Alzheimer Disease for Emergency Personnel

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					Alzheimer’s Disease for
  Emergency Personnel
                      Helle Brand, PA
          Banner Alzheimer’s Institute

 Describe Alzheimer’s disease
 Outline the impact of coexisting diseases
  on dementia and discuss delirium
 Identify the challenges of providing care
  to patients with dementia
 Discuss specific strategies to enhance
  care and outcomes for patients with
Demographics of Dementia

   5.3 million Americans have dementia
   By 2050, numbers will more than triple

 About 10% of age 65+; nearly half of
  those 85+ are affected
 Average life expectancy following
  diagnosis is 8 – 10 years

   6th leading cause of death among older
About Dementia…

 Dementia is not a specific diagnosis
 Each type of dementia has unique
  features and is progressive
 Most common types of dementia include:
    ◦   Alzheimer’s disease (AD)
    ◦   Lewy body dementia (LWD)
    ◦   Vascular dementia (VaD)
    ◦   Frontotemporal dementia (FTD)
            Mild                    Moderate     Severe      Terminal
N   Impaired
D                                   Confusion; Resistivenes   Bedfast;
    memory;                                          s
E                                   Agitation;                  Mute;
P Personality                       Insomnia; Incontinence Intercurrent
E   changes;                                         ;
                                     Aphasia;                infections;
N    Spatial                                      Eating
D disorientatio                      Apraxia                 Dysphagia
E                                              difficulties;
        n                                         Motor
C                                              impairment


Progression of Dementia
Reference: Hurley & Volicer, 1998
Clinical Presentation of Dementia

     Cognition              Function

   Insidious onset with progressive decline
   Impaired social or occupational
   Memory loss
   Cognitive loss in at least 1 other domain
     ◦ Language
     ◦ Calculations
     ◦ Orientation
     ◦ Judgment
   Deficits not due to other systemic disease
   Deficits NOT in the setting of a delirium

DSM IV Criteria for
Alzheimer’s Dementia
    Early (MILD) Stage
     Short term memory loss
     Problems with language
      and abstract thinking
     Misplacing things
     Disorientation of time
     Poor/ decreased judgment
     Changes in mood/behavior
      and/or personality                 Treatment
     Loss of initiative
                               • Cholinesterase Inhibitor
     May have difficulty in a
                               • Manage depression and
                                    other co-existing health

Maintaining Independence
   may get lost driving or be unsure of self
    in new surroundings
   Forget appointments, family events
   Lists may not make sense
   May compensate for weaknesses

Early changes in AD, continued
   Medication management
   Driving
   Weight loss
   Mood, especially depression
   Changing awareness and concern for
   Need for life planning: financial, legal
   Balancing autonomy vs supervision

Special concerns early on
 Memory loss, confusion and attention worsen
  over a 2-10 year span
 Judgment and problem solving a problem
  Can’t think logically, organize thoughts
  Loss of ability to handle complex tasks and
  technology, gradual problems with taking care of
 Personality and behavior changes
 Increasing dependence
 Increasing language difficulties
 Vulnerable adults, cannot live alone

Moderate Stage Alzheimer’s
    Middle (MODERATE) Stage


Living with help
   Behaviors: suspiciousness, irritability,
    restless, impulsivity, seeing or hearing
    things not present, agitation,
    wandering, sleep disturbance,
   Changing communication/expectations
   Increasing dependence, behaviors cause
    increasing caregiver burden/stress
   Safety: need 24 hour supervision
     Recognizing delirium

Concerns with mid stage AD
 Memory loss is severe, including long term
 Loss of recognition of others beyond self
 Problems controlling bowel/bladder
 Fully dependent for care needs
 Minimal to no speech
 Changes in posture/walking, may not walk
   and/or become bed bound
 Neurologic changes: myoclonic jerks,
  seizures, dysphagia

Late to End Stage Alzheimer’s
Late stage AD
   Risk for falls
   May be prone to infection or skin
   Weight loss
   Potential for seizures
   Increasing sleep
   Planning for death and dying
   Comfort in terms of mood and pain

    Issues in advanced Alzheimer’s
    Dementia + Comorbidities

        Large numbers have chronic medical

        Acute medical issues associated with
         advanced dementia

        Medications can hasten decline
          ◦ Antihistamine, anticholinergics, corticosteroids,
            anti-parkinson, hypnotics, sedatives, opioids,

