Title: Dementia Boot Camp
1Dementia Boot Camp
- Melanie Bunn, RN, MS, GNP
- melanie.bunn_at_yahoo.com
- Geriatric Grand Challenge Institute Dementia
Care - Duke University School of Nursing
- March, 2013
2Objectives
- 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
3What 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
4Risk Based Dementia Prevention
5Non-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.
6SCREEN SHOTALZ prevention
7Risk Based Dementia Prevention
- Nutrition
- Mental exercise
- Physical activities
- Stress management
- Other lifestyle choices
- http//www.alzprevention.org/
8Traditional Approach
9Alternative ApproachMotivational Interviewing
10Screening for DementiaMedicare Annual Wellness
Visit
11DiagnosisPrevious 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
12Medicare Annual Wellness Visit
- Normalizes cognitive assessment and screening
- Sets individual baseline
- Identify early changes
- Standardizes simplifies approach
- Research into tools, phone screening
13SCREEN SHOTAnnual Wellness Visit
14Medicare 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
15Diagnosis
16What should happen next?Dont assume, check it
out!
- Physical exam
- (Especially neurological cardiac)
- Lab studies
- Imaging study
- Cognitive evaluation emotional screen
- (What works what doesnt work)
- Functional assessment
- Review medications
17What could it be?Identifying underlying issue
- Possibilities
- Normal aging
- Mild cognitive impairment
- Acute confusion or delirium
- Dementia
18Differential Diagnosis
19DEMENTIA
Lewy Body Dementia
Alzheimers Disease
70-80 Other Dementias
Fronto- Temporal Lobe Dementia
20Go to slide
21Type of Dementia
22Alzheimers Disease
23AD 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
24AD Memory
- Early on Storage, not retrieval problem
- Later on Storage and retrieval
- Retained Emotional and motor memory
25AD 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 explainedbut pattern immerges
26Alzheimers
- 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
27Vascular Dementia
28Vascular 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
29Vascular 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 impairedor
not!
30Lewy Body Dementia
31LBD
- 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
32LBD diagnosis (LBDA website)
- DEMENTIA plus
- 3 core symptoms
- fluctuating cognition (bad days good days)
- vivid visual hallucinations and/or delusions
- motor dysfunction
- OR
- 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
33LBD Medications
- Reactions can be extreme unpredictable or
opposite than expected - Parkinsons Disease (tremors)
- Dont always help
- Make thinking and hallucinations worse
- Antipsychotics (hallucinations)
- Dont always help
- Make mobility worse
- AChEI/NMDA (thinking behaviors)
- Antidepressants
34Frontal Temporal Dementia
35Fronto-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
- Cant speak or get words out
- Cant understand what is said, sound fluent
nonsense words
36Common combinations
37Public awareness/community engagement
38Public awareness/community engagement
- TV/magazine/health care offices public service
ads - Research/conference blips
- Non-profit local efforts (fund raising/public
awareness)
39Public awareness/community engagement
- These are your communities and why you are
here!!! - Heres what Im 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!!!
40Public 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
41Screen shotALZNC
42Brain Failure
- Structural brain failure
- Chemical brain failure
43Go to slide
44Structural Brain Failure
- One way street
- Depending on type of dementia, changes happen in
different areas resulting in different changes
45Normal Brain
Alzheimers Brain
46(No Transcript)
47Hearing Sound Not Changed
48Understanding Language BIG CHANGE
49 SENSORY MOTOR STRIP
50 EXPRESSIVE LANGUAGE
51 OTHER LANGUAGE
52(No Transcript)
53Chemical failure
- Fluctuations
- Extremely good moments and
- Extremely bad moments
54PET and Aging
ADEAR, 2003
55Positron Emission Tomography (PET) Alzheimers
Disease Progression vs. Normal Brains
Late Alzheimers
Early Alzheimers
Child
Normal
G. Small, UCLA School of Medicine.
56The 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 doesnt recognize the complexity of
people with dementia - Efforts to improve systems of care arent keeping
up with the focus on prevention and treatment
57Dementia 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/
58Screen shot Alz.gov
59NAPA
- 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
60Alternative 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
61Final Questions
- How do the structural chemical changes in the
brain effect behavior function in people
with dementia? - What are the limits of current systems of care
for addressing the needs of people with dementia
what are some explore alternative approaches?
62Suggested Next Steps
- Go to the Alzheimers Association site and
familiarize yourself with the Medicare Annual
Wellness Visit algorithm and screening tools - Download the 2011-2012 Alzheimers Disease
Progress Report from the NIA/NIH Alzheimers site - Review prevention recommendations on the AFA site