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4
Alzheimer's disease is the sixth leading
cause of death in the United States.
More than 5 million Americans are living
with the disease.
1 in 3 seniors dies with Alzheimer's or another dementia.
In 2012, 15.4 million caregivers provided
more than 17.5 billion hours of unpaid care valued at $216 billion.
Nearly 15% of caregivers for people with
Alzheimer's or another dementia are long-
distance caregivers.
In 2013, Alzheimer's will cost the nation $203
billion. This number is expected to rise to $1.2
trillion by 2050.
Source: Alzheimer’s Association, www.alz.org
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• Not a specific disease
• A general term that describes a wide range of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities
• Alzheimer's disease accounts for 60 to 80 percent of cases
• Vascular dementia, which occurs after a stroke, is the second most common dementia type
WHAT IS DEMENTIA?
Source: Alzheimer’s Association, www.alz.org
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DEMENTIA
Alzheimer’s Disease Vascular Dementia
Lewy Body
Parkinson’s Disease
Frontotemporal
Mixed Dementia
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At least two of the following core mental functions must be significantly impaired to be considered dementia:
• Memory
• Communication and language
• Ability to focus and pay attention
• Reasoning and judgment
• Visual perception
SYMPTOMS OF DEMENTIA
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#1: Alzheimer’s disease
#2: Vascular dementia
CAUSES OF DEMENTIA
• Dementia with Lewy bodies
• Mixed dementia
• Parkinson’s disease
• Frontotemporal dementia
• Creutzfeldt-Jakob disease
• Normal pressure hydrocephalus
• Huntington’s disease
• Wernicke-Korsakoff Syndrom
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Symptoms:
• Difficulty remembering names and recent events
• Apathy and depression
• Impaired judgment
• Disorientation
• Confusion
• Behavior changes
• Difficulty speaking, swallowing and walking
ALZHEIMER’S DISEASE
Source: Alzheimer’s Association
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Brain changes:
• Deposits of the protein fragment beta-amyloid (plaques) that build up between brain cells
• Twisted strands of the protein tau (tangles) that build up inside cells
• Evidence of nerve cell damage and death in the brain
ALZHEIMER’S DISEASE
Source: Alzheimer’s Association
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STAGES
Source: Alzheimer’s Association
Stage 1 No impairment The person does not experience any memory problems. An interview with a medical professional does not show any evidence of symptoms of dementia.
Stage 2 Very mild cognitive decline The person may feel as if he or she is having memory lapses — forgetting familiar words or the location of everyday objects. But no symptoms of dementia can be detected during a medical examination or by friends, family or co-workers.
Stage 3 Mild cognitive decline Friends, family or co-workers begin to notice difficulties. During a detailed medical interview, doctors may be able to detect problems in memory or concentration.
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STAGES
Source: Alzheimer’s Association
Stage 4 Moderate cognitive declineAt this point, a careful medical interview should be able to detect clear-cut symptoms in several areas: forgetfulness of recent events, greater difficulty performing complex tasks, such as planning dinner.
Stage 5 Moderately severe cognitive declineGaps in memory and thinking are noticeable, and individuals begin to need help with day-to-day activities.
Stage 6 Severe cognitive declineMemory continues to worsen, personality changes may take place and individuals need extensive help with daily activities.
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STAGES
Source: Alzheimer’s Association
Stage 7 Very severe cognitive declineIn the final stage of this disease, individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement.
