How Aging and Dementia Effect Resident Behaviors

Transcription

1 How Aging and Dementia Effect Resident Behaviors November 3, :00 2:00 PM EST Webinar Presented by: Alfred W. Norwood, BS, MBA Education Arm of the Carmelite Sisters for the Aged and Infirm Webinar Goals By the end of this Seminar you should: Understand the effects of Aging & Dementia on Resident Behavior. Be able to Recognize the Triggers of Resident Behaviors. Be familiar with Methods of Managing Behavioral Concerns or Residents. 2 What we will cover Brain development & brain aging. How Dementia Impacts the brain. How the Dementia brain Impacts behavior. Dementia behavior & stress. The problem with drug solutions. The use of behavioral interventions instead. Q & A. 3 1

2 Human Brain Events Progressive Events Neurogenesis Axon guidance Synapse formation Neurotransmitter receptor development Regressive Events Normal programmed cell death (apoptosis) Axon pruning Synapse elimination Brain events: Take place throughout life. More dependent on experience than genetics. Function based on Use it or lose it basis. Quartz, S. R., & Sejnowski, T. J. (1998). The neural basis of cognitive development: A constructivist manifesto; Behavioral and Brain Sciences, 20, below shows, it's inevitable Peter V. Rabins, M.D., M.P.H.; The 2011 Johns Hopkins Memory White Paper 5 Normal Memory Problems ENCODING STORAGE RETREVIAL ENCODING STORAGE RETREVIAL 6 2

3 Normal Brain 7 Dementia Memory Problems ENCODING STORAGE RETREVIAL ENCODING STORAGE RETREVIAL 8 Comparing Normal / Dementia Normal Dementia 9 3

4 Marked by Slow Changes High Normal Aging Mental Ability Mild Cognitive Impairment 13.7% of year olds DEMENTIA Low Time in years 10 Understanding the Change Left Brain Right Brain Frontal Lobe 11 Understanding the Change Long Term Potentiation DENDRITES DENDRITES AXON AXON NUCLEUS 12 4

5 Dementia is Progressive Neural Loss Frontal Cortex Pre-frontal Lobe Inhibition & Attention Frontal Lobe Conscious Executive Medial Temporal Hippocampus Conscious Memory Amygdala Emotional Memory 13 Brain / Function Loss Refer to Handout A Pre-Frontal Loss Sensory gating & inhibition Differentiate among sensory information, determine good, bad, better, best, same Future consequences of current activity, Working toward a defined goal, Prediction of outcome (what happens next) Expectation of actions, and social "control" Medial Temporal Loss File clerk for conscious memory Some loss if episodic memory (flasbulb) Loss of declarative memory. Less short to long term memory transfer Less control of spatial memory & behavior Frontal Lobe Loss Reduced activity e.g spontaneous activity, Lack of drive, can t plan ahead, no concern. Restless, aimless uncoordinated behavior. Disturbed. affect, apathy, blunted personality Indifference to the world around him. 14 Dementia Staging The 4 Stage Model No Dementia Mild Dementia Moderate Dementia Severe Dementia Refer to Handout B The 7 Stage Model No Cognitive Decline Very Mild Cognitive Decline Mild Cognitive Decline Moderate Cognitive Decline Moderately Severe Cognitive Decline Severe Cognitive Decline Very Severe Cognitive Decline 15 5

6 Different Causes of Dementia Refer to Handout C Mild Cognitive Dementia. Alzheimer s disease. Vascular Dementia. Depression Dementia. Lewy Body Dementia. Parkinsonian Dementia. Frontal Temporal Lobe Dementia. 16 Explaining the Normal Brain EMOTION AUTOMATED PROCEDURAL REFLEX PRIMING HABITS & SKILLS STIMULATION SENSORY INHIBITION & FOCUS SHORT TERM CONSCIOUS LONGTERM EPISODIC SEMANTIC 17 Explaining the Normal Brain STIMULATION SENSORY INHIBITION & FOCUS SHORT TERM AUTOMATED PROCEDURAL EMOTION REFLEX UNCONSCIOUS PRIMING HABITS & SKILLS CONSCIOUS LONGTERM EPISODIC CONSCIOUS SEMANTIC 18 6

