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Dementia
1. Alzheimers
2. Vascular
dementia
3. others
Delirium
Acute state of confusion
Usually reversible in 3 weeks
Unfamiliar settings eg. hospital
Behaviour typically – hypo/hyperactive
Many causes – infections UTIs, meds, metabolic
disturbances, surgery
Management – remove the cause
Alzheimer’s Disease
Chronic, progressive, degenerative disease
accounts for 60% of dementias occurring in
people older than 65 years
Loss of memory, judgment, and visuospatial
perception and change in personality
Increasing cognitive impairment, severe physical
deterioration, death from complications of
immobility *aspiration pneumonia most frequent
cause of death
Structural Changes in the Brain
Alzheimer’s disease creates changes that include:
Neurofibrillary tangles
Amyloid plaques
Nerve cells stop working, lose connections with
other nerve cells and then die
Leads to:
Memory failure
Personality changes
Problems performing ADLs
Manifestations
Changes in cognition
Alterations in communication and language
abilities
Changes in behavior, personality, and judgment
Changes in self-care skills
Short term memory impairment one of the first
symptoms*
Requires Psychosocial assessment: especially
patient’s reaction to changes in routine
Stages of Alzheimer’s Disease
Describe the stages of Alzheimer’s Disease
Middle:
Late:
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Cognitive Assessment
Folstein’s Mini Mental State Exam (MMSE)
List five major areas it assesses
What is the range of possible scores and what does a high or
low score indicate?
Which patients are excluded from assessment with the
MMSE?
Score of 30 is a perfect score
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Priority Problems
Confusion
Agitation/aggression
Confused & fearful
Safety: Risk for Injury
No longer recognize danger
May wander
Self Care
Forget how to do things (ADLs)
Nutrition
Forget that they’ve eaten
Dysphagia
Lose recognition of hunger
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Agitation triggers: Loss*
May remember activities they used to enjoy
such as being able to:
drive a car
cook
care for children
Whether at home or in a facility, safe
activities should be substituted that satisfy
the individual
Depression should be treated
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Agitation triggers - Stimuli
Excessive, noise, commotion or people
can trigger agitation behavior
More than 20 people in a group can
cause undue stress
TV, images in mirror, dolls or figurines
may represent extra people in the
environment.
Before medicating with anti-psychotic
drugs, the family member & health care
team should decrease above factors
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Agitation triggers – Excessive Demand
Mental functions Cause stress & a sense of
steadily lost = cannot futility rather than
bringing back lost function
perform routine tasks
Instead, provide
Avoid
Positive support &
Quizzing,
understanding
Reality orientation
Encourage
“Brain exercises”
independence as able
Retraining or pushing
Assist when they are
individual to try harder unable to perform a
task
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Agitation triggers - Delirium
Infections, hypoxemia, pain, constipation, trauma
or drug interactions may cause dementia-like
symptoms!
Check for the above sources of confusion
Prevent if possible via:
Good oral care
Balanced nutrition
Adequate fluid intake
Adequate exercise balanced with rest periods
Simplified medication regimens
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Problem behaviours
Screaming:
Consider pain, depression or hearing loss as possible causes for
screaming
Sexual aggression:
Try to determine whether the sexual gesture is indeed sexual in
nature & not an expression of the need to go to the bathroom
Hallucinations/illusions:
Consider presence of confusing stimuli (e.g., shadowy lighting,
televisions, dolls)
Pacing & wandering:
Wanders for a reason, which may be hard to determine
Locking him/her in a room or restraining in a chair is inappropriate
Gathering/shopping:
May rearrange objects around the home, hoard or take other’s
possessions
Provide a canvas “shopping bag” and a “safe” place where s/he
1
can store items
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Terms
What is sundowning?
What is traumatic relocation syndrome?
Define:
Apraxia
Aphasia
Anomia
Agnosia
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Management – overall approach
Modify the environment:
Create a calm environment; reduce glare, noise, background noise; move to a
quieter place; offer rest, privacy
Limit caffeine; develop soothing rituals; use gentle reminders
Simplify tasks & routines
Schedule wisely:
Schedule the most difficult tasks (e.g., bathing, medical appointments) for time
of day when individual is most calm & agreeable
Establish routines to make the day more predictable/less confusing
Modify the behavior
Check personal comfort – pain, hunger, thirst, constipation, full bladder, fatigue,
infection, skin irritation
Be sensitive to fears, misperceived threats & frustration
Check own response: use low voice, do not corner, restrain, criticize, ignore,
argue with or shame the person
Medicate as a last resort
2
0
Management - reduce frustrations
Let him or her help. Involve in tasks as much as possible.
