactivity

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Pain Rating Scales

• Verbal 0-10 scale
• Abbey pain scale
• Pain assessment for the dementing elderly
• Faces Pain scale
• Pain assessment in advanced dementia (PAINAD)
• Checklist of nonverbal pain indicators CNPI)

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Evaluate the consequences

• Do the behaviors need to change for the comfort
  and the safety of the patient or the caregiver?
• Some behaviors do not bother the patientdo they
  need to be modified?

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Set the tone

• Relax. Center.
• Use a clear, low, loving tone of voice.
• Calm, gentle, matter-of-fact approach.
• Humor.
• Cheerful.

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Set the tone

• Use the mirroring technique.
• Chat about a happy topic before starting a task.
• Use short, simple sentences, familiar words.

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Build trust

• Use non-threatening, factual words who, what,
  when, where, and how.
• Avoid asking why something happened or why they
  did something.

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Do not attempt to reason

• People with dementia lose their ability to
  reason.
• Insight is often impaired.

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Rephrasing

• The individual is validated/comforted when their
  own words are acknowledged by another.
• Repeat the gist of what the person has said,
  using the same key words.
• Use a similar tone and cadence.

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Use redirection to stop undesired behavior

• Can the patient be distracted with another
  activity, treat, topic of conversation?
• You may have to say, Now we are going to
  rather than asking or suggesting a task or
  activity.

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Reminiscing

• Exploring the past can help re-establish familiar
  coping methods and ways of handling stress.
• Use always and never to trigger earlier
  memories.

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Easier to change the environment

• Under stimulation
• Restlessness, pacing, wandering, or calling out.
• Over stimulation
• Nervousness, agitation, physical aggression.

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Progressively Lowered Stress Threshold Concept
(PLST)

• A proactive intervention to reduce likelihood of
  challenging behaviors.
• Based on premise that those with dementia have a
  decreased ability to respond to stressors.
• The cumulative effect of stressors prompts
  behaviors.

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Stabilize the environment

• Routine daily schedule.
• Create a level of quiet and peace.
• Make sure the patient is comfortable.

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Maximize sensory input

• Validate the patients reality without
  exacerbating anxiety
• Keep simple, but provide multi-sensorial
  opportunities
• Music
• Fabrics, pets
• Touch

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Identify and Use the Preferred Sense

• Enables caregiver to speak the persons language
  and improve communication.
• Builds trust.
• Vision
• Hearing
• Touch
• Smell

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Touch

• Confused individuals often need to feel the
  presence of another human being.
• Pleasant memories are often evoked.
• Personal space must be respected.

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Music

• When words are gone, melodies return.
• Comforts, reduces agitation and stress.
• Provides channel for expression of emotion.
• Enhances communication.

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Consider life experiences

• Former life experiences can play a major role in
  behavior.
• At times, thinking of the persons former role
  may help in the development of activities.

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Need for staff training is critical.

• Staff who are trained in dementia and its
  management are better prepared to care for
  residents.
• But, nearly 88 of resident assistants thought
  that confusion was a normal consequence of aging.
  
• Hawes and Phillips (2000) Luxenberg (2003),
  Alzheimers Association (2005).

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Education and training will be key

• Growing elderly population.
• Projected nursing workforce shortage.
• Rates of staff turnover are likely to increase.
• Retention of adequate staff will become even more
  difficult in the future.
• Callahan, 2001 General Accounting Office GAO,
  2001 Noelker, 2001, Stone, 2001.

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Awareness of Abuse

• A closer look at agitation/aggression

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Abuse

• Physical, psychological, sexual, and/or financial
  maltreatment, that may be the result of the
  actions of others or may result from neglect by
  others or by self.
• (Dyer et al., 2000).

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Prevalence of elder abuse

• All forms are under-reported
• 1 to 4 all elders
• 5.4 to 11.9 for demented elderly

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Risk factors for elder abuse

• Excessive physical and psychological demands
  associated with care giving
• Advanced age
• Poor health and physical frailty
• Impaired activities of daily living

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Risk factors for elder abuse

• Alcohol and substance abuse
• Psychopathology
• History of abusive behavior
• Poor pre-morbid relationships

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Risk factors for elder abuse

• Families caring for relatives with Alzheimers
  Disease in the community are particularly
  vulnerable to episodes of violent behavior.
• Caregiver depression
• Living arrangement with immediate family member,
  but not spouse
• Paveza, Cohen, et al. The Gerontologist, 1992

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Abuse from care recipients

• 57-67 of dementia patients manifest some form of
  aggressive behavior.
• Nearly 16 patient to caregiver violence.
• In one study, 66.2 of nursing home assistants
  reported minor physical injuries on a daily
  basis, with 58.2 experiencing more serious
  injury in last 12 months.

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Neuroanatomy of Aggression

• Many areas of the brain are involved
• Prefrontal cortices (trouble thinking)
• Left temporal lobe (short fuse)
• Limbic system (anxiety moodiness)
• Hypothalamus
• Amygdala
• Brainstem

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Neurophysiology of Aggression

• Complex interplay of neurotransmitters and
  hormones
• Serotonin
• Norepinephrine
• Testosterone

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Diagnose the cause of agitation

• Infection
• Injury
• Pain or discomfort
• Illness physical, psychiatric
• Sleep disorders
• Medication side effects or interactions
• Environmental triggers
• People triggers

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Prevention of agitation or aggressive behavior

• Address the causes or antecedents
• Provide a structured environment
• Provide appropriate activity
• Address emotional needs
• Modify caregiver communication techniques and
  approaches
• Provide sunlight

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Treatment of agitation and aggression

• Behavioral
• Pharmacological

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Behavioral treatment of agitation and aggression

• Identify the level of agitation and respond
  accordingly.
• Mild validate and talk.
• Moderate structure environment distract.
• Severe establish understandable limits decrease
  stimuli.

