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1 1 For the slides from this presentation, visit: Slides will be available for 2 weeks 2 Handouts are intended for personal use only. Any copyrighted materials or DVD content from Positive Approach, LLC (Teepa Snow) may be used for personal educational purposes only. This material may not be copied, sold or commercially exploited, and shall be used solely by the requesting individual. Copyright 2017, All Rights Reserved Teepa Snow and Positive Approach to Care Any redistribution or duplication, in whole or in part, is strictly prohibited, without the expressed written consent of Teepa Snow and Positive Approach, LLC 3 1

2 Brain Changes in Dementia 4 PET and Aging: PET Scan of 20-Year-Old Brain PET Scan of 80-Year-Old Brain ADEAR, As we age, we do not lose function in our brains, unless Something Goes Wrong with Our Brains 6 2

3 Normal vs. Not Normal Normal Aging: Slower to think Slower to do Hesitates more More likely to look before leaping Know the person but not the name Pause to find words Reminded of the past Harder Not Normal Aging: Can t think the same Can t do like before Can t get started Can t seem to move on Doesn t think it out at all Can t place the person Words won t come even later Confused about past versus now Very different 7 Ten Early Warning Signs: 1. Memory loss for recent or new information, repeats self frequently 2. Difficulty doing familiar but difficult tasks: managing money, medications, driving 3. Problems with word finding, mis-naming, or misunderstanding 4. Getting confused about time or place, getting lost while driving, missing several appointments 5. Worsening judgment, not thinking thing through like before 6. Difficulty problemsolving or reasoning 7. Misplacing things or putting them in odd places 8. Changes in mood or behavior 9. Changes in typical personality 10. Loss of initiation: withdraws from normal patterns of activities and interests 8 What Could It Be? - Another medical condition symptom - Medication side effect - Hearing loss or vision loss - Depression/anxiety - Acute illness, delirium - Pain or medication for pain - Other things 9 3

4 10 Drugs That Can Affect Cognition in Elders: Anti-arrhythmic agents Antibiotics Antihistamines - decongestants Tricyclic antidepressants Anti-hypertensives Anti-cholinergic agents Anti-convulsants Anti-emetics Histamine receptor blockers Immunosuppressant agents Muscle relaxants Narcotic analgesics Sedative hypnotics Anti-Parkinsonian agents Washington Manual Geriatrics Subspecialty Consults edited by Kyle C. Moylan (pg 15) published by Lippencott, Wilkins & Williams, 2003 Screening Options: Old: - MMSE New: -SLUMS 7 minute screen -Animal fluency 1 minute # of animals -Clock Drawing 2 step - Full Neuropsychological testing panel 11 What Should the Doctor Do? - A thorough physical and medical history - Blood work - A neurological exam - A good history from the person and the family - A complete medication review - A CAT scan or MRI or PET scan - Neuropsychological testing: screening for cognitive changes - Follow-up and counseling, or at least a referral 12 4

5 So, What is Dementia? It is not part of normal aging! It is a disease! It is more than just forgetfulness - which is part of normal aging It makes independent life impossible, eventually 13 Cognitive Changes with Aging: - Normal changes: more forgetful and slower to learn - MCI: Mild Cognitive Impairment: Immediate recall, word finding, or complex problem-solving problems -Half these folks will develop dementia in 5 years - Dementia: Chronic thinking problems in > 2 areas - Delirium: Rapid changes in thinking and alertness, seek medical help immediately - Depression/anxiety: Chronic unless treated, poor quality of life, I don t know or I just can t responses, no pleasure, can look like agitation and confusion

6 16 Alzheimers: - New information lost - Recent memory worse - Problems finding words - Misspeaks - More impulsive or indecisive - Gets lost - Notice changes over 6 months 1 year 17 Positron Emission Tomography (PET) Alzheimers Disease Progression vs. Normal Brains Normal Early Alzheimers Late Alzheimers Child 18 G. Small, UCLA School of Medicine. 6

