Interventions to Minimize Behavioral Symptoms of Dementia: Moving Beyond Redirection Part I

1. Interventions to Minimize Behavioral Symptoms of Dementia: Moving Beyond Redirection Part I Margaret Hoberg MSN, GNP-BC Siobhan McMahon MSN MPH GNP-BC

2. Objectives Learning Objectives • Explain the effects of dementia on thinking, emotions and communication • Use a theory to help explain behavioral and communication changes associated with dementia and to guide interventions • Respond to behavioral changes with a calm, validating approach • Comprehensively assess verbal and nonverbal messages, including those that are associated with stress • Develop a plan whose non-pharmacological interventions reflect an understanding of and respect for the person and their preferences.

3. Clara • 91-year-old woman • AD (recent MMSE score 12) • “Severe agitation” per LPN who is passing meds A few hours ago she hit another resident. • CNA adds she has been irritable and pacing. • The night CNA also notes she has been having trouble sleeping and has expressed feelings that others • She has heart disease and mild COPD. She has a history of recurrent UTIs . • Clara cooperates at times, but when left in her room, she wanders the hall, seeming confused. When “redirected” to her room, she insists that she had to go home and would refuses assistance with care.

4. What is the most appropriate next step in the care of Clara? (A) Administer prn lorazepam .5mg-1 mg intramuscularly, sublingual or po (B) Administer haloperidol 1 mg intramuscularly or po (C) Ask family member, nurse or CNA to spend one-on-one time with her; begin a thorough assessment for acute illness and unmet physical need. (D ) Restrain Clara to obtain a blood and urine work-up

5. What is the most appropriate next step in the care of Clara? (A) Administer lorazepam 1 mg intramuscularly, sublingual or po (B) Administer haloperidol 1 mg intramuscularly or po (C) Ask family member, nurse or CNA to spend one-on-one time with her; begin a thorough assessment for acute illness and unmet physical emotional or social needs. (D) Restrain the patient to obtain a blood and urine work-up

6. 5.3 million 7th leading cause of death Risk >65: 9.1 % men/ 17.2% women Risk: Over age 85 12.1% men 20.3% women Long term care AL 45-67 % with some dementia 41 % with moderate to severe cognitive impairment Dementia Statistics

7. Memory / Cognitive Changes • Normal aging • Mild cognitive impairment • Delirium (e.g. acute infection) • Other medical / health causes (B12 deficiency; thyroid dysfunction) • Depression • Alzheimer’s disease • Vascular (multi-infarct) dementia • Dementia associated with Lewy bodies • Other (alcohol, frontotemporal dementia, Parkinson’s Disease, Neurosyphilis)

8. Dementia persistent and progressive

9. Alzheimer’s disease • Alzheimer’s disease (AD) is an irreversible, progressive brain disease that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks of daily living. In most people with AD, symptoms first appear after age 60. • AD is the most common cause of dementia among older people, but it is not a normal part of aging.

10. Cause of Alzheimer’s Dementia • Amyloidplaques and neurofibrillary tangles which start in area of brain affecting memory and spread to other areas • Gradual loss of connections between nerve cells (neurons) in the brain. This loss leads to diminished cell function and cell death. • Read more about Alzheimer’s Disease by connecting to this link: • Alzheimer's Association Web Page with Description of Alzheimer's Dementia

11. Causes of Vascular Dementia • Complete blockage of blood vessels in the brain. The complete blockage of an artery in the brain usually causes a stroke, but some blockages don't produce stroke. These "silent brain infarctions" increase a person's risk of vascular dementia. The risk increases with the number of infarctions experienced over time. One variety of vascular dementia is called multi-infarct dementia. Heart disease and irregular heart rhythms, such as atrial fibrillation, can increase your risk of stroke. • Narrowing of the blood vessels in the brain. Vascular dementia also can occur without a complete blockage of an artery. Portions of the brain can be starved for oxygen and food by reduced blood flow from arteries narrowed by vascular disease. • Vascular dementia can also be caused by: very low blood pressure, bleeding brain, blood vessel damage from such disorders as lupus erythematosus or temporal arteritis

12. Other conditions that cause memory loss or dementia • medication side effects • chronic alcoholism • certain tumors and infections in the brain • blood clots in the brain • vitamin B12 deficiency • dehydration • high fever • some thyroid, kidney, or liver disorders

13. Dementia symptoms • Memory impairment- getting lost in familiar settings, forgetting previous conversations, names, faces • Language impairment- difficulty finding words or following conversation, inability to communicate needs and preferences through verbal means • Apraxia-unable to perform previously learned tasks such as not knowing how to drink from a cup even though person may have sensory and physical ability intact • Agnosia-unable to recognize objects or other sensory stimuli • Impaired executive function- poor planning and judgement, difficulty solving problems

14. Progressive Symptoms of AD Mild Moderate • Memory problems • Getting lost • Difficulty handling money or medications • Taking a longer time than usual completing a task • Poor judgment • Losing things • Mood changes • Increased memory loss • Problems recognizing family and friends • Inability to learn new things • Difficulty carrying out routine multi-step tasks • Problems coping with new situations • Impulsive • Delusions and paranoia

15. Progressive Symptoms of AD Severe • Difficulty recognizing one self or family • Inability to verbally communicate • Weight loss • Seizures • Difficulty swallowing • Groaning • Moaning • Increased sleeping • Loss of bladder and bowel control