Dementia Boot Camp

1. Dementia Boot Camp Melanie Bunn, RN, MS, GNP melanie.bunn@yahoo.com Geriatric Grand Challenge Institute: Dementia Care Duke University School of Nursing March, 2013

2. Objectives • Describe the structural & chemical changes in the brain & their effect on behavior & function in people with dementia • Discuss the limits of current systems of care for addressing the needs of people with dementia & explore alternative approaches

3. What are the currentissues/systems of care? • Risk based dementia prevention • Diagnosis (Medicare wellness visit) • Public awareness/community engagement • Care coordination & transitions • Safety issues • Managing & preventing comorbidity • Behavioral management/skills • End of Life Care

4. Risk Based Dementia Prevention

5. Non-compliance • Acute illness 20% to 40% • Chronic illness 30% to 60% • Prevention 80% • See the pattern? Why? Christensen AJ. Patient adherence to medical treatment regimens: bridging the gap between behavioral science and biomedicine. New Haven: Yale University Press; 2004. Current perspectives in psychology.

6. SCREEN SHOTALZ prevention

7. Risk Based Dementia Prevention • Nutrition • Mental exercise • Physical activities • Stress management • Other lifestyle choices http://www.alzprevention.org/

8. Traditional Approach

9. Alternative Approach:Motivational Interviewing

10. Screening for Dementia:Medicare Annual Wellness Visit

11. Diagnosis:Previous Approaches • “Screening” at health fairs • Evaluation when symptoms are noticed • Lack of insight/cooperation with assessment • Absence of baseline • Attitudes as a barrier to screening • Untreatable • Part of aging • Something to be hidden

12. Medicare Annual Wellness Visit • Normalizes cognitive assessment and screening • Sets individual baseline • Identify early changes • Standardizes & simplifies approach • Research into tools, phone screening

13. SCREEN SHOTAnnual Wellness Visit

14. Medicare Annual Wellness Visithttp://www.alz.org/professionals_and_researchers_14899.asp • Cordell CB, Borson S, Boustani M, Chodosh J, Reuben D, Verghese J, et al. Alzheimer's Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting.Alzheimer's & Dementia: The Journal of the Alzheimer's Association. 2012. In Press. • Alzheimer's Association Medicare Annual Wellness Visit Algorithm for the Assessment of Cognition • Tools highlighted in the recommendations • Medical Learning Network article on the Annual Wellness Visit (billing information on pages 4-6) • Medicare Annual Wellness Visit Fact Sheet

15. Diagnosis

16. What should happen next?Don’t assume, check it out! • Physical exam (Especially neurological & cardiac) • Lab studies • Imaging study • Cognitive evaluation & emotional screen (What works & what doesn’t work) • Functional assessment • Review medications

17. What could it be?Identifying underlying issue Possibilities • Normal aging • Mild cognitive impairment • Acute confusion or delirium • Dementia

18. Differential Diagnosis

19. Vascular (Multi-infarct) Dementia DEMENTIA Lewy Body Dementia Alzheimer’s Disease 70-80 Other Dementias Fronto- Temporal Lobe Dementia

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21. Type of Dementia

22. Alzheimer’s Disease

23. AD: Basic info • Changes happen over months and years, not hours or days • Usually, changes happen in a slow, steady, predictable manner • STRUCTURAL and CHEMICAL changes: • Structural: Plaques & tangles • Chemical: Neurotransmitters drop • Medications impact chemical changes, NOT structural changes

24. AD: Memory • Early on: Storage, not retrieval problem • Later on: Storage and retrieval • Retained: Emotional and motor memory

25. AD: Common changes • MOOD • Blame others: defensive • Blame self: depressed • Impulsive or indecisive • MOBILITY • Not impacted until later in disease • COMMON ISSUES • Getting lost • Making mistakes: words, finances, decisions • Can be explained…but pattern immerges

26. Alzheimer’s • New info lost • Recent memory worse • Problems finding words • Mis-speaks • More impulsive or indecisive • Gets lost • 2 major types: YOUNG or TYPICAL onset • Notice changes over 6 months – 1 year

27. Vascular Dementia

28. Vascular disease • Changes depend on where in the brain damage occurs so… • Each person and each disease is different • Changes are often sudden, inconsistent and less predicable • Not a brain disease: a circulation disease • Big change, improvement, plateau, big change (swelling then absorbed or revascularization) • Associated with diabetes, heart disease, high blood pressure

29. Vascular Dementia • Can have bounce back & bad days • Judgment and behavior ‘not the same’ • Spotty loss (memory, mobility) • Emotional & energy shifts • Memory, mood & mobility can all be impaired…or not!

30. Lewy Body Dementia

31. LBD • Fine motor changes • Using hands • Swallowing • Mobility problems • Rigidity • Tremor • Falls • Periodic limb movements • Fluctuations in abilities & function (fine one day, impaired the next) • Other changes • Syncope • Hallucinations • Delusions • Nightmares • Insomnia • Memory inconsistent (temporary loss of LT) • Attention/executive function • Visual spatial changes • REM sleep BD

32. LBD diagnosis (LBDA website) DEMENTIA plus • 3 core symptoms: • fluctuating cognition (bad days & good days) • vivid visual hallucinations and/or delusions • motor dysfunction OR • 3suggestive symptoms • REM sleep behavior disorder with acting out of dreams or excessive daytime sleepiness • abnormal brain CT/MRI • extreme sensitivity to antipsychotics/other psychotrophic medications

33. LBD: Medications Reactions can be extreme & unpredictable or opposite than expected • Parkinson’s Disease (tremors) • Don’t always help • Make thinking and hallucinations worse • Antipsychotics (hallucinations) • Don’t always help • Make mobility worse • AChEI/NMDA (thinking & behaviors) • Antidepressants

34. Frontal Temporal Dementia

35. Fronto-Temporal Dementias • Many types • Frontal – impulse and behavior control loss (not memory issues) • Says unexpected, rude, mean, odd things to others • Dis-inhibited – food, drink, sex, emotions, actions • OCD type behaviors • Hyperorality • Temporal – language loss • Can’t speak or get words out • Can’t understand what is said, sound fluent – nonsense words

36. Common combinations

37. Public awareness/community engagement

38. Public awareness/community engagement • TV/magazine/health care offices public service ads • Research/conference blips • Non-profit local efforts (fund raising/public awareness)

39. Public awareness/community engagement • These are your communities and why you are here!!! • Here’s what I’m doing: community education programs through ANC, law enforcement education through CIT, profession education through ANC, Duke SON, AHEC sessions • ANC, AA, AFA are all reaching out • You have potential to make more impact!!!

40. Public awareness/community engagement • Alternative approaches • Going to where people are www.alznc.org • Using informal opinion leaders • Prostate cancer screening in African American communities • Churches, barber shops, hair salons

41. Screen shotALZNC

42. Brain Failure Structural brain failure Chemical brain failure

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44. Structural Brain Failure • One way street • Depending on type of dementia, changes happen in different areas resulting in different changes

45. Normal Brain Alzheimers Brain

47. Hearing Sound – Not Changed

48. Understanding Language – BIG CHANGE

49. SENSORY MOTOR STRIP

50. EXPRESSIVE LANGUAGE