Dementia/ Delirium an Overview

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Dementia/ Delirium an Overview

• October 2011

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Introduction to Harvest Healthcare

• Experience. Education. Excellence.
• Harvest is a leading full-service behavioral
  health provider, specializing in the delivery of
  progressive and innovative consultative
  behavioral health services for patients and
  residents residing in skilled nursing,
  rehabilitation, and assisted living facilities.
  Our multidisciplinary team of highly skilled
  professionals work together to offer a broad menu
  of services including but not limited to 24-hour
  prescriber on-call services and hospitalization
  support, comprehensive cognitive assessments,
  documentation review, OBRA compliance support and
  customized educational programs designed for the
  individual needs of your facility.

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Objectives

• This presentation was developed for the
  continuing education of health care providers
• At the conclusion of this presentation the
  audience will have a basic understanding of
  dementia and delirium, symptoms and management.
• Mental health care professionals should be
  consulted for the treatment of patients with
  dementia or delirium.

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Dementia (taken from Latin, originally meaning
"madness", from de- "without" ment, the root of
mens "mind")

• Is a serious loss of cognitive ability in a
  previously unimpaired person, beyond what might
  be expected from normal aging.
• It may be static, the result of a unique global
  brain injury, or progressive, resulting in
  long-term decline due to damage or disease in the
  body.
• Although dementia is far more common in the
  geriatric population, it may occur in any stage
  of adulthood.

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Dementia

• Is a non-specific illness syndrome (set of signs
  and symptoms) in which affected areas of
  cognition may be memory, attention, language, and
  problem solving.
• It is normally required to be present for at
  least 6 months to be diagnosed cognitive
  dysfunction that has been seen only over shorter
  times, in particular less than weeks, must be
  termed delirium.
• In all types of general cognitive dysfunction,
  higher mental functions are affected first in the
  process.

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Diagnosis of Dementia

• The earlier the better as there are medications
  that slow the process of cognitive loss.
• Diagnosis is made through the review of medical
  history, review of medical record, medical
  evaluation and cognitive testing with multiple
  measures.
• MMSE is no longer the standard for detection as
  it is unreliable.

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Orientation concerns

• Especially in the later stages of the condition,
  affected persons may be
• disoriented in time (not knowing what day of the
  week, day of the month, or even what year it is),
  
• in place (not knowing where they are),
• and in person (not knowing who they are or others
  around them).

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Behavioral and psychological symptoms of dementia
(BPSD)

• Dementia is a condition in which individuals
  progressively lose cognitive function and, as a
  result, often develop difficult behaviors that
  cause stress for both patients and their
  caregivers. These behaviors, are collectively
  known as behavioral and psychological symptoms of
  dementia (BPSD).
• BPSD include screaming, wandering, resisting
  care, hitting, and psychological symptoms such as
  depression, psychosis, and sexual disinhibition.

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BPSD

• BPSD is prevalent in nursing homes where 67-78
  percent of patients have dementia and, of them,
  76 percent exhibit BPSD.
• In fact, it is common for patients to be
  institutionalized because of BPSD, so clinicians
  must become proficient in assessing and managing
  these symptoms.

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Medications

• Acetylcholinesterase inhibitors Tacrine
  (Cognex), donepezil (Aricept), galantamine
  (Razadyne), and rivastigmine (Exelon) are
  approved by the United States Food and Drug
  Administration (FDA) for treatment of dementia
  induced by Alzheimer's disease. They may be
  useful for other similar diseases causing
  dementia such as Parkinson's or vascular
  dementia.
• N-methyl-D-aspartate Blockers. Memantine
  (Namenda) is a drug representative of this class.
  It can be used in combination with
  acetylcholinesterase inhibitors.

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Off-Label Medications

• Antidepressant drugs Depression is frequently
  associated with dementia and generally worsens
  the degree of cognitive and behavioral
  impairment. Antidepressants effectively treat the
  cognitive and behavioral symptoms of depression
  in patients with Alzheimer's disease, but
  evidence for their use in other forms of dementia
  is weak.

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Anxiolytic drugs Many patients with dementia
experience anxiety symptoms.

• Although benzodiazepines like diazepam (Valium)
  have been used for treating anxiety in other
  situations, they are often avoided because they
  may increase agitation in persons with dementia
  and are likely to worsen cognitive problems or
  are too sedating. Buspirone (Buspar) is often
  initially tried for mild-to-moderate anxiety.
  There is little evidence for the effectiveness of
  benzodiazepines in dementia, whereas there is
  evidence for the effectiveness of antipsychotics
  (at low doses).

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Antipsychotic drugs Both typical antipsychotics
(such as Haloperidol) and atypical antipsychotics
such as (risperidone) increase the risk of death
in dementia-associated psychosis.