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Symptoms:
• Impaired judgment or ability to plan steps needed to complete a task is more likely to be the initial symptom, as opposed to the memory loss often associated with the initial symptoms of Alzheimer's
• Occurs because of brain injuries such as microscopic bleeding and blood vessel blockage
• The location of the brain injury determines how the individual's thinking and physical functioning are affected
VASCULAR DEMENTIA
Source: Alzheimer’s Association
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Brain changes:
• Brain imaging can often detect blood vessel problems implicated in vascular dementia
• In the past, evidence for vascular dementia was used to exclude a diagnosis of Alzheimer's disease (and vice versa)
• That practice is no longer considered consistent with pathologic evidence, which shows that the brain changes of several types of dementia can be present simultaneously
VASCULAR DEMENTIA
Source: Alzheimer’s Association
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• An acute confusional state
• Medical condition that results in confusion and other disruptions in thinking and behavior, including changes in perception, attention, mood and activity level
• Individuals living with dementia are highly susceptible to delirium
• Can easily go unrecognized
DELIRIUM
Applicable Regulations
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• Applicability
• Mild Cognitive Impairment
• Fire clearance
• Training
• Adequate staffing
• Medical assessments and appraisals
• Safety modifications
• Personal grooming and hygiene items
CARE OF PERSONS WITH DEMENTIA
• 87705
• Wrist bands and egress alert devices
• Exit alarms
• Delayed egress
• Locked doors
Applicable Regulations
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• Plan of operations
• Philosophy
• Assessments
• Admission procedures
• Activity programming
• Staff qualifications
• Staff training
• Physical environment
ADVERTISING DEMENTIA SPECIAL CARE…
• 87706
• Changes in condition
• Success indicators
• Admission agreement
• Advertisements
Applicable Regulations
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• Direct care staff: 6 hours of orientation within the first four weeks
• Various methods of instruction allowed
• 8 hours of inservice training every 12-months
• Require topics
• Documentation
• Trainer requirements
TRAINING REQUIREMENTS IF ADVERTISING…
• 87707
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• 40 hours total orientation
• 20 hours before working independently
• 6 hours dementia
• 4 hours postural supports, hospice
• 20 hours within first 4 weeks of employment
• 6 hours dementia
2016 CAREGIVER ORIENTATION TRAINING
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• 20 hours annually
• 8 hours dementia
• 4 hours postural supports, hospice
2016 CAREGIVER ONGOING TRAINING
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• Complications related to the disease
• Significant concern for safety and quality of life
• Often related to eventual cause of death
• Creates risk management issues for the provider
CO-MORBIDITIES IN DEMENTIA CARE
Dysphagia:
Occurs when there is a
problem with any part of
the swallowing process.
SWALLOWING DISORDERS
Aspiration:
Occurs when liquids or solids are breathed into the respiratory system instead of properly being swallowed I into the stomach.
SWALLOWING DISORDERS
Monitoring Residents for Dysphagia and Aspiration
• Choking on foods, liquids or medication
• Coughing during or after eating
• Wet sounding voice
SWALLOWING DISORDERS
Monitoring Residents for Dysphagia and Aspiration (cont.)
•Extra effort to chew or swallow
• “Pocketing” food
SWALLOWING DISORDERS
1. Have Resident sit upright when eating.
2. Tilt the resident’s head slightly forward when eating.
3. Ensure the resident remains sitting or standing upright for at least 15-20 minutes after finishing a meal.
4. Minimize distractions in dining area.
INTERVENTIONS/SWALLOWING DISORDERS
(cont.)
5. Do not encourage residents to talk until he/she has swallowed his/her food.
6. Cut food into small pieces.
7. Encourage swallowing more than once after each bite or drink.
INTERVENTIONS/SWALLOWING DISORDERS
(cont.)
8. Modified diets if physician ordered.
9. Request a speech therapy evaluation from the physician to evaluate swallowing.
INTERVENTIONS/SWALLOWING DISORDERS
SWALLOWING DISORDERS
Examples of Modified Diets forResidents with Cognitive
Impairment and Swallowing Disorders
• Thick liquids
• Soft foods
• Pureed
• Minced, ground and
chopped
MODIFIED DIETS/ SWALLOWING DISORDERS
Bacteria
• Bacteria enters through inhalation or the bloodstream.
• Bacteria infect the alveoli.
• Immune system responds by releasing white blood cells to attack bacterium.
• Release of white blood cells also triggers body to respond with fever, chills and fatigue.
CAUSES OF PNEUMONIA
Virus
• Virus enters body through droplets that enter the mouth or nose.
• Virus invades cells around the alveoli and airways.
• Attacked cells die which leads to swift response from body’s immune system
• Fluid leaks into alveoli which affects the transportation of oxygen into bloodstream.
CAUSES OF PNEUMONIA
Fungus
• Least common cause of pneumonia
• Fungi enters body through inhalation of spores, or through the bloodstream
• Fungi travel to alveoli and surrounding cells.
