Transcript Different Strokes for Different Folks: Variable Approaches to Different Forms of Dementia

Different Strokes for
Different Folks: Variable
Approaches to Different
Forms of Dementia
Julie Feil, MSW, LCSW
The Memory Center
Affinity Health System
The Goals of The Memory
Center
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We see individuals of all ages with all
forms of memory loss in various
stages.
To identify and provide treatment
options for those with memory
disorders
To advocate for early detection!
Why is the Diagnosis
Important?
It allows us to identify what form of memory
problem we are dealing with. This results
in:
 More focused education and supportappropriate to family and individual
 More accurate and effective pharmaceutical
treatment modality choice
 Increased awareness for families and
individual
 Rule out treatable causes of dementia
It is like Stopping a
Rolling Truck!
Barriers to Obtaining a
Diagnosis
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Belief that it is “Just normal aging”
Stigma attached to “Alzheimer’s
Disease”
Fear
Lack of Insight into Problem
Denial
Embarrassment
Determining the
Diagnosis
Appointment includes:
 The Neurological or Medical
Examination
 The Neuropsychological
Testing
 The Psychosocial Evaluation
Possible Diagnosis’
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Alzheimer’s Disease
Mild Cognitive Impairment
Probable Lewy Body Dementia
Vascular Dementia
Frontotemporal Dementia
Normal Pressure Hydrocephelus
Sleep Apnea
Pseudodementia- Depression
Epilepsy
Parkinson’s Disease Plus
Alcohol Related Dementia
Imaging Studies
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Extremely helpful tool in diagnosing which
particular type of memory disorder is likely present.
A trained physician can now identify classic
Alzheimer’s Disease with 98% certainty.
Alzheimer’s Disease
What is Alzheimer’s
Disease?
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The most common cause of dementia
Irreversible, progressive disease
Affects the brain by destroying neurons –
first in the hippocampus (memory area of
the brain) then spreading to other areas
Neuron degeneration is felt to be from
plaques consisting of beta amyloid proteins
that are deposited and tangles in nerve cells
Is it in the Water?
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“Why are so many
people ‘getting it’ “ is a
common question.
We do not know the
exact cause nor do we
have a cure. Latest
research is focusing on
diet and lipids.
This is a disease that,
predominantly affects
those > 65.
As we are living longer,
the prevalence is thus
higher.
Neuropsychological
Testing
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Following testing, individuals with MCI
show an isolated memory loss. Those
with Alzheimer’s Disease show a
pattern of increased difficulty with
memory, categorical fluency,
orientation, and emerging problems in
construction and calculations.
Exercise
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Name as many animals as you can in 1
minute
Measures catagorical fluency
Individuals with some form of progressive
memory disorder will score less than 12 and
should be evaluated.
A better predictor of Alzheimer’s disease or
MCI than the Mini Mental and can easily be
used quickly as a screen in doctor’s offices
Mild Cognitive
Impairment
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Being researched as a likely “precursor” to Alzheimer’s Diseaseconsists of mild memory loss that
appears progressive in nature
It is crucial that these individuals are
assessed as early preventative
interventions are showing promise in
delaying the onset or “conversion” to
Alzheimer’s Disease!
Assessment Questions
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Short term memory loss?
Financial management
Repetitive questions?
Depression? Anxiety?
Misplacing items or hiding
items?
Orientation to person, place
and time
Change in ability to perform
hobbies or household tasks?
Occupational issues?
Depression Screen
It is also important to address depression
using a depression screening tool such as
the Geriatric Depression Scale or Beck
Depression Inventory.
Why? Studies suggest between 20 and 30%
of dementia patients in early stages develop
Major Depressive Disorder and between 3040% in middle stages. Not uncommon,
depressive symptoms need to be monitored
closely on a frequent basis and treated
appropriately.
Characteristics - Early
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Short term memory loss
and asking questions
repeatedly are often the
first signs
Inability to complete
familiar tasks
Difficulty learning and
retaining new information
Misplacing items, often in
inappropriate places
A growing awareness of
subtle changes may cause
depression and frustration.