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Behavioral treatment of aggression

• Panic Phase
• Intervention is needed to prevent injury.
• Get away (pre-planned exit strategy).
• Obtain assistance.

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Rescue

• 911
• Facility code-response team

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Psychiatric Hospitalization

• Careful consideration.
• Behavioral and pharmacological treatment first.
• Goal is to eliminate aggressive symptoms and
  return to his/her environment.

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Medications to treat agitation and aggression

• No medications are approved by the FDA for the
  specific treatment of aggression.
• Medications that are used must be monitored to
  determine effectiveness.

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Medications

• SSRI Antidepressants
• Used to treat lowered serotonin levels.
• sertraline, fluoxetine, citalopram, escitalopram,
  etc.
• Some effect can be noted in 3 to 5 days, but can
  take two weeks for full effect.

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Medications

• Beta-blockers propranolol, metropolol
• Antipsychotics Risperdal, Haldol, quetiapine
• Anti-convulsants valproate, Tegretol, Neurontin,
  Lamictal
• Combination therapy, such as
• buspirone propranolol
• valproate anti-psychotic medication

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About those benzodiazepines

• Medications, such as Ativan and Xanax, are used
  for anxiety in non-demented patients
• When used with demented patients, they can
  increase confusion, falls, and agitation.
• Limit to an as needed basis only.
• Avoid gels.

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When to report to APS

• When the caregiver is unable to protect self
  and/or the care recipient from elder abuse.
• Other interventions have been unsuccessful.

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Recommendations

• The likelihood of aggressive behaviors needs to
  be an expectation among the demented and mentally
  ill population.
• Improved recognition and assessment.
• Education and training.
• Improved reporting.

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Case Management and Care Coordination

• Each case is unique.
• It is never just about the patient.
• Case management interventions must be directed at
  the patient and his/her caregiver(s).

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Outpatient Case and Disease Management

• Case Management Process
• Engagement
• Assessment
• Plan of Care Collaboration
• Intervention
• Evaluation

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Assessment for Intervention

• Due to changes in the brain from dementia, a
  person needs the environment and the caregiver to
  compensate for impaired memory functions.
• The more we know about how a persons memory
  ability has changed, the more we can target
  successful strategies to improve their quality of
  life.

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Engagement

• With whom will you be working?
• Size up family dynamics.
• Capacity/insight issues.
• Medical decision-making.
• Recognizing and responding to caregiver stress.
• Empathetic approach.

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Assessment

• Biopsychosocial
• Active listening approach
• Assess ability/stress of care provider

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Assessment

• Patient Goals
• Caregiver Goals
• Long term care plans?
• Existing Strengths and Resources
• Medical Record
• Reassess at 6 months

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Tools for Assessment

• Case management organizations
• Biopsychosocial assessment tools via internet
• Katz activities of daily living
• Create a short form

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Plan of Care Collaboration

• Patient
• Caregiver(s)
• Medical providers
• Community resources

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Interventions

• What is needed to keep patient safe?
• What will provide for patients dignity?
• What will improve patients quality of life?
• What offers least restrictive environment?

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Interventions

• What communication techniques and behavioral
  approaches will be most effective?
• What is needed to support the caregiver?

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Interventions

• Medication management
• Financial security
• Environmental adjustments
• Personal care assistance
• Nutrition/hydration
• Physical exercise
• Social activities
• Caregiver support

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Interventions

• Identify key agencies
• Alzheimers Association others
• Area Agency or Commission on Aging
• Senior Neighbor Centers and Service
• Social Security Administration
• Veterans Administration
• Secretary of State
• MDCH
• Medicare Medicaid

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Interventions

• Identify Home Supports
• Adult day programs
• Home delivered meals
• Home helper services
• Respite care
• Transportation

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Interventions

• Assist with long-term care planning
• DPOA or guardianship
• Housing advisors
• Long term care facilities
• PACE
• AL
• AL dementia
• Skilled nursing facilities
• Hospice

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The Alzheimers Disease Bill of Rights

• To be informed of ones diagnosis.
• To have appropriate medical care.
• To be productive in work and play for as long as
  possible.
• To be treated like an adult, not a child.
• To have expressed feelings taken seriously.

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The Alzheimers Disease Bill of Rights

• To be free from psychotropic medications, if
  possible.
• To live in a safe, structured, and predictable
  environment.
• To enjoy meaningful activities that fill each
  day.
• To be outdoors on a regular basis.

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The Alzheimers Disease Bill of Rights

• To have physical contact, including hugging,
  caressing, and hand-holding.
• To be with individuals who know ones life story,
  including cultural and religious traditions.
• To be cared for by individuals who are well
  trained in dementia care.
• The Best Friends Approach to Alzheimers Care, by
  Virginia Bell and David Troxel 1997 Health
  Professions Press, Inc., Baltimore

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