7 Vascular Dementia: - Sudden changes - Picture varies by person - Can have good and bad days - Judgment and behavior not the same - Spotty losses - Emotional and energy shifts year duration 19 Vascular Dementia: CT Scan: The white spots indicate dead cell areas caused by mini-strokes

8 Latest Thinking About Vascular Dementia? - Lots of similarity with Alzheimer s - Manage blood flow issues carefully! - Watch for and manage depression 22 Lewy Body Dementia: - Movement problems, falls - Visual hallucinations - Fine motor problems: hands, swallowing - Episodes of rigidity and syncopy - Nightmares or insomnia - Fluctuations in abilities - Drug responses can be extreme and strange 23 - Use AChIs Latest Thinking about Lewy Body Treatment: - Add Namenda early - Be very careful about anti-psychotic meds - Parkinson s meds may help movement but may make hallucinations and delusions worse - Anti-depressants and anti-convulsants may be used to help anxiety, sleep, and depression but can increase confusion, movement, and drowsing 24 8

9 Fronto-Temporal Dementias: - Many types - Frontal: impulse and behavior control loss - Says unexpected, rude, mean, odd things to others - Disinhibited about food, drink, sex, emotions, actions - Becomes stuck or obsessed about things -Temporal: language loss - Can t speak or get words out - Can t understand what is said, uses nonsense words 25 Pick s Disease: PET Scan

10 Latest Thinking About FTD Treatments: - Consider Namenda earlier - Look at SSRI medications - May use medications used to treat OCD - May not use AChI Medications 28 The person s brain is dying 29 Normal Brain Alzheimers Brain Used with permission from Alzheimers:The Broken Brain, 1999 University of Alabama 30 10

11 Learning and Memory Center: Hippocampus Big Change 31 Understanding Language Big Change 32 Hearing Sound Not Changed 33 11

12 Sensory Strip Motor Strip White Matter Connections: Big Changes Automatic Speech Rhythm Music Expletives: Preserved Formal Speech and Language Center: Huge Changes 34 Executive Control Center: Emotions Behavior Judgment Reasoning 35 Vision Center Big Changes 36 12

13 What is Dementia? It is both a chemical change in the brain and a structural change in the brain So Sometimes they can and sometimes they can t 37 Brain Atrophy: -The brain actually shrinks -Cells wither, then die -Abilities are lost -With Alzheimer s, area of loss are fairly predictable, as is the progression, but the experience is individual 38 Memory Loss: Losses: Immediate recall Attention to selected info Recent events Relationships Preserved Abilities: Long ago memories Confabulation Emotional memories Motor memories 39 13

14 Understanding: Losses: Can t interpret words Misses some words Gets off target Preserved Abilities: Can get facial expression Hears tone of voice Can get some non-verbals Learns how to cover 40 Losses: Sensory Changes: - 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 41 Self-Care Changes: Losses: - Initiation and termination - Tool manipulation - Sequencing Preserved Abilities: - Motions and actions -The doing part - Cued activity 42 14

15 Language: Losses: Can t find the right words/vague language Word salad Single phrases Sounds and vocalizing Can t make needs known Preserved Abilities: Singing Automatic speech Swearing/sex words/forbidden words 43 Impulse and Emotional Control: Losses: Becomes labile and 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 44 Sensory Processing and Dementia: With dementia or brain change, it matters 45 15

16 Five Ways Humans Get Information: What we: - See - Hear - Feel - Smell - Taste 46 Two Major Categories of Sensory Information: - Protective - Discriminatory 47 Two Categories: Protective: Fast Reflexive Try to keep you safe Autonomic reflexive Big! Strong Emotions!!! Spinal and primitive Flight-Fight-Flight Discriminatory: Slower Brain driven Exploring and figuring out Details and differences Focused Ignore big world to experience immediate Want more or want less 48 16

