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. 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

3. 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.

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

5. Alternative Approach:Motivational Interviewing

6. 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

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

8. 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

9. Dementia update • Prevalence • Biology • Genetics • Risk factors • Detection • Developing treatments • Testing therapies • Caregiving • Health disparities http://www.nia.nih.gov/alzheimers/publication/2011-2012- alzheimers-disease-progress-report/

10. Diagnosis • Physical exam (Especially neurological & cardiac) • Lab studies • Imaging study • Cognitive evaluation & emotional screen (What works & what doesn’t work) • Functional assessment • Review medications

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

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

13. 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

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

15. 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

16. 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

17. 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

18. 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!

19. 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

20. 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

21. 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

22. 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

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

24. 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!!!

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

26. Brain Failure Structural brain failure Chemical brain failure

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

28. Memories • Losses • Where & when you are • What is going on • Where you want to go • What you want to do • Preserved abilities • Confabulation! • Emotional memories • Motor memories

29. Issues of Understanding • Losses • Can’t interpret information • Can’t make sense of words • Gets off target • Preserved abilities • picks up on facial expression • picks up on tone of voice

30. Language Issues • Losses • Can’t find the right words • Not able to say what you mean • Can’t make needs known • Preserved abilities - • automatic speech • singing • swearing • turn taking

31. Sensory Changes • Losses • Awareness of body and position • Ability to locate and express pain • Awareness of feeling in most of body • Preserved Abilities • 4 areas can be sensitive • Any of these areas can be hypersensitive • Need for sensation can become extreme

32. Self-Care Changes • Losses • initiation & termination • tool manipulation • sequencing • Preserved Abilities • motions and actions • the doing part • cued activity

33. Issues of Impulses & Emotions • Losses • becomes labile & extreme • think it - say it • want it - do it • see it - use it • Preserved • desire to be respected • desire to be in control • regret after action

34. Chemical failure • Fluctuations • Extremely good moments and… Extremely bad moments

35. The 3 major problems (as I see it) • Current systems of care are set up BY logical people FOR logical people • Reimbursement is based on procedures & acute care models & doesn’t recognize the complexity of people with dementia • Efforts to improve systems of care aren’t keeping up with the focus on prevention and treatment

36. NAPA • Research – developing new and targeted approaches to prevention and treatment. • Tools for Clinicians • Easier access to information to support caregivers www.alzheimers.gov, • Awareness campaign

37. Alternative Approaches • Geriatric Grand Challenge Institute: Dementia Care • Turning around system care views (inside-out? bottom-top?) • Better communication b/t systems • Better communication b/t families/informal and formal • Smaller group settings • Adult day programs/PACE

38. Suggested Next Steps • Go to the Alzheimer’s Association site and familiarize yourself with the Medicare Annual Wellness Visit algorithm and screening tools • Download the 2011-2012 Alzheimer’s Disease Progress Report from the NIA/NIH Alzheimer’s site • Review prevention recommendations on the AFA site