Dementia and Stroke

1. Dementia and Stroke Central South Regional Stroke Program September 2007 Funded by the Ministry of Health and Long-Term Care

2. Session Overview • The types of stroke. • The common changes that result from stroke. • The connection between stroke and dementia. • The behaviour changes that result from dementia • Strategies to assist in working with residents with dementia

3. What is a Stroke • An interruption of the supply of blood and oxygen to an area of the brain. • This causes the brain cells in an area to die, and reduces the brain function in that area. • The area of the body controlled by the damaged area in unable to function properly. • There are two types of stroke. http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

4. What is a Stroke? A stroke can happen when a blood clot blocks a blood vessel in the brain. 80% of strokes are this type. A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996

5. What is a Stroke? A stroke can also happen when a blood vessel breaks and results in bleeding in the brain. 20% of strokes are this type. A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996

6. High blood pressure High blood cholesterol Heart disease Diabetes Being overweight Excessive alcohol use Physical inactivity Smoking Stress Risk factors you can do something about…

7. What does a resident who has had a stroke look like in LTC?

8. What are some of the losses due to stroke? • paralysis or weakness on one side of the body; • vision problems (double vision); • trouble speaking or understanding language; http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

9. What are some of the losses due to stroke? • inability to recognize or use familiar objects; • tiredness; • depression; http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

10. What are some of the losses due to stroke? • exaggerated or inappropriate emotional responses; • difficulty learning and remembering new information; and • changes in personality. http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

11. Stroke Statistics • There are between 40,000 and 50,000 strokes survivors in Canada each year. • 10% (4-5,000) of strokes survivors each year require long-term care. • 40% (16-20,000) of strokes survivors each year are left with a moderate to severe impairment. http://ww2.heartandstroke.ca/Page.asp?PageID=33&ArticleID=1078&Src=news&From=SubCategory

12. Dementia

13. Dementia is a syndrome…that includes loss of memory, judgment and reasoning, and changes in mood, behaviour and communication abilities. Alzheimer’s Society of Canada

14.  in memory And at least one of the following: Difficulty with language Difficulty with voluntarily moving despite having normal muscle function Difficulty recognizing and identifying objects or persons Difficulty with planning, reasoning, problem solving and judgment. What is dementia? The Diagnostic and Statistical Manual published by the American Psychiatric Association

15. Types of Dementia Other (3.1%) Dementia with Lewy bodies (1.9%) Frontotemporal dementia (5.4%) Vascular Dementia 8.7% Alzheimer’s 47.2% Mixed Dementia 33.7% Adapted from Feldman H, Levy A, Hsiung G, et al. A Canadian Cohort Study of Cognitive Impairment and Related Dementias (ACCORD): Study Methods and Baseline Results. Neuroepidemiology 2003;22: 265-274.

16. How many people have dementia? (Canadian Study of Health and Aging Working Group, 1994).

17. Vascular dementia is related to stroke and can cause a loss in memory, reasoning, thinking, attention span and independence with activities of daily living. Alzheimer Society of Canada Health and Quality of Life Outcomes 2004, 2:52

18. Vascular dementia results when a critical part of the brain does not receive enough oxygen. http://www.emedicinehealth.com/stroke-related_dementia/article_em.htm

19. What symptoms may be present in vascular dementia? • Problems concentrating and communicating • Depression accompanying the dementia • Symptoms of stroke, such as physical weakness or paralysis • Seizures http://www.alzheimers.org.uk/Facts_about_dementia/What_is_dementia/info_vascular.htm

20. What are the symptoms of vascular dementia? • Memory problems (although this may not be the first symptom) • A ‘stepped’ progression, with symptoms remaining at a constant level and then suddenly deteriorating • Periods of acute confusion http://www.alzheimers.org.uk/Facts_about_dementia/What_is_dementia/info_vascular.htm

21. Other symptoms may include: • Hallucinations (seeing things that do not exist) • Delusions (believing things that are not true) • ‘Wandering’ and getting lost • Physical or verbal aggression • Restlessness • Incontinence http://www.alzheimers.org.uk/Facts_about_dementia/What_is_dementia/info_vascular.htm