• White blood cells are released to destroy the fungi, which also triggers the body to respond with fever, chills and fatigue.
CAUSES OF PNEUMONIA
Signs and Symptoms to Monitor (cont.):
• Cough
• Chest Pain
• Blue tint to lips or nails
• Flu like symptoms
• Inability to clear throat
PNEUMONIA
1. Septic Shock
Untreated bacteria growth in the bloodstream can cause normal circulation to shut down. In some cases, body tissues can swell uncontrollably and cause organ failure.
COMPLICATIONS OF PNEUMONIA
2. Lung Abscess
In some cases of pneumonia, a cavity forms within the affected area and fills with puss.
COMPLICATIONS OF PNEUMONIA
3. Acute Respiratory Distress Syndrome (ARDS)
Sometimes pneumonia becomes so widespread in the lungs breathing becomes increasingly difficult. As a result, the body does not receive enough oxygen to function properly.
COMPLICATION OF PNEUMONIA
4. Pleural Effusion
This condition occurs when fluid accumulates in the membrane that surrounds the lungs. When this membrane becomes inflamed form pneumonia, it is more susceptible to fluid retention and infection.
COMPLICATIONS OF PNEUMONIA
• Good nutrition and hydration
• Regular physicalactivities
• Monitor for aspiration
INTERVENTIONS TO AVOID PNEUMONIA
Factors that Contribute to Skin Problems:
• Poor nutrition
• Dehydration
• Lack of ability to ambulate or move about easily
• Inability to turn in bed or from side to side in chair
PRESSURE ULCERS
Factors That Contribute to Skin Problems (cont.)
• Decreased sensation
• Poor circulation
• Shearing
• Loss of bladder and/or bowel control
• Decreased activity
• Poor cognitive function (especially residents with dementia)
PRESSURE ULCERS
• Turn and reposition minimally every 2 hours
• Hydrate skin with topicalapplication of lotions/creams
STRATEGIES FOR HEALTHY SKIN
• Utilization of a barrier cream/ointment for incontinence
• Meticulous incontinent care
• Adequate hydration and nutrition
STRATEGIES FOR HEALTHY SKIN
1. Blood Poisoning – condition when bacteria enters the blood stream. Requires immediate medication attention, or could progress to sepsis which is life threatening.
2. Infection in the Bone – also known as “Osteomyelitis”. Infection enters bone through outside wound or from the bloodstream. If left untreated may cause permanent bone damage.
COMPLICATIONS WITH PRESSURE ULCERS
3. Infection with Antibiotic – Resistant Bacteria: a bacteria that is not killed or controlled by antibiotics. This is a serious health problem for the resident and everyone in the facility.
4. Pain and Associated Depression –
Persistent and chronic pain from pressure ulcers can cause emotional distress and depression.
5. Amputation – severe ulcers can lead to amputation of infected extremity.
COMPLICATIONS WITH PRESSURE ULCERS
Four Stages of Pressure Ulcer:
Stage 1: The initial sign of a pressure ulcer is reddening of the skin. At this point, the wound is only superficial and the skin is typically unbroken. A Stage 1 pressure ulcer will heal quickly when the pressure point is relieved on the area.
PRESSURE ULCERS
Stage 2 – This stage is characterized by a blister on the surface of the skin. The blister can be broken or unbroken. There are now layers of the skin that have become injured, so the wound is no longer superficial.
PRESSURE ULCERS
Stage 3 – In this stage, the wound has progressed through all layers of the skin. The affected area is at high risk for contracting a serious infection. Relieving the pressured area is essential, along with additional padding or coverings to protect the wound and promote healing. Surgery may be needed to remove dead tissue.
PRESSURE ULCER
Stage 4: This is the final and most severe stage of a pressure ulcer. The wound has now progressed through the skin layers and has reached underlying muscle, tendons, and bone. The wound itself may not appear large in diameter when observing the skin, but the depth of the wound is very severe.
