DEMENTIA CARE UPDATE. Introduction to Dementia Care 42% of residents in assisted living have Alzheimer s disease or another form of dementia

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1 DEMENTIA CARE UPDATE Introduction to Dementia Care 2 42% of residents in assisted living have Alzheimer s disease or another form of dementia 3

2 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 longdistance caregivers. In 2013, Alzheimer's will cost the nation $203 billion. This number is expected to rise to $1.2 trillion by Source: Alzheimer s Association, 4 WHAT IS DEMENTIA? 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 Source: Alzheimer s Association, 5 DEMENTIA Alzheimer s Disease Frontotemporal Mixed Dementia Vascular Dementia Lewy Body Parkinson s Disease 6

3 SYMPTOMS OF DEMENTIA 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 7 CAUSES OF DEMENTIA #1: Alzheimer s disease #2: Vascular dementia Dementia with Lewy bodies Mixed dementia Parkinson s disease Frontotemporal dementia Creutzfeldt-Jakob disease Normal pressure hydrocephalus Huntington s disease Wernicke-Korsakoff Syndrom 8 ALZHEIMER S DISEASE Symptoms: Difficulty remembering names and recent events Apathy and depression Impaired judgment Disorientation Confusion Behavior changes Difficulty speaking, swallowing and walking Source: Alzheimer s Association 9

4 ALZHEIMER S DISEASE 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 Source: Alzheimer s Association 10 ALZHEIMER S DISEASE 11 ALZHEIMER S DISEASE Source: Alzheimer s Association 12

5 STAGES Stage 1 Stage 2 Stage 3 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. 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. 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. Source: Alzheimer s Association 13 STAGES Stage 4 Stage 5 Stage 6 Moderate cognitive decline At 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. Moderately severe cognitive decline Gaps in memory and thinking are noticeable, and individuals begin to need help with day-to-day activities. Severe cognitive decline Memory continues to worsen, personality changes may take place and individuals need extensive help with daily activities. Source: Alzheimer s Association 14 STAGES Stage 7 Very severe cognitive decline In 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. Source: Alzheimer s Association 15

6 VASCULAR DEMENTIA 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 Source: Alzheimer s Association 16 VASCULAR DEMENTIA 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 Source: Alzheimer s Association 17 DELIRIUM 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 18

7 Regulatory Requirements for Dementia Care 19 CARE OF PERSONS WITH DEMENTIA Applicability Mild Cognitive Impairment Fire clearance Training Adequate staffing Medical assessments and appraisals Safety modifications Personal grooming and hygiene items Wrist bands and egress alert devices Exit alarms Delayed egress Locked doors Applicable Regulations ADVERTISING DEMENTIA SPECIAL CARE Plan of operations Philosophy Assessments Admission procedures Activity programming Staff qualifications Staff training Physical environment Changes in condition Success indicators Admission agreement Advertisements Applicable Regulations

8 TRAINING REQUIREMENTS IF ADVERTISING 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 Applicable Regulations CAREGIVER ORIENTATION TRAINING 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 CAREGIVER ONGOING TRAINING 20 hours annually 8 hours dementia 4 hours postural supports, hospice 24

9 CCG CAN HELP 25 Co-Morbidities 26 CO-MORBIDITIES IN DEMENTIA CARE 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 27

10 Swallowing Disorders SWALLOWING DISORDERS 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.

11 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 Interventions for Residents With Swallowing Difficulties

12 INTERVENTIONS/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 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.

13 SWALLOWING DISORDERS Examples of Modified Diets for Residents with Cognitive Impairment and Swallowing Disorders MODIFIED DIETS/ SWALLOWING DISORDERS Thick liquids Soft foods Pureed Minced, ground and chopped Pneumonia

14 PNEUMONIA Causes of Pneumonia CAUSES OF PNEUMONIA 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.

15 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. PNEUMONIA Signs and Symptoms to Monitor: Drowsiness High Fever Rapid Breathing Chills PNEUMONIA Signs and Symptoms to Monitor (cont.): Cough Chest Pain Blue tint to lips or nails Flu like symptoms Inability to clear throat

16 PNEUMONIA Complications of Pneumonia Especially in Residents with Cognitive Impairment COMPLICATIONS OF 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.

17 COMPLICATION 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. COMPLICATIONS 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. PNEUMONIA Interventions to Avoid Pneumonia

18 INTERVENTIONS TO AVOID PNEUMONIA Good nutrition and hydration Regular physical activities Monitor for aspiration INTERVENTIONS TO AVOID PNEUMONIA Manage Dysphagia Report symptoms to physician immediately Pressure Ulcers

19 PRESSURE ULCERS 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 Strategies to Keep the Resident s Skin Healthy

20 STRATEGIES FOR HEALTHY SKIN Turn and reposition minimally every 2 hours Hydrate skin with topical application of lotions/creams STRATEGIES FOR HEALTHY SKIN Utilization of a barrier cream/ointment for incontinence Meticulous incontinent care Adequate hydration and nutrition PRESSURE ULCERS Complications with Pressure Ulcers

21 COMPLICATIONS WITH PRESSURE ULCERS 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. 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.

22 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 ULCER 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.

23 PRESSURE ULCERS PRESSURE ULCERS Preventing Pressure Ulcers Urinary Tract Infections

24 URINARY TRACT INFECTIONS (UTI S) 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

25 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) Monitoring Residents for UTI s MONITORING RESIDENTS FOR UTI S Observe for change in condition Changes in behavior Resident is holding his/her abdominal area Increased urgency in the need to void

26 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 URINARY TRACT INFECTION (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. Falls

27 FALLS 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 nonsecured rugs

28 FALLS Environmental Risk Factors (Cont.) Clutter Poorly maintained walking aids Lack of safety equipment FALLS Fall Risk Reduction Strategies FALL RISK REDUCTION STRATEGIES 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.

29 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 FALLS Other Factors in Risk Reduction Medications Footwear Exercise Assistive Devices 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.

30 FALLS How to Properly Respond to a Fall Treating Alzheimer s Disease 89 CURRENTLY APPROVED TREATMENTS Name Brand name Approved For FDA Approved 1. donepezil Aricept All stages galantamine Razadyne Mild to moderate memantine Namenda Moderate to severe rivastigmine Exelon All stages

31 CURRENT TREATMENTS 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 91 TREATMENT HORIZON 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 92 TARGETS FOR FUTURE DRUGS Beta-amyloid Tau protein Inflammation Insulin resistance Brain imaging and biomarkers 93

32 BETA-AMYLOID Click on the link to view the video. Make sure you re connected to the internet. pages/understanding_attacking_alz.html 94 INFLAMMATION Click on the link to view the video. Make sure you re connected to the internet. /inflammation.html 95 INSULIN RESISTANCE Click on the link to view the video. Make sure you re connected to the internet. /insulin_and_alz.html 96

33 BRAIN IMAGING AND BIOMARKERS Click on the link to view the video. Make sure you re connected to the internet. /quest_for_biomarkers.html 97