Maslow, Nur Cl N Am, 2004; 39: 561-579; Feil et al. JAGS 2007; 55:S293-301.
   Those with some form of dementia are at
    increased risk for developing delirium
   Delirium is a risk factor for future delirium
    and for developing a permanent dementia
   Age contributes to both
   Medications play a role
   Recognition of symptoms and treatment is

What we need to know about
delirium and dementia
 Incidence of Delirium
At least 25% >70 are admitted with
 ◦ Occurs in about half of elderly patients during
   or after acute hospitalization
 ◦ More than half of these are found to have
   permanent dementia, previously undiagnosed
 ◦ Up to 70% of ICU patients develop delirium
 ◦ Delirium occurs in 28 – 83% of patients near
   the end of life (terminal agitation, restlessness)

  Girad, Crit Care. 2008;12 Suppl 3:S3. Epub 2008 May 14; Waszynski, AJN, 2007,
  107:12, 50-59
   D: dementia
   E: electrolytes, dehydration
   L: lung, liver, heart, kidney, brain
   I: infection
   R: Rx drugs
   I: injury/pain/stress
   U: unfamiliar environment
   M: metabolic

Causes of Delirium
    Delirium                         Dementia
     ◦ Abrupt onset (hours –
       days)                           ◦ Insidious onset
     ◦ Duration days to                  (months – years)
       weeks                           ◦ Duration 2-20 years
     ◦ Symptoms include                ◦ Symptoms include
       confusion, forgetfulness,
       altered sleep-wake                decline in memory,
       cycle, high frequency of          speech/ language
       delusions, hallucinations         difficulty, loss of self-
       and illusions                     care abilities and a
     ◦ Causes include acute              variety of behavior
       medical conditions,               problems
       meds, ETOH abuse,
       acute psychosis                 ◦ Causes depends of
     ◦ Treatment of                      etiology of disease
       underlying condition;           ◦ Treatment limited to
       supportive techniques             managing symptoms
                                         and behaviors

In summary, how to differentiate
     Delirium vs. Dementia
Your challenges with confused

   Assessing confusion: Delirium v. Dementia
          or Delirium Superimposed on Dementia

 Safety
 Identification and treatment of pain

   Health Care Decisions
   Family Caregivers
  Confusion Assessment Method
      ◦ Feature 1: Acute Onset or Fluctuating Course
         Is there any evidence of an acute ∆ in MS from
          baseline? Did the behavior fluctuate during the day,
          increase/decrease in severity?
      ◦ Feature 2: Inattention
         Did the patient have difficulty focusing attention, being
          easily distracted, or have difficulty tracking
      ◦ Feature 3: Disorganized thinking
         Was the patient’s thinking disorganized or incoherent,
          unclear, rambling or switching topics?
      ◦ Feature 4: Altered Level of Consciousness
         Overall, how would you rate the patient’s level of
          consciousness? Alert - Vigilant – Lethargic – Stupor -

Inouye, S. (1990) Annals of Internal Med 113(12) 941-948.
Clock Drawing
   Simple screening tool:
    ◦ Ask the patient to draw a clock
    ◦ Place all the numbers on the clock
    ◦ Set the time at 11:10
   Scoring: 5 points totals
    ◦ 1 point for   the clock circle
    ◦ 1 point for   the numbers in correct order
    ◦ 1 point for   numbers being in proper special
    ◦ 1 point for   two hands of the clock
    ◦ 1 point for   the correct time
1. What are the date,         SCORING:*
  month, and year?             0-2 errors: normal mental
2. What is the day of the       functioning
  week?                         3-4 errors: mild cognitive
3. What is the name of this     impairment
                                5-7 errors: moderate cognitive
4. What is your phone           impairment
5. How old are you?             8 or more errors: severe
6. When were you born?          cognitive impairment
7. Who is the current           *One more error is allowed in
  president?                    the scoring if a patient has
8. Who was the president        had a grade school education
                                or less.
  before him?                   *One less error is allowed if
9. What was your mother's       the patient has had education
  maiden name?                  beyond the high school level.
10. Can you count backward
  from 20 by 3's?