Moderate
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Forgetting to turn off
stoves, appliances
Emerging safety
concerns
Problems with
calculations and
financial management
Inappropriate in public
More problems
communicating,
reading, writing
Severe
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Severe loss of memory
May be unable to recognize loved ones
More hallucinations or delusions
Void of emotion
Needs assistance with all personal
cares
Difficulty chewing or swallowing.
Treatments
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Cholinesterase Inhibitors are being used to
slow the progression with good success:
– Aricept
– Razadyne
– Exelon
Other medication often used in conjunction with
cholinesterase inhibitors (NMDA receptor
antagonist)
– Namenda
Key Psychosocial Issues
Individuals and families coping
with Alzheimer’s Disease
require ongoing support as
the disease progresses.
A referral to the local
Alzheimer’s Association is
recommended for ongoing
needs
Although there is “staging”
documented and many
follow the pattern loosely,
everyone has a unique,
individual experience.
Supportive Approaches
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Care partners have various
thresholds in terms of their
ability to manage the care of
someone with progressive
Alzheimer’s Disease.
Goal is to tackle each
symptom as it emerges and
seek manageable solutions
Behavior issues are often
signs of unmet, unexpressed
needs.
Important to increase activity
level and provide cognitive
“exercise” as well as physical
and social activity.
The Alzheimer’s
Association
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Excellent organization for all types of
memory disorders
Provide support, education, advocacy
and programming encompassing all
aspects of the disease to individuals
and their care partners.
Other Resources for
Individuals and Care
Partners
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Adult Day Centers
Home health agencies
Respite care
Transportation resources
Care consultants
Assisted living options
County Departments on Aging / Benefit
Specialists
Aging and Disability Resource Centers
Elder Law Attorney
Support Groups
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Support groups are very valuable and
take many forms. Groups exist for:
– MCI patients
– Early onset Alzheimer’s disease
– Care partners (spouses, family, etc)
– Adult Children of people with Alzheimer’s
Disease
– Early stage Alzheimer’s Disease
Key Resources
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Books and Magazines:
– The 36 Hour Day – Mace and Rabins
– A Dignified Life: The Best Friend’s Approach to
Alzheimer’s Care – Bell and Troxel
– Reminiscence magazine (Reiman Public.)
– Aging with Grace - Snowdon
– Learning to Speak Alzheimer’s - Coste
– Mayo Clinic on Alzheimer’s Disease - Peterson
Resources continued:
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Websites:
– www.alz.org – The Alzheimer’s Assoc.
– www.alzheimers.org - Alzheimer’s Disease
Education and Referral Center
– www.alzstore.com – The Alzheimer’s Store
– www.cwag.org – Coalition of WI Aging Groups
– www.dhfs.state.wi.us/aging/dementia - WI
Bureau of Aging & Long Term Care Resources
– www.mayoclinic.com – Mayo Clinic Health Info
Lewy Body Dementia
Lewy Body Dementia
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A progressive brain disease and second leading
cause of dementia in elderly. (20% of all dementia
cases)
Appears to affect men more than women
Consists of protein deposits or “lewy bodies” that
are widespread throughout the brain. Often the
memory area looks fine on imaging.
Cognitive decline occurs prior to or concurrent with
parkinsonian features
Earlier age of onset than Alzheimer’s
Characteristics
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A probable Lewy Body Disease is
defined when one meets 2 out of the
3 symptoms:
– Fluctuating Cognition with clear variations
in alertness.
– Recurrent visual hallucinations that are
very detailed
– Parkinsonism – muscle stiffness and rigid,
slowed movements
Other Suggestive Features
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REM sleep disorders – vivid dreams,
purposeful and sometimes violent
movements
Severe sensitivity to neuroleptics
(medications for psychiatric symptoms)
Abnormal depth perception – problems in
visuospatial skills
Mood lability, depression, aggression
Neuropsychological
Testing
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Individuals with LBD have difficulty in
the following areas of cognitive
thinking:
– Orientation
– Construction
– Perception
– Memory
Hooper Visual Organization
Test
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30 “puzzle” pictures
Indicator of visuospatial skills and posterior
functioning.
Shows how we perceive and make sense of
the world around us.