22. Communication Strategies • Eliminate distractions (e.g. TV, radio) • Approach the person slowly and from the front; establish and maintain eye contact • Use short, simple sentences • Speak slowly • Give one instruction at a time • Ask “yes/no” rather than “open-ended” questions • Repeat messages using the same wording • Paraphrase repeated messages • Avoid interrupting the person; allow plenty of time to respond • Encourage the person to “talk around” or describe the word he is searching for. Small et.al., (2003) Effectiveness of Communication Strategies Used by Caregivers of Persons With Alzheimer’s Disease During Activities of Daily Living, Journal of Speech, Language and Hearing Research; 46, 2:353

23. ADLStrategies

24. Eating • Offer one food at a time • Use contrasting colours for food, plate, placemat • Try lighter weight utensils & cup • Serve more finger foods • Check for dentures, problems with chewing http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

25. Eating • Provide a relaxing eating area • Provide adequate fluids - serve jello, popsicles, juices, and ice cream to increase fluids • If appetite is poor, contact your registered staff or doctor • Some residents benefit from dietary supplements (Ensure) http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

26. Bathing • Ensure privacy and respect • Have the bath water ready beforehand. • Ensure that the water is not cold. • Let the resident touch the water. • Use gentle touch and cueing http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

27. Bathing • Save shampooing until last (avoid showering the face) • Avoid bath oils that make the tub slippery • Use coloured decals/mat to indicate the tub bottom • Cover up mirrors if they disturb the patient http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

28. Dressing • Lay articles of clothing out in sequence • Pick clothes that fit easily • Keep the dressing routine as consistent as possible • If the patient wants to wear the same thing over and over, obtain duplicates http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

29. Toileting • Make sure that the toilet is visible from the resident’s bed or hallway • clearly mark the bathroom door with a sign • Provide adequate lighting along the pathway to the bathroom http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

30. Toileting • Encourage a toileting routine to avoid incontinence e.g. every 2 hours • Continually evaluate the level of assistance needed • Remember that urinary tract infections are common in elderly people; if a fever persists for more than 24 hours, contact your doctor http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

31. Mobility • Increase daily exercise & activity level • provide safe access to the outdoors • decrease or increase the resident's stimulation • add familiar items to the resident’s room

32. Mobility • Remind residents to use their walking aid due to memory problems, • Remind/teach residents about the need to use walker brakes, • It is important to use these strategies to decrease the risk of falls

33. Always remember that you can request an OT referral from CCAC if you need assistance with finding the right strategy.

34. Jerry Jerry is a 68 year old man who has been living at Cozy Acres for the last 6 months. Jerry entered the nursing home after his wife was admitted to hospital. Jerry has had episodes of forgetfulness (left the stove on, and tap running) and impulsivity and needs help completing multi-step activities since his stroke 2 years ago. Jerry is well-liked by everyone and gets around Cozy Acres independently with his walker.

35. Jerry Recently Jerry has been found wandering around the facility. He usually finds his way back but sometimes needs staff to bring him back to his unit. Jerry at times forgets to use his walker and becomes angry when staff reminds him that he needs to use it at all times. Jerry has said that he feels that they are just trying to “boss him around” and that he really does not need the walker, even though he has had 2 falls in the last week.

36. Jerry Today when you entered Jerry’s room he did not recognize who you were. You initially thought he was joking with you. What do you think is going on with Jerry? What else could be happening with Jerry? What are you going to do next?

37. Next Steps… • You are the eyes, ears and voice of your facility. • Be aware of the diagnosis of your residents • Take this information and use it with your residents. • Share this information with other staff.

38. More Information • Acute Changes and Stroke • Continence and Stroke • Dementia and Stroke • Falls and Stroke • Pain and Stroke Please contact: Rebecca Fleck or Kim Young Community and Long Term Care Specialist Central South Regional Stroke Program 905-521-2100 x 44127

39. Acknowledgements • Best Practices long term care advisory group • Best Practices long term care evaluation group • Barb McCoy and Deb Bryson, Psycho –geriatric consultants, Hamilton • Mary-Lou Vander Horst, Regional Best Practice Coordinator Long-Term Care Central South Region • Wendy McDougall, Regional Best Practice Coordinator Long-Term Care, Central West Region • Central South Regional Stroke Program • Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuro-ambulatory Centre • Melanie Fall Stratton, Regional Stroke Program, Program Manager, • Kim Young, Regional Stroke Program, Community and Long-term Care Specialist • Lisa Colizza, Regional Stroke Program, Regional Stroke Development Specialist • Nancy van Essen, Regional Stroke Program, Stroke Rehabilitation Coordinator • Carol Pereira, Regional Stroke Program, LTC Project Coordinator