PRESSURE ULCER
Types of Infections Associated with Urination:
•Bladder Infection
•Kidney Infection
•Urethra Infection
URINARY TRACT INFECTIONS (UTI’S)
Causes and Risk Factors of UTI’s
Escherichia Coli Bacteria (E. Coli)
Chlamydia and Mycoplasma
Bowel Incontinence
Kidney Stones
Immobility
Dehydration
Lack of Nutrition
URINARY TRACT INFECTIONS (UTI’S)
Common Symptoms:
Burning pain while urinating
Frequent/Urgent urination
Abdominal or pelvic pain
Itching or tenderness in lower abdomen
Fever and chills
URINARY TRACT INFECTIONS (UTI’S)
Common Symptoms (Cont.)
Fatigue
Blood in urine or cloudy urine
Foul or strong odor
Back or side pain
Confusion or rapid cognitive decline
Nausea and vomiting
URINARY TRACT INFECTIONS (UTI’S)
• Observe for change incondition
• Changes in behavior
• Resident is holdinghis/her abdominalarea
• Increased urgency in the need to void
MONITORING RESIDENTS FOR UTI’S
• Resident complains of pain
• Smaller amounts of urine when voiding
• Urine may smell foul, and look cloudy and dark in color
• Low grade fever
MONITORING RESIDENTS FOR UTI’S
Interventions to Avoid UTI’s
• Encourage/assist the resident to stay hydrated and have balanced nutrition.
• Good incontinence care as well as proper hygiene for the continent resident.
• Encourage/assist using the bathroom throughout the day.
URINARY TRACT INFECTION (UTI’S)
• More than 1/3 of adults 65 and older fall each year in the US.
• Men are more likely to die from a fall. However, women are 67% more likely than men to have a nonfatal fall injury.
• When an older adult falls, the effects go beyond physical injury.
FALLS
Resident Risk Factors of Falls:
• Effects of Medications
• Eyesight problems
• Hip, leg and foot disorders
• Disease and illness
FALLS
Environmental Risk
Factors
• Elevated Bed Heights
• Low-seated chairs
• Poor lighting
• Slippery floors or non-secured rugs
FALLS
Environmental Risk Factors (Cont.)
• Clutter
• Poorly maintained walking aids
• Lack of safety equipment
FALLS
Fall risk assessment
Condition of resident, medications used by resident, history of falls, gait and balance assessment, walking aid assessment, medical history, evaluation by physical therapist, etc.
FALL RISK REDUCTION STRATEGIES
General strategies
• Observe environment for potentially unsafe conditions.
• Identify residents who are “at risk” for falling and implement specific fall risk reduction strategies for that resident.
• Many others
FALL RISK REDUCTION STRATEGIES
General Strategies
• Remind resident to request assistance as needed.
• Ensure all pathways are free from obstacles.
• Provide adequate lighting
• Provide appropriate chairs with arms that are solid and secure.
FALL RISK REDUCTION STRATEGIES
89
CURRENTLY APPROVED TREATMENTS
Name Brand name Approved For FDA Approved
1. donepezil Aricept All stages 1996
2. galantamine Razadyne Mild to moderate 2001
3. memantine Namenda Moderate to severe
2003
4. rivastigmine Exelon All stages 2000
90
• Target key chemicals in the brain (neurotransmitters) that are disrupted by Alzheimer’s
• Do not cure the disease
• Do not treat the underlying cause
• May help to improve symptoms
CURRENT TREATMENTS
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• New drugs in development are trying to modify the disease process itself
• Impacting one or more of the many brain changing caused by Alzheimer’s disease
• Researchers believe effective treatment will require a “cocktail” of medications
• Obstacles to progress: not enough volunteers, not enough federal funding for research
TREATMENT HORIZON
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• Beta-amyloid
• Tau protein
• Inflammation
• Insulin resistance
• Brain imaging and biomarkers
TARGETS FOR FUTURE DRUGS
93
• Jerry… Please insert this video:• http://www.alz.org/research/video/video_pages/
understanding_attacking_alz.html
BETA-AMYLOID
94
• Jerry… Please insert this video:• http://www.alz.org/research/video/video_pages/
inflammation.html
INFLAMMATION
95
• Jerry… Please insert this video:• http://www.alz.org/research/video/video_pages/
insulin_and_alz.html
INSULIN RESISTANCE
96
• Jerry… Please insert this video:• http://www.alz.org/research/video/video_pages/
quest_for_biomarkers.html
BRAIN IMAGING AND BIOMARKERS