17 With Dementia: Protective: -Less able to pick up on danger signals/cues -More likely to over-react to normal range -To non-demented seems unpredictable -But, it s the new predictable set point -May move toward dangerous versus away from it Discriminatory: -Either hyper-focused or unobservant -From multi-modal awareness to single characteristic attention -Shortened task attention span -Variable sensory attention -Atypical focus on a characteristic: edges of the frame versus the picture 49 With Dementia All Senses Are Affected: - Miss information - Misunderstand information - Over-react to information - Under-react to information - Get stuck on a sensation - Can t stand a sensation - Variable abilities - Can t adjust or adapt to sensation 50 With Dementia, It s All About Finding the Balance!!!! 51 17

18 Balance: Like Want Pleasant Comforting Stimulating Calming Nothing Familiar Good for you Tolerate Unpleasant Annoying Frightening Boring Too much New 52 Sensation: A common stimulus that causes an individual experience 53 The Stimulus: - Single mode versus multi-modal - Constant versus intermittent - Subtle versus extreme - Still versus moving - Gradual versus sudden - Sought out versus given - Controlled by me versus by you - Expected versus unexpected 54 18

19 Vision Changes: Protective: Peripheral awareness Visual field Depth perception Light-dark accommodation Tracking Blink Discriminatory: Organized scanning Saccadic eye movements Color discrimination Figure ground perception Near-far accommodation Near acuity Night vision Object recognition Facial recognition 55 Hearing-Comprehension Changes: Protective: Discriminatory: Direction Localization Emergency signals Comprehension Alerting communication Sound recognition Voice recognition Foreground-background Tracking Following a conversation Interpreting meaning Multi-step information 56 Touch and Movement Changes: - This one is both complicated and important! - Sensation, Processing, Reactions and Responses happen fast! Almost automatic due to habits and procedural memories: looping once started - Active versus passive: different 57 19

20 Touch: Movement: Balance Coordination Speed Accuracy Strength Bilateral and unilateral Gross motor Fine motor Reflexes Sensations: Pressure Temperature Moving touch Texture Shapes 58 Touch: Protective: Extreme Temperature Sharp, cutting High velocity impact Sustained pressure Friction Discriminatory: Variation in temperature Variable textures Massage Wet/dry Manipulation Grasp 59 Movement: Protective: Balance against gravity Block incoming Avoid contact Catch balance Maintain upright Discriminatory: Voluntary movements to meet goals Tool use Object manipulation Construction 60 20

21 Olfactory-Smell Changes: Protective (becomes limited): Smoke Chemicals or gas Spoiled food Body odor Urine or feces Discriminatory: Emotional memories Emotional reaction Pleasant-unpleasant Smell identification Stimulate hunger or thirst Stimulate nausea Localization and tracking 61 Gustatory-Taste Changes: - Less able to pick up on sweet and salty, so they want more! - Still keep bitter and sour, so they may not like things they used to - Things may taste wrong, so may order something then refuse to eat it 62 Truths About Dementia? - It changes everything over time - It is not something the person can control - It is not always the same for every person - It is not a mental illness - It is real - It is hard at times 63 21

22 Believe: People with dementia are doing the best they can! 64 Dementia is not curable, but it can be treated: - With knowledge - With skill building - With commitment - With flexibility - With practice - With support - With compassion 65 DISCLAIMER The content contained in this presentation is strictly for informational purposes. Therefore, if you wish to apply concepts or ideas contained from this presentation you are taking full responsibility for your actions. Neither the creators, nor the copyright holder shall in any event be held liable to any party for any direct, indirect, implied, punitive, special, incidental or other consequential damages arising directly or indirectly from any use of this material, which is provided as is, and without warranties. Any links are for information purposes only and are not warranted for content, accuracy or any other implied or explicit purpose. This presentation is copyrighted by Positive Approach to Care and is protected under the US Copyright Act of 1976 and all other applicable international, federal, state and local laws, with ALL rights reserved. No part of this may be copied, or changed in any format, sold, or used in any way other than what is outlined within this under any circumstances without express permission from Positive Approach to Care. Copyright 2017, All Rights Reserved Teepa Snow and Positive Approach to Care 66 22

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