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 Dementia Fundamentals: Brain Changes PET and Aging: PET Scan of 20-Year-Old Brain PET Scan of 80-Year-Old Brain ADEAR, 2003 As we age, we DO NOT lose function in our brains, UNLESS Something Goes Wrong with Our Brains Normal vs. Not Normal Normal Aging: NOT Normal Aging: Slower to think Can t think the same Slower to do Can t do like before Hesitates more Can t get started More likely to look before leaping Can t seem to move on Know the person but not the name Doesn t think it out at all Pause to find words Can t place the person Reminded of the past Words won t come even later HARDER Confused about past versus now VERY DIFFERENT 1
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, misnaming, 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 problem-solving 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 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 Anti-arrhythmic agents Antibiotics Drugs That Can Affect Cognition in Elders: 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 Screening Options: Old: - MMSE New: -SLUMS 7 minute screen -Animal fluency 1 minute # of animals -Clock Drawing 2 step -Full Neuropsychological testing panel Washington Manual Geriatrics Subspecialty Consults edited by Kyle C. Moylan (pg 15) published by Lippencott, Wilkins & Williams, 2003 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 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 2
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 - 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 Alzheimer s Disease Early - Young Onset Normal Onset Vascular Dementias (Multi-infarct) Lewy Body Dementia Fronto- Temporal Lobe Dementias Other Dementias Genetic syndromes Metabolic pxs ETOH related Drugs/toxin exposure White matter diseases Mass effects Depression(?) or Other Mental conditions Infections BBB cross Parkinson s Alzheimer s: - New information lost - Recent memory worse - Problems finding words - Misspeaks - More impulsive or indecisive - Gets lost - Notice changes over 6 months 1 year Positron Emission Tomography (PET) Alzheimer s Disease Progression vs. Normal Brains Normal Early Alzheimer s Late Alzheimer s Child G. Small, UCLA School of Medicine. 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 - 3-30 year duration Vascular Dementia: CT Scan: The white spots indicate dead cell areas caused by mini-strokes 3
Latest Thinking About Vascular Dementia? - Lots of similarity with Alzheimer s - Manage blood flow issues CAREFULLY! - Watch for and manage depression 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 - 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 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 Pick s Disease: PET Scan 4
Latest Thinking About FTD Treatments: - Consider Namenda earlier - Look at SSRI medications - May use medications used to treat OCD - May NOT use AChI Medications The person s brain is dying Normal Brain Alzheimers Brain Used with permission from Alzheimers:The Broken Brain, 1999 University of Alabama Learning and Memory Center: Hippocampus: BIG CHANGE Understanding Language BIG CHANGE 5
Sensory Strip Motor Strip White Matter Connections BIG CHANGES Automatic Speech Rhythm Music Expletives PRESERVED Hearing Sound Not Changed Formal Speech and Language Center HUGE CHANGES Executive Control Center: Emotions Behavior Judgment Reasoning Vision Center BIG CHANGES 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 -The brain actually shrinks -Cells wither, then die -Abilities are lost Brain Atrophy -With Alzheimer s, area of loss are fairly predictable, as is the progression BUT the experience is individual 6
Memory Loss: Losses: Immediate recall Attention to selected info Recent events Relationships Preserved Abilities: Long ago memories Confabulation Emotional memories Motor memories 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 Understanding: Sensory Changes: Losses: -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 Self-Care Changes: Losses: -Initiation and termination -Tool manipulation -Sequencing Preserved Abilities: -Motions and actions -The doing part -Cued activity 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 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 7
Sensory Processing and Dementia: With dementia or brain change, it matters Five Ways Humans Get Information: What we: - See - Hear - Feel - Smell - Taste Two Major Categories of Sensory Information: - Protective - Discriminatory Protective: Fast Reflexive Try to keep you safe Two Categories: 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 Protective: With Dementia: 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 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 8
Balance: With Dementia, It s All About Finding the BALANCE!!!! Like Want Pleasant Comforting Stimulating Calming Nothing Familiar Good for you Tolerate Unpleasant Annoying Frightening Boring Too much New Sensation: A common stimulus that causes an individual experience 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 Vision Changes: Hearing-Comprehension 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 Protective Direction Emergency signals Alerting communication Discriminatory Localization Comprehension Sound recognition Voice recognition Foreground-background Tracking Following a conversation Interpreting meaning Multi-step information 9
Touch & Movement Changes - This one is both complicated and IMPORTANT!!!! - Sensation, Processing, Reactions OR Responses Happen FAST!!! Almost automatic due to habits and procedural memories looping once started - Active versus passive - different Touch: Movement: Sensations: Balance Pressure Coordination Temperature Speed Moving touch Accuracy Texture Strength Shapes Bilateral and unilateral Gross motor Fine motor Reflexes Touch: Protective: Discriminatory: Extreme Temperature Variation in temperature Sharp, cutting Variable textures High velocity impact Massage Sustained pressure Wet/dry Friction Manipulation Grasp Protective: Balance against gravity Block incoming Avoid contact Catch balance Maintain upright Movement: Discriminatory: Voluntary movements to meet goals Tool use Object manipulation Construction 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 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 10
Create a Sensory Preference List for YOU: - Visual likes: stimulating and calming - Auditory likes: stimulating and calming - Touch likes: stimulating and calming - Movement likes: stimulating and calming - Smell likes: stimulating and calming - Taste likes: stimulating and calming Create a Sensory Intolerance List For YOU: - Visual Irritants - Auditory Irritants - Touch Irritants - Movement Irritants - Smell Irritants - Taste Irritants GEMS Sensory Changes: - Sapphires: you and me, as is - Diamonds: more vocal and rigid - Emerald: visual and auditory MOST - Amber: ALL SENSES critical - Ruby: touch, movement, personal and intimate space awareness - Pearl: touch, movement, intimate space are KEY! 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 Believe: People with dementia are doing the BEST they can! Reality Orientation Use empathy and go with the flow Telling Lies 11
Dementia is not curable, but it can be treated: - With knowledge - With skill building - With commitment - With flexibility - With practice - With support - With compassion How can we help better? It all starts with your approach! 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 To learn more about the information covered in this educational presentation, join our email list. Text TEEPA to 22828 Resources are provided free of charge. Message and data rates may apply to text. 12