• This means that any use of antipsychotic
  medication for dementia-associated psychosis is
  off-label and should only be considered after
  discussing the risks and benefits of treatment
  with these drugs, and after other treatment
  modalities have failed.
• In the UK around 144,000 dementia sufferers are
  unnecessarily prescribed antipsychotic drugs,
  around 2000 patients die as a result of taking
  the drugs each year.

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Agitation

• One of the greatest impacts on quality of life
  for patients with dementia is the presence of
  agitation behavior in the middle stages of the
  disease process.
• More than half of patients with dementia exhibit
  some type of "agitation" behavior over the course
  of a year, in addition to depression or
  psychosis.
• Experts suggest that the best way to manage
  agitation is through environmental and atmosphere
  changes rather than medications. Medications are
  a last resort.

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Agitation

• Behavior management experts define "agitation
  behavior" as "inappropriate verbal or motor
  activity.
• Non-aggressive Verbal Behavior Incoherent
  babbling, screaming or repetitive questions is
  frustrating to the caregiver and family members,
  especially as a sign that the person with
  dementia is "losing it."

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Agitation

• Non-aggressive Physical Behavior Pacing,
  wandering, repetitive body motions, hoarding or
  shadowing represent ways for the person with
  dementia to communicate boredom, fear, confusion,
  search for safety or inability to verbalize a
  request for help or a feeling of pain.

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Agitation

• Aggressive Verbal Behavior Cursing and abusive
  language can be shocking when the person with
  dementia was previously upright and proper.
• Aggressive Physical Behavior Clearly, physically
  aggressive behavior such as hitting, scratching
  or kicking can be dangerous or life-threatening
  to the caregiver and care recipient.

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Agitation

• Men are twice as likely to exhibit aggressive
  behavior, especially in the middle to late stages
  of the disease, or if they have major depression.
  
• The degradation of different parts of the brain
  causes aberrant behavior. Other conditions, such
  as pain, can also lead to it.

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Agitation

• Some caregivers cope by ignoring agitation
  behaviors. This is one of the worst things to do
  since it ultimately makes things worse for both
  the caregiver and the person with dementia.
• The stress placed on the caregiver at home by
  these agitation behaviors often forces premature
  placement in a nursing facility, health problems
  for the caregiver and lessened quality of life
  for both.

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Understanding Agitation Behavior

• Experts say that all types of behavior are forms
  of communication. The patient is trying to tell
  you something even though the disease has robbed
  them of other ways (i.e., talking) of telling
  you.
• They may be expressing depression or pain and
  the person does not know how to express it in
  words.
• Some experts believe that agitation behavior is
  "the inability the deal with stress."

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Sundowning

• Refers to a state of confusion at the end of the
  day and into the night. The cause isn't known.
  But factors that may aggravate late-day confusion
  include
• Fatigue
• Low lighting
• Increased shadows

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Some tips for reducing sundowning

• Plan for activities and exposure to light during
  the day to encourage nighttime sleepiness.
• Limit caffeine and sugar to morning hours.
• Serve dinner early and offer a light snack
  before bedtime.
• Keep a night light on to reduce agitation that
  occurs when surroundings are dark or unfamiliar.
• In a strange or unfamiliar setting such as a
  hospital, bring familiar items such as
  photographs or a radio from home.

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Sundowning

• When sundowning occurs in a care facility, it may
  be related to the flurry of activity during staff
  shift changes. Staff arriving and leaving may cue
  some people with dementia to want to go home or
  to check on their children or other behaviors
  that were appropriate in the late afternoon in
  their past. It may help to occupy their time
  during that period.

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Is Behavior Event-Related?

• Organization by the caregiver will help a great
  deal in beginning to combat these behaviors
• Modify the environment to reduce known stressors
  (e.g., shadowy lighting, mirrors, loud noises)
• Note patterns of behavior and subtle (and not so
  subtle) clues that tension and anxiety are
  increasing (i.e., pacing, incoherent
  vocalization)
• Dysfunctional behavior often increases at the end
  of the day as stress builds as the person becomes
  tired.

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Certain stressors can trigger agitation behaviors.

• As the caregiver, you have to use all of your
  senses to understand the environment and the
  behaviors.
• Fatigue
• Change of Environment, Routine or Caregiver
• Affective Responses to Perception of Loss
• Responses to Overwhelming or Misleading Stimuli.
• Excessive Demand
• Delirium

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Fatigue

• If confusion and agitation increase late in the
  day, suspect that fatigue may be a factor.
• Encourage rest or have quiet periods for up to
  two times a day.

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Change of Environment, Routine or Caregiver

• Sameness and routine help to minimize stress in
  the patient with Alzheimers Disease.

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Affective Responses to Perception of Loss

• This means that persons with dementia still have
  memories and perceptions of activities that they
  used to enjoy. They miss being able to drive a
  car, cook or care for children.
• Safe activities should be substituted to deal
  with grief and loss.
• Depression should be treated.

