Dementia Boot Camp

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

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

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.

Risk Based Dementia Prevention

• Nutrition

• Mental exercise

• Physical activities

• Stress management

• Other lifestyle choices

http://www.alzprevention.org/

Alternative Approach:Motivational Interviewing

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

Medicare Annual Wellness Visit

• Normalizes cognitive assessment and screening

• Sets individual baseline

• Identify early changes

• Standardizes & simplifies approach

• Research into tools, phone screening

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

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/

Diagnosis• Physical exam

(Especially neurological & cardiac)

• Lab studies

• Imaging study

• Cognitive evaluation & emotional screen(What works & what doesn’t work)

• Functional assessment

• Review medications

What could it be?Identifying underlying issue

Possibilities

• Normal aging

• Mild cognitive impairment

• Acute confusion or delirium

• Dementia

Alzheimer’sDisease

Vascular (Multi-infarct)

Dementia

Lewy Body Dementia

DEMENTIA

70-80 Other

Dementias

Fronto-Temporal

Lobe Dementia

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

AD: Memory

• Early on: Storage, not retrieval problem

• Later on: Storage and retrieval

• Retained: Emotional and motor memory

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

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

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

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!

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

LBD diagnosis (LBDA website)

DEMENTIA plus•3 core symptoms:

– fluctuating cognition (bad days & good days) – vivid visual hallucinations and/or delusions– motor dysfunctionOR

•3 suggestive 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

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

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

Public awareness/community engagement

• TV/magazine/health care offices public service ads

• Research/conference blips

• Non-profit local efforts (fund raising/public awareness)

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!!!

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

Brain Failure

Structural brain failure

Chemical brain failure

Structural Brain Failure

• One way street

• Depending on type of dementia, changes happen in different areas resulting in different changes

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

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

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

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

Self-Care Changes

• Losses– initiation & termination– tool manipulation– sequencing

• Preserved Abilities– motions and actions– the doing part– cued activity

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

Chemical failure

• Fluctuations

• Extremely good moments and…

Extremely bad moments

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

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

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

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