General excerpts from curriculum on dementia for healthcare professionals

Someone in our local support group recently sent me this link to US Dept. of Health and Human Services’s curriculum for physicians (especially primary care physicians) and healthcare professionals (social workers, psychologists, pharmacists, emergency department staffs, dentists, etc.) on dementia. Here’s a link to the curriculum:

Training Curriculum: Alzheimer’s Disease and Related Dementias
Health Resources and Services Administration (part of Dept of HHS)

Included are excerpts on:
* diagnosing dementia and the value of early diagnosis
* general strategies for managing behavioral and psychological symptoms
* managing apathy
* treating sleep disorders
* home safety considerations
* hospice care



Diagnosing Dementia (Module 2)

Key Take-home Messages
* There are several brief validated tests that can detect dementia.
* Dementia is a group of symptoms and not a part of normal aging.
* Dementia is caused by many diseases and conditions affecting the brain. The most common type of dementia is Alzheimer’s disease, followed by vascular dementia, dementia with Lewy bodies, Parkinson’s disease dementia, frontotemporal degeneration, and mixed dementia.
* Early diagnosis of dementia and its underlying causes allows for appropriate medical management, access to resources and clinical trials, and future planning with input from the persons living with dementia (PLwD).
* Use of biomarkers for Alzheimer’s disease is an emerging field – brain amyloid PET scans are available with FDA-approved radioactive tracers.

Value of Early Detection and Diagnosis
* Diagnosis of dementia is life changing.
* Early detection and diagnosis affords many benefits to PLwD and their care partners:
– Involves PLwD in decision-making
– Can help preserve functioning
– Allows optimization of other medical conditions
– Allows for long-term care planning
– Allows for development of interprofessional care team (Johnson et al., 2013)
* Need to balance benefits of routine screening of asymptomatic patients and early detection against costs of routine screening and early diagnosis.
* Currently, there is insufficient evidence as to the benefits or harms associated with routine screening for cognitive impairment in older adults.
* Early cognitive impairment may have treatable components.
* Medicare covers a free Annual Wellness Visit for every beneficiary.

When to Consider Dementia in a Differential Diagnosis
* Dementia is an umbrella term encompassing many symptoms that together interfere with daily functioning.
* Dementia often is undetected in primary care setting.
* PLwD may not be aware of or raise issues regarding cognitive impairments.
* Dementia should be considered part of differential diagnosis if:
– Symptoms of memory difficulty interfere with daily functioning.
– Unexplained functional decline or new onset psychiatric symptoms are evident.
– Personal hygiene deteriorates.
– There is sudden difficulty adhering to a medication regimen.

Treatable Conditions Causing Cognitive Impairment
* Many treatable conditions can cause cognitive impairment.
* 3D’s of geriatric psychiatry: Dementia, delirium, depression.
* Others:
– Vitamin deficiencies
– Endocrine disorders
– Infections
– Diseases
– Drug/alcohol abuse
– Sleep disorders
– Brain tumors/lesions


Understanding Early-Stage Dementia for an Interprofessional Team (Module 5)

General Strategies for Managing Behavioral and Psychological Symptoms of Dementia (BPSD)
* Patient engagement: contributes to greater sense of well-being
* Physical activity: can improve cognitive thinking, physical fitness, and mood; promising evidence that physical activity programs may improve ability to perform activities of daily living
* Communication: allow person living with dementia sufficient time to respond; use simple commands; use a calm voice; avoid harsh tones and negative words; offer no more than two simple choices; help person find appropriate words for self-expression; lightly touch the person to provide reassurance if upset
* Cognitive stimulation: evidence of some benefit to persons with early- to middle-stage dementia; stimulate thinking, concentration, and memory in social settings. Reminiscence therapy.
* Sensory stimulation: music therapy; white noise; art/craft therapy; bright light therapy
* Environmental changes: remove clutter; use labels and visual cues (signs, arrows pointing to bathroom)
* Task simplification: break tasks into simple sets; use cues (verbal, tactile) or prompts at each stage; create structured daily routines.
* Other interventions being investigated include animal-assisted therapies, massage, reflexology, herbal supplements, etc.

Managing Memory Impairments and Executive Dysfunction
* Provide cues or prompts.
* Address repetitive questioning:
– Respond with calm reassuring voice.
– Use calming touch for reassurance.
– Structure with daily routines.
– Use distraction and meaningful activities.
– Inform patient of events only as they occur.
* Address difficulties with IADLs.

Mood Disturbances: Addressing Apathy
* Apathy is a common behavioral disturbance in all types of dementia, across all stages of dementia. Apathy is commonly reported by family members and worsens over time. Prevalence increases with increasing cognitive impairment. Prevalence differs across different dementias. It contributes to poor quality of life for PLwD (persons living with dementia) and care partners.
* It is distinct from depression and does not necessarily coexist with other mood disturbances.
* Nonpharmacological management may reduce apathy:
– Engaging the person living with dementia
– Activity
– Sensory stimulation
– Environmental changes

Providing Support to the Care Partner
* Help the care partner recognize when the person living with dementia has an unmet need. What is the relationship of the PLwD (person living with dementia) to the care partner?
* Zero in on troubling behaviors of the PLwD. What is the behavior that concerns the care partner and what is it related to? Does the behavior need to change or can the care partner live with it? If it needs to change, what can be done?
* Utilize care partner strengths to see how many potential solutions can be found.
* Help the care partner recognize the importance of self-care.

Addressing Care Partner Issues
* Care partner roles depend on stage and type of dementia and where the PLwD resides (home or institutional setting).
– Early-stage dementia: Care partners provide assistance with transportation and housekeeping.
– Middle-stage dementia: Care partners continue to aid and assist with mobility, ADLs, and protection/safety.
– Late-stage dementia: Care partners provide personal care of the PLwD and decision-making.
* Caring for PLwD, though rewarding and gratifying, can be stressful and difficult; caregiving responsibilities are increasingly time-consuming. Care partner requires support, education, guidance in providing appropriate care for PLwD as well as self. Interprofessional team can provide education, identify support services to ensure care partner’s needs are recognized and addressed.


Understanding the Middle Stage of Dementia for the Interprofessional Team (Module 6)

Behavioral and Psychological Symptoms of Dementia (BPSD)
* Common symptoms include mood disorders, sleep disorders, psychotic symptoms, and agitation.
* These are predominantly caused by progressive damage to brain.

The DICE (describe, investigate, create, evaluate) Approach
(see slides)

Treating Sleep Disorders in Dementia
* Nonpharmacologic interventions:
– Sleep hygiene
– Sleep restriction therapy
– Cognitive behavioral therapy
– Light therapy
– Continuous positive airway pressure therapy (CPAP) for sleep apnea (OSA)
* Melatonin/melatonin agonists
* Medications (especially sedative-hypnotics or antipsychotics) can have significant adverse effects.

Home Safety Concerns
* Care partner and dementia care team need to assess safety of the PLwD in the home throughout course of dementia. Problems can arise during early-stage and become more pronounced and possibly dangerous during middle-stage dementia.
– Is PLwD able to continue living at home in middle-stage dementia?
– Is PLwD able to be left alone?
– What needs to be done if the answers are NO?
* Home assessments focus on fall prevention, bathing/toileting safety, kitchen and laundry-room safety.
* Strategies for eliminating fall hazards include keeping floors dry and removing tripping hazards, like small toys or animals.
* Other accommodations include use of alarm bells and safety mechanisms on windows, doors and appliances, monitors.
* Guns and ammunition should be secured separately.


Palliative and End-of-Life Care for Persons Living with Dementia (Module 12)

Key Take-Home Messages
* Persons living with late-stage dementia should be considered candidates for hospice care.
* Hospice care is a Medicare benefit that requires forsaking active aggressive therapeutic treatment.
* As dementia progresses and quality of life decreases, the value placed on living longer by the person may change.

Manifestations of End-Stage Dementia
* Dementias are progressive, incurable illnesses.
* Persons living with most types of end-stage dementia have profound memory deficits, minimal verbal abilities, cannot ambulate, are incontinent, and are dependent on others for activities of daily living (ADLs). These manifestations of end-stage dementia are similar for persons diagnosed with Alzheimer’s disease, Lewy body dementias, or vascular dementias. Persons living with some forms of end-stage frontotemporal degeneration (FTD) have similar signs and symptoms but a faster progression to death.
* The most common clinical complications associated with advanced dementia are eating problems, febrile episodes (fevers), and aspiration pneumonia.
* Risk factors for a faster decline include greater functional disability, extrapyramidal symptoms, a history of falls, arterial coronary disease, stroke, and urinary incontinence.
* PLwD (people living with dementia) should undergo more frequent monitoring during the end stage, especially if they are on medications.

End-of-Life Goals
* End-of-life goals may differ for PLwD vs. care partners.
* Goals may be curative or comfort-based.
* It is important to educate all about terminal nature of dementia.
* End-of-life goals for PLwD encompass many issues.
* Need to perform risk/benefit analysis regarding value of hospitalizations in end-stage dementia.

Behavioral and Psychological Symptoms of End-Stage Dementia
* Behavioral and psychological symptoms of dementia may become more prominent in advanced dementia.
* New onset or acute behavioral problems are usually indicative of a new problem.
* Agitation requires prompt attention and evaluation; management should begin with nonpharmacologic interventions.
* PLwD should be assessed for sleep problems, delirium, and pain.

Distinguishing Palliative Care from Hospice Care
(good slide