10/20/2015. Stages of Dementia. Strategies & Medications for Treating Symptoms & Behaviors OBJECTIVES. Demographics of Dementia

Transcription

1 Stages of Dementia Strategies & Medications for Treating Symptoms & Behaviors Sandra Stom, CRNP, FNP-BC Penn Highlands Healthcare Brookville/Clearfield/Dubois/St. Marys, PA OBJECTIVES Distinguish Types of Dementia Identify Early, Middle & Late Stages of Dementia Define What is Normal Memory Loss Learn Strategies to Treat Symptoms: Pharmacological and Non-Pharmacological Know When/What/Why & How to Treat Symptoms Learn Screenings for Dementia (Differential Diagnosis) Learn Ways to Prevent/Slow Cognitive Decline Early recognition and intervention are key!! Demographics of Dementia Census million Americans living are over age states with highest % over 65 are: Florida, West Virginia, Maine, PENNSYLVANIA, Iowa. In the general population, dementia affects 5-10% of those aged 65 to 74, and 40% of those over 85. It accounts for more than 50% of nursing home admissions. At least 5 million people in the United States are diagnosed with dementia. The term is retained with the DSM-5 for continuity. Neurocognitive disorder is now the preferred terminology, especially with impairments secondary to other conditions that affect younger individuals (e.g., TBI). 1

2 WHERE??? Brain Regions Classifications of Dementia DSM-5: Major or Minor Neurocognitive Disorder due to Types: o Alzheimer s vs. Non-Alzheimer s o Vascular o Lewy Body o Frontotemporal o Hydrocephalus o Traumatic Brain Injury o Substance/Medication-Induced o Prion (Transmittable Disease) o Parkinson s and Huntington s o Multiple Etiologies o Unspecified Over 170 irreversible dementias Some forms are reversible (treatable) Thyroid disorders, drug interactions, dehydration Early Stage 2 4 years This stage often becomes apparent in hindsight. It may be impossible to identify the exact time it began. Short-term memory loss forgetful recent events Mood Changes - irritability, hostility, and agitation Difficulty in handling tasks Withdrawal from activities & unwilling to try new things Difficulty with word finding Routines may take longer Poor judgement Repetitive - Indecisive Memory impairment usually affects registration, storage, and retrieval of new information In the early stage, individuals with Alzheimer's disease are often better groomed and neater than those with other dementias. 2

3 Is it Dementia or Just Getting Older??? Early Stage (Do I have Dementia?) Ask yourself Is this something new? What are the normal.typical age-related changes? There is NO typical person with Dementia wide variability! Why is it important to get early diagnosis and the right diagnosis? What is the biggest question Caregivers need to know? What things are best done in Early Stage? Intermediate(Middle) Stage 2 10 years Problems are more apparent and disabling Length of stage depends on other co-morbidities & Care Very forgetful about recent events. Confuse one family member with another. Forget names of friends. Neglectful of hygiene, eating, or attire. Easily disoriented as they miss social and environmental cues. Tend to get lost if away from familiar surroundings. Risk of falls and accidents increase substantially. Become easily distressed when frustrated. Restlessness and aggression may occur due to confusion, particularly at night (Sundowning Effect). Sleep patterns are often disorganized 3

4 Intermediate(Middle) Stage SAFETY biggest concern now - Wandering Parts of the brain damaged in Middle stage I Want to go Home!! Suggestions?? Other Changes Seen & What can you Change? What things are best done in Middle Stage? Late Stage 1-3 years Requires total care 24 hour Unable to remember information, even for a few minutes. Lose their ability to understand and use speech. Become immobile and incontinent. Show no recognition of friends and family. Fail to recognize everyday objects. Older (long-term memory) is also lost birthplace, names of children/siblings/spouse End-stage dementia results in coma and death, usually due to immune system compromise. Late Stage Things you can do? Choices? What you need to know? Caregiver Survival Tips 4

5 Screenings for Dementia Tests may include the MMSE, Cognistat, RBANS, & MOCA, KELS, Geriatric Depression Scale Brain scan, blood and urine tests What about sensory deficitis - hearing/visual exams Interview with caregivers Short-term memory tests : Registering 3 objects and recalling them after 5 minutes List names of objects within categories (animals, foods, furniture) GOLD STANDARD SCREEENING: NeuroPsych Testing The only way to confirm diagnosis is with an autopsy Just because you were newly diagnosed doesn t mean you are in Early Stages DIAGNOSTIC CRITERIA Diagnosis requires deficits in at least one of the following areas: Executive Dysfunction : impaired ability to plan, initiate, and set goals Agnosia: Inability to identify objects despite intact senses Apraxia: Problems with learned activities despite intact motor functions Aphasia: Impairment in comprehending or expressing language Each cognitive deficit must substantially impair functioning and represent a significant decline from the previous ability level. Differential Diagnosis Delirium is a reversible condition. The features are usually inattentiveness and poor awareness. The symptoms have a short duration. It can be superimposed on dementia. Side-effects to certain medications may mimic or worsen symptoms of dementia : Antihistamines Benzodiazepines and anticholinergics Tricyclic antidepressants and antipsychotics Other Important Medical Considerations: Substances (Intoxication or Withdrawal States) Mixed level of activity Urinary tract infections Renal or liver failure causing toxicity Is the condition better accounted for by another medical condition or mental disorder? 5