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Responses to Overwhelming or Misleading Stimuli

• Excessive, noise, commotion or people can trigger
  agitation behavior. Researchers have found that
  more than 23 people in a group (e.g., dining room
  or holiday party) can cause undue stress in a
  person with dementia. The television, mirror
  image, dolls or figurines may represent extra
  people in the environment.
• Before medicating with anti-psychotic drugs, the
  health care team should consider these
  environmental factors.

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Excessive Demand

• Caregivers and families must accept that the
  individual has lost (and continues to lose)
  mental functions. No amount of quizzing, reality
  orientation, "brain exercises," retraining or
  pushing them to try harder will improve their
  mental capabilities. Indeed, it can cause stress
  and a sense of futility.
• The best a caregiver can do is provide positive
  support and understanding, encourage independence
  and assist the individual when they are unable to
  perform a task.

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Delirium

• Illnesses such as infections, pain, constipation,
  trauma or drug interactions may cause
  dementia-like symptoms.
• Preventive measures such as good oral care,
  nutrition, simplified medication regimens and
  adequate fluid intake play an important role in
  well-being.

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Some Specific "Problem" Behaviors

• Wandering Caregivers should understand that
  individuals wanders for a reason. The exact
  reason may be hard to determine. Nevertheless,
  locking him/her in a room or restraining in a
  chair is inappropriate. Implement activities and
  adjust the environment to relieve agitation if
  possible. Minimize all safety risks.

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Specific problem behaviors (BPSD)

• Screaming Consider medical causes for screaming
  that the person cannot verbalize such as pain,
  depression or hearing loss.
• Gathering/Shopping An individual with dementia
  who rearranges objects around the residence,
  hoards or appropriates others possessions can be
  a disruptive nuisance. Provide the individual
  with a "safe" place where s/he can store items
  (and you can retrieve them). You may provide the
  individual with a canvas "shopping bag."

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BPSD

• Pacing An individual with dementia who paces
  incessantly can burn off too many calories.
  High-calorie finger foods may help the problem.
  You can try to reduce pacing by providing
  inviting places for the individual to sit and
  relax.

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BPSD

• Sexual Aggression Try to determine whether the
  sexual gesture is indeed sexual in nature and not
  an expression of the need to go to the bathroom.
• Refer to psychiatry to determine treatment
  options. Medications may not be useful in
  treating sexual symptoms.
• Symptoms may indicate an atypical dementia such
  as Lewy Body Dementia or Picks Disease. These
  may require different types of psychiatric and
  behavioral interventions.

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BPSD

• Hallucinations/Illusions After you have removed
  confusing stimuli (e.g., shadowy lighting,
  televisions, dolls), refer to psychiatry to
  assess for signs of an atypical dementia such as
  Lewy Body Dementia or Picks Disease.
• These may require different types of psychiatric
  and behavioral interventions.

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What can be done

• A simplified approach to managing agitation
  behaviors can be summed up as "Modify the
  environment, modify the behavior and medicate as
  a last resort."
• Recent research is starting to show that some
  relatively basic interventions can be used to
  ease agitation behaviors.

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Music Therapy

• Some studies show that playing calming music or a
  favorite type of music can lead to a decrease in
  agitation. When used during meals, soothing music
  can increase food consumption when used during
  bathing, relaxing or favorite music can make it
  easier to give a bath. Experiment with relaxing,
  soothing, classical, religious or period (e.g.,
  1920s or Big Band) music.

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Exercise and Movement

• Light exercise, such as chair exercises as
  directed by a physical therapist or activities
  coordinator each day can help to maintain
  function of limbs and decrease problem behaviors.
  Walking after dinner several times each week may
  help reduce aggression.
• When small groups of 3-4 people go on walks, it
  may lead to beneficial social interactions such
  as singing and talking.

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Activities

• Safe activities are a good way to get back in
  touch with their earlier life and find meaning
  throughout the disease process.
• Activities can reflect either things the person
  enjoyed in the past or can reflect what they did
  for work.

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Socialization

• Human interaction is essential for people with
  dementia. As mentioned, large groups and most
  strangers are definitely out. But you can
  introduce new individuals as a "new friend" or
  companion to spend time with the person who has
  dementia.
• They can reminisce, converse, walk or perform
  activities together.

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What can you do?

• Help to identify dementia early by documenting
  memory loss and confusion.
• Request a cognitive assessment from the Cognitive
  Assessment Program at Harvest.
• Practice patience.
• Be a detective and work toward finding the cause
  of agitation in an effort to resolve it.

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Thought Provoking Questions

• Can you describe sundowning and name some
  potential causes?
• Can you identify some potential causes of
  agitation?
• Can you describe the difference between delirium
  and dementia?