Limit choices. Having fewer options makes deciding easier.
E.g.,
Provide only two snacks (apple or orange) to choose
between
Reduce distractions at mealtimes or during
conversations
Take more time. Expect things to take longer
Schedule more time to complete even simple tasks
Provide instructions one step at a time
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Management – prevent agitation
Music Therapy:
Calming music or favorite type of music can lead to a decrease in
agitation
During meals, soothing music can increase food consumption
During bathing, relaxing or favorite music can make it easier to give a
bath
Exercise and Movement:
Regular light exercise (e.g., chair exercises)
Walking for up to 1½ hours after dinner several times each week
Activities: Select safe activities that mimic individual’s previous hobbies &
career
Socialization:
Have a few regular visitors or caregivers
Small gatherings of family or friends on a regular, predictable basis
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Talk with him/her
Eating
Eat at regular times; may need 4-5 small meals instead of 3 large
Vary the menu
Choose foods that contrast with the colour of the plate; use plain colour plate
Serve things one at a time
Be careful when serving hot food
Limit distractions during mealtimes; phone & TV off; no extra items on table
Dressing:
Limit choices.
Offer no more than two clothing options each morning
Clear closets of rarely worn clothes that may complicate the decision
Provide direction.
Lay out pieces of clothing in the order they should be put on, or,
hand out clothing one piece at a time & provide short, simple dressing instructions
Be patient.
Rushing the dressing process may cause anxiety.
Consider person’s tastes and dislikes.
Don't argue if individual doesn't want to wear a particular garment or wants to wear the
same outfit repeatedly.
Could buy duplicates of a few favorite outfits.
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Bathing
Find the right routine.
Preference for showers or tub baths?
Preferred time of day? Experiment with morning,
afternoon & evening bathing
Be flexible. If daily bathing is traumatic, alternate tub
baths or showers with sponge baths.
Help individual feel in control.
Explain each step of the bathing process
Make it comfortable.
Make sure the bathroom is warm
keep towels or bath blankets handy
Keep it private.
Provide a towel for cover when he or she gets in & out
of the shower or tub
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Toileting
Make the bathroom easy to find. Place a sign that says
"Toilet" or a picture of a toilet on the door.
Be alert for signs. Restlessness or tugging on clothing
may signal the need to use the bathroom.
Establish a schedule. Schedule bathroom breaks every
two hours, before and after meals and before
bedtime.
Make clothing easy to open or remove. Replace
zippers and buttons with Velcro. Choose pants with an
elastic waist.
Take accidents in stride. Praise toileting success — and
offer reassurance when accidents happen.
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Communication
See:
1. http://www.alzinfo.org/alzheimers-treatment-
communicating.asp
2. http://www.ec-
online.net/community/Activists/difficultbehavior
s.htm
(Number 2 uses labeling: “dementia person”, which
is demeaning but otherwise has excellent
suggestions.)
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Reality orientation
Reorient confused individual to time place & person
Used when change in environment + stressors such as
pain, surgery, medications have caused disorientation
Use reminders & environmental cues such as clocks,
calendars, stability of routine
Useful in the early stages of Alzheimer’s
Reorientation often inappropriate in the later stages
of Alzheimer’s
Person becomes agitated if contradicted
Clocks & calendars no longer have meaning
BUT: Stable routine continues to be useful
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Validation Therapy
Acceptance of the reality and personal truth of
another's experience
Work around rather than confront expression of
factual inaccuracies
Focus on emotional content of the message rather
than factual content
Does not involve re-orienting to present time
Works well with gentle re-direction
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Reminiscence
Recollection of the past to
bring meaning & understanding to the present
resolve current conflicts
find new meaning in past events
Reminds person of past positive coping
Express personal identity
Support self-esteem
Suitable for person with dementia
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Drug Therapy
Cholinesterase Inhibitors
Donepezil (Aricept), galantamine (Reminyl),
rivastigmine (Exelon)
Slows onset of cognitive decline in some patients
Do not alter course of disease