6 Pseudodementia (Depressive Disorder) Depression may be the first sign of early stage dementia. Prevalence of major depressive disorder in people with dementia is falls between 6% to 20%. Dementia can cause brain changes that lead to depression. Those with only depression rarely forget important current events or personal matters. Neurologic examinations are normal except low motivation or psychomotor slowing. Those with depression make little effort to respond, while those with dementia often try hard, but respond incorrectly. When depression and dementia coexist, treating depression does not fully restore cognition. Psychiatric Symptoms of Dementia Psychosis hallucinations, delusions, or paranoia occur in 10% of individuals with dementia, although a higher percentage may experience these symptoms temporarily. Anger and Aggression Dementia causes individuals to lose their impulse control and become disinhibited. Anxiety the diagnosis of dementia itself can cause anxiety. The person may fear the effects of the disease in the future, worry about making mistakes and forgetting things, get anxious when separated from caregivers, or become confused when schedules are changed. DX: Major Neurocognitive Disorder Significant decline from previous level of cognitive functioning: Complex Attention, Executive Functions, Memory, Language, Motor Abilities or Social Skills Based on collateral information including self-report and standardized neuropsychological testing or quantified clinical assessment. Cognitive deficits interfere with everyday activities: For example, requires assistance in areas that were previously independent. 6

7 DX: Mild Neurocognitive Disorder Modest decline from previous level of cognitive functioning: Complex Attention, Executive Functions, Memory, Language, Motor Abilities or Social Skills Based on collateral information including self-report and standardized neuropsychological testing or quantified clinical assessment. Cognitive deficits do not interfere with the capacity for independence in everyday activities PHARMACOLIGIC INTERVENTIONS: Two Types of Anti-Dementia Medications 1. Actelycholinesterase inhibitors are intended to preserve functioning (i.e., delay worsening) and usually prescribed for mild to moderate symptoms. These include Cognex, Aricept, and Exelon. 2. Other medications regulate glutamate to treat moderate to severe symptoms of Alzheimer s, such as problems performing simple tasks. These include Namenda Also use, anti-depressants and Antipsychotics. RULE Start Low and go slow and titrate off ASAP Non-Pharm Interventions Non-drug approaches should be 1 st line in treating dementia patients. Evidence for non-drug approaches to challenges is better than evidence for medications. ISSUE & CHALLENGE is that our health care system has not incentivized training in Alternatives to drug use. There is little to no reimbursement for caregiver=based methods.!! (Drugs still have their place, especially for acute situations involving safety) 7

8 NON-PHARM INTERVENTIONS: Communication is only 10% verbal And People with Dementia maintain their ability to understand non-verbal after verbal is forgotten. REMEMBER Try approach from front Establish eye contact - speak at eye level Approach from front and use gentle touch Anticipate problems or events Provide a routine Establish rapport Talk with a calm voice Do not attempt to use reason or logic Do not rush Avoid arguing Focus on abilities NON-PHARM STRATGIES Enter the person s reality Look for feelings behind the words Empathize Be non-judgmental Respect their needs Communicate comfort, warmth, and praise Smile! Put the person s feelings into words Allow for negative feelings Preventing Behaviors 8

9 NON PHARM INTERVENTIONS Individuals with Dementia are Highly Sensitive to their Environment Provide clear, calm, and comforting structure and routine. Changes in surroundings and people should be explained simply to avoid distressing reactions. Rooms should be reasonably bright and contain sensory stimuli to reinforce orientation. Regularly engage in low-stress activities. Redirect with distractions and substitutions. Be flexible. Always use soothing and reassurance. PREVENTION It is impossible to stop aging. But, there are many things that improve health as one ages. For instance: Eating well: Meet with a dietitian and use the Food Guide Plate to choose healthy food. Exercising: Have a doctor or therapist create a special exercise program. Keeping the mind active: Participate in activities that encourage thinking. Seeing the physician for regular check-ups and for special screenings and examinations NOTES: Our goal is to help patients live as well as they can-we have to remember that like the body, the aging brain shows wear and tear. People differ in the speed in which their abilities deteriorate. Some may change from day to day, while others may decline slowly over a number of years. It is important to remember that not all features will be present in every person, nor will every individual go through every stage. Don t refer to things as PROBLEMS, refer to them as CHALLENGES (Reframe) 9

10 Thank You!!!! Questions? Resources ADRC Alzheimer s Disease and Research Center Alzheimer s Disease Education & Referral Center Alzheimer s Association Alzheimer s Foundation of America National Library of Medicine National Academy of Elder Law Attorneys ( Safety Recommendations Family Caregiver Alliance Fisher Center for Alzheimer s Research The Hartford ( WebMD ( sastom@phhealthcare.org 10