7 Explaining the Dementia Brain EMOTION AUTOMATED LONGTERM (Habits) REFLEX PRIMING STIMULATION SENSORY SHORT INHIBITION TERM & FOCUS HABITS & SKILLS CONSCIOUS LONGTERM EPISODIC SEMANTIC 19 Resident Behaviors in Dementia Apathy: withdrawn, lack of interest, amotivation. Depression: sad, tearful, hopeless, low self-esteem, anxiety, guilt. Aggression: aggressive resistance, physical aggression, verbal aggression. Agitation: walking aimlessly, pacing, trailing, restlessness, repetitive actions, dressing/undressing, sleep disturbance. Psychosis: hallucinations, delusions, misidentifications. 20 Resident Behaviors Progressively Lowered Stress Syndrome FIGHT STRESS FLIGHT 21 7

8 Resident Behaviors Progressively Lowered Stress Syndrome FIGHT Hitting, slapping Resisting Care Paranoia Yelling Biting, spitting Anger STRESS CHRONIC ILLNESS FLIGHT Apathy Withdrawal Anxiety Hides, hoards Elopement Wandering 22 STEAM Triggers Behavior Sensory Too much, too little or conflicting stimulation. Taste, touch, smell, hear, see, movement. Tangible Needing water, food, doll. Defending territory. Escape Avoiding tasks/demands/places/people. Retaining isolation. Attention Who will take care of me. Establish recognition or dominance. Medical Pain, Drug Intoxication, Infection etc. 23 Drug Intoxication Low Efficacy, High Cost, Drug Reactions OBRA limited SNF psycho-drug use Use Behavioral Interventions first. Never use on most behaviors e.g. wandering. Up to 70% of SNF Residents take them 23.4 % had no appropriate indications % doses exceeding recommendations 17.6 % had both. They are perceived to make things easier. Slater EJ, Glazer W: Use of OBRA-87 guidelines for prescribing neuroleptics in a VA nursing home. Psychiatric Services 46: , 1995 Schweizer, A et al; Is psychoactive medication usage in nursing homes related to staffing; Int. Jour. Pharmaceutical Practices, 2003, 11 R42 Briesacher, B; et al.; The Quality of Antipsychotic Drug Prescribing in Nursing Homes; Arch Intern Med. 2005;165:

9 Anatomy of a Behavior Problem NEGATIVE BEHAVIOR PROACTIVE ACTIVE REACTIVE POSITIVE CONSUMER CONTROL STAFF 25 Anatomy of a Behavior Problem NEGATIVE PROACTIVE ACTIVE REACTIVE BEHAVIOR POSITIVE Make Physical Modifications Reduce Demands Use Behavior Modification STAFF TRAINING TEAMWORK ABA Unmet Needs Sensory Need Tangible Need Escape Attention Seeking Medical Warning Signs Verbal Outburst Threatening Increased Activity Agitation Depression Chronic Illness Strategies Attention Distraction Rewards Ignoring Behaviors Delusions Hallucinations Physical Aggression Verbal Aggression Agitation No Sleep Resistance Non Comply Withdrawl Strategies Punishment Calming One on One Removal Isolation Ignoring RESIDENT CONTROL STAFF 26 Reduce Pain Refer to Handout D Most Residents have Arthritis. ADLs & Exercise cause Pain Stress. Residents have Digestive Problems & Hidden injuries. Residents can have Psychsomatic pain. Conducting a Pain Audit. 27 9

10 Physical Modifications Install equipment and assistive devices. Remove objects causing confusion. Rearrange objects. Label objects. Color contrast objects. Place objects in sequence of use. Declutter. Corcoran, M., & Gitlin, L.N. (1991, Fall/Winter). Environmental influences on behavior of the elderly with dementia: Principles for intervention in the home. Occupational and Physical Therapy in Geriatrics, 9(3&4), Reduce Demands Refer to Handout for ADLs Give short verbal/written instructions Provide verbal/tactile cueing. Keep needed items in easy reach. Simplify activities. Plan a routine. Instruct CR through demonstration. Gitlin, et al., 2002, Strategies Used by Families to Simplify Tasks for Individuals with Alzheimer's Disease and Related Disorders: Psychometric Analysis of the Task Management Strategy Index (TMSI). The Gerontologist 29 Managing ADLs Refer to Handout E ADLS can cause up to 80% of behavior problems in nursing home Pain. Confusion (novelty, processing time, memory). Need to escape. Using ADL Rituals Reduces novelty. Uses Healthy Procedural Memory

11 Summary Normal brain aging shows decline. Dementia causes accelerated loss. Losses increase stress & dependency. Stress & dependency cause STEAM behaviors. All interventions are problematic. Drugs solutions can be problematic & toxic. Behavioral interventions can work. Be proactive stop behaviors before they start