 Describe actual behaviors or symptoms
  demonstrated and the frequency which
  they occur
 Determine if the behavior is new or has
  increased in frequency
 Obtain from family any successful
  interventions for identified behaviors

Assessment of Behavior(s)
    Moderate Dementia:           Advanced Dementia:
     ◦ Resisting/fighting          ◦ Resisting/fighting
       hands-on caregivers           hands-on caregivers
     ◦ Assaultive toward
       caregivers/peers            ◦ Fall risk (wanting to
     ◦ Wandering and                 walk when unable to)
       rummaging                   ◦ Physical restlessness
     ◦ Physical restlessness
     ◦ Sundowning                  ◦ Resisting/refusing to
     ◦ Eating problems
                                   ◦ Disruptive sleep
     ◦ Sleeping problems             patterns
     ◦ Yelling                     ◦ Disruptive yelling
     ◦ Sexual behaviors

Common behaviors
   Decreased ability to recognize familiar
    places and faces
   Can forget names, addresses
   Become disoriented
   Decreased reasoning and judgment
   Behavioral changes
   Increasing confusion
   All worse with any stressors
   concrete thinking

Let’s remember!
Approach Strategies
   Introduce yourself at each encounter
   Use touch as appropriate
   Start with the “Soft Approach”
    ◦   Smile, warm demeanor
    ◦   Remain calm, reassuring, RESPECTFUL
    ◦   Pleasant voice and tones
    ◦   Go slow
    ◦   Talk in short, simple sentences; rephrase
    ◦   Avoid correcting/confrontation
    ◦       aka CONNECT NOT CORRECT

    ◦ Actions help when communication may fail: use
      gestures, demonstrate, touch affected areas
    Comfort Techniques
   Anticipate and meet basic comfort needs
    such as continence care, food/fluids,
    positioning, room temperature
   Give the patient something to hold on to such
    as a washcloth, stuffed animal, doll, your
    hand, etc.
   Food is ultimate distractor
   Touch
   Sing or play music
   Read a prayer, poem, scripture verse
Pharmacological Interventions
   Antipsychotics to manage psychosis
    (delusions, paranoia, hallucinations)
   Mood stabilizers (for aggression/mania)
   Trazadone for sleep
   Avoid benzodiazepines to manage
    psychosis or agitation
   Avoid medications with anticholinergic
Maintaining Safety
    Falls due to impulsivity, confusion

    Compliance with care, may pull at tubes,
    resist medications

    Psychosis: hallucinations, misperceptions,
    paranoia, delusions

    Home situation: weapons
Identification & Treatment of Pain

 Patients with moderate to severe
  dementia cannot reliably report pain
 Pain is often under recognized and under
  treated in dementia patients
 Pain tolerance does NOT change due to
 Pain left untreated will lead to challenging
  behaviors such as striking out and yelling
   How to Measure Pain?
                              0                       1                        2               Score

   Breathing               Normal            Occasional labored     Noisy labored breathing.
Independent of                                   breathing.              Long period of
  vocalization                                 Short period of          hyperventilation.
                                              hyperventilation.          Cheyne-stokes
  Negative                  None             Occasional moan or        Repeated troubled
 Vocalization                                      groan.                  calling out.
                                            Low level speech with       Loud moaning or
                                                      a                     groaning.
                                                 negative or                 Crying.
                                            disapproving quality.
    Facial               Smiling, or          Sad. Frightened.         Facial grimacing.
  Expression            inexpressive               Frown.

    Body                  Relaxed.                  Tense.           Rigid. Fists clenched,
  Language                                    Distressed pacing.         knees pulled up.
                                                  Fidgeting.        Pulling or pushing away.
                                                                           Striking out.

                         No need to             Distracted or          Unable to console,
 Consolability            console.          reassured by voice or     distract or reassure.
   Warden et al. J Am Med Dir Assoc 2003, 4: 9-15.
Pharmacological Interventions
for Pain
 Routine administration of acetaminophen
  up to 3 grams daily for mild to moderate
 Use small doses of opioids for moderate
  to severe pain
 If pain medications are effective,
  they should be ordered routinely NOT
 Use other strategies as well!
 Use the family as appropriate: identify
  baseline, changes; effective strategies
 Medic Alert bracelets:
 Other technologies: GPS, radio
  transmitters for repeat wanderers
 Community education

Other considerations

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