Often a good predictor of whether or not
someone should be retested for driving
abilities.
Hooper Visual Organization
Example
Answer:
LIGHTHOUSE
Clock Draw Example
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Goal- To draw the face of a clock, put the
numbers in the correct positions, and
indicate the time at 11:10.
Key Psychosocial Issues
Families and affected person
may be dealing early on with
safety issues involving the
physical issues,
hallucinations, and
misperceptions (often leading
to trouble with driving).
Also, the inconsistency of
symptoms and confusion,
creates stress as the family
never quite knows what is
coming next.
Loved one may not recognize
family or home at an earlier
stage.
Assessment Questions
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Sleep disturbance?
Gait disturbance / Falls?
Appears socially withdrawn at times
Variable symptoms?
Hallucinations?
Disorientation?
Suspiciousness?
Wandering?
Apparent slowed processing verbally
and physically
Other behavior problems or
aggression?
Supportive Approaches
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Families struggle with
misperceptions- benefit from
support of others in same
situation (support groups).
Care partners need respite!
Often occurs at a younger agegrieve loss of retirement plans,
etc.
Individual often very insecure
without loved one
More rapid course than AD
Physical and communication
issues in addition to cognitive
Common Interventions
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Due to Parkinsonism, individual is at a higher fall
risk. Need to adapt environment and consider a
Physical therapy evaluation
Misperceptions! Eg. May perceive that a black rug is
a hole, or texture change represents a different
height/level. Occupational therapist evaluation,
adjusting home environment, adjusting lighting and
visual cues
Wandering Risk – easily disorientated- Obtain Safe
Return
Driving Issues – becomes lost or does not recognize
once familiar landmarks. Driver evaluation and
subsequent referral to transportation resources
suggested
Treatments for LBD
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Cholinesterase inhibitors (medications
approved for Alzheimer’s Disease) tend to
work even better for people with LBD
Parkinson’s Disease medications often help
with the symptoms related to movement
It is important to diagnose LBD as some
antipsychotic medications given for
hallucinations can cause severe reactions in
patients with this disease. (eg. Haldol)
Key Resources
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The Alzheimer’s Association
The Lewy Body Dementia Association
Websites:
– www.lewybodydementia.org LBD Assoc.
– www.zarcrom.com/users/alzheimers/ode
m/od-d.html Directory of other
Dementias
– www.alz.org – The Alzheimer’s Assoc.
The Frontotemporal
Dementias
Frontotemporal
Dementias
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Neurodegenerative changes in the frontal
and temporal lobes of the brain
Several types depending on which areas
show damage – eg. Picks disease (involves
only frontal lobes)
Occurs between the ages of 35 and 75
years (younger than AD and LBD) Some
forms are genetic.
Many early research programs are focusing
on the frontotemporal dementias and
“possible” reversible causes
Characteristics
There is generally an early loss of personal
awareness and sometimes an increase in
social disinhibition and mood swings.
Depression is common
Often diagnosed at an earlier age, therefore
occupational problems may exist.
Family members are usually quite frustrated
and require special counseling or support
More rapid progression
The Frontal Lobe - the
Gatekeeper
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People who suffer from
the FTDs may exhibit
inappropriate behaviors
in public, be less
inhibited, may show
mood swings, or may
become quite the
opposite- more
depressed, apathetic
and socially withdrawn.
Neuropsychological
Testing
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Frontal area involves the “doing” part
of the brain- executive functioning
thus testing shows difficulties in the
areas of:
– Behavior
– Reasoning and Judgment
– Planning
– Initiation
Neuropsychological
testing continued…
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Temporal Area involves speech and
language thus testing reveals difficulty
with
– Naming
– Comprehension
– Word finding
– Speech (aphasia often noted)
Example – Boston
Naming Test
Key Psychosocial Issues
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Loss of Insight: Often people
with frontotemporal dementias
do not have insight into their
difficulties. This makes it more
challenging for families to
provide care and that care is
occasionally met with
resistance
Compulsive behaviors
Lack of empathy for othersOften the care partner desires
an acknowledgement for their
hard work that never comes.
Assessment Questions
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Judgment and Insight
Decision making, impulsivity
Mood changes – depression,
apathy
Alteration in planning and
initiation
Susceptible to sweepstakes
Compulsive behaviors
Speech and language issues
Socially or sexually
inappropriateness
Work related problems
Supportive Approaches
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Often the disinhibition and behavior changes
combined with the lack of insight put care partners
in very difficult situations. Families benefit greatly
by connecting with others.
Examine behaviors and look at underlying needs
that are unexpressed or the emotions behind the
behaviors. Document approaches and redirections
that work.
Compulsive behaviors can be draining on loved
ones.
Need to choose battles wisely!
Communication
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As the temporal lobes
become damaged, one
will often will see
changes in ability to
express self and
converse with others.
A referral to a speech
therapist and
communication books
may be helpful
Treatments
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The cholinesterase inhibitors (Alzheimer’s
medications) work in approximately 1 in 3
patients with FTD. We are not sure why.
SSRIs or specific anti-depressants are being
investigated as chemically beneficial and
also help control behavior symptoms and
accompanying depression
Key Resources
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Books:
– The 36 Hour Day – Mace and Rabins
– What if it’s Not Alzheimer’s? A Caregiver’s
Guide to Dementia – Radin and Radin
– Websites:
www.alz.org – The Alzheimer’s Assoc.
 www.ftd-picks.org – The Assoc. for
Frontotemporal Dementias
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Vascular Dementia
Vascular Dementia
or Multi Infarct Dementia
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Caused by “hardening of the arteries” or
mini silent strokes in the brain
The blockages of the small arteries of the
brain caused by poor blood flow. Can be
prevented by a heart healthy diet and other
stroke prevention techniques (controlled
blood pressure and cholesterol)
More common in those with Alzheimer’s
Disease as a co-existing problem.
Characteristics
Early on there may be changes in:
Memory and cognition
Decision-making
Sleep disturbance
Apathy
Sensory Loss
More physical limitations
Language problems
Assessment and
Approaches
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Any or all of the above symptoms or
approaches mentioned may apply
dependent on where the damage has
occurred in the brain.
A clear differentiation of diagnosis is
thus important.
Treatments
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Goal is to prevent further strokes through
diet and exercise.
Generally speaking, what is good for the
heart is good for the brain
Anticoagulants such as Aspirin, Aggrenox,
Plavix, or Vit. E are often used.
Cholinesterase inhibitors are utilized –
Razadyne has been approved for use and
has shown benefit in those with Vascular
Dementia
Summary
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There are many kinds of dementia – it is
inaccurate to assume “Alzheimer’s Disease”
prior to a complete diagnostic assessment.
It is important to determine which type of
memory loss one has as there are various
treatments, prognosis, and expectations
related to each. Some are also preventable!
Each form has its own unique effects on
family and care partners. It is important to
tailor our approach to that individual’s
needs.
What Comes First?
Alzheimer’s Disease
Memory, repetition,
confusion
Lewy Body Dementia
Hallucinations,
variability, movement
problems
Behavior changes,
apathy, language
problems
Depends on area of
damage
Frontotemporal
Dementias
Vascular Dementia
QUESTIONS?
FOR YOUR REFERENCE
Comprehensive Psychosocial
Interventions
Should include:
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Assessment of psychosocial needs of the
individual with the memory loss and their family.
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Ruling out other possible contributing causes of
dementia such as depression and alcoholism
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Providing support and counseling as they journey
through the various stages of the disease
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Providing education and resources to meet
ongoing needs.
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Advocating for the individual and family.
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Promotion of healthy lifestyle and nonpharmaceutical interventions if possible
Continued…
Assessments of:
 Family History of Memory Loss
 Family Dynamics and Support
Systems
 Social and Occupational implications
 Safety and Potential Environmental
Barriers
 Communication Issues
Continued…
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Mental health history
Activities of Daily Living – grooming,
dressing, and bathing (The Functional
Activity Questionnaire is often given)
IADLs- meal preparation, cleaning,
shopping, money management
Medication compliance
Continued…
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Driving
Financial Planning
Emerging Behavioral Issues
Advanced Directives and Financial
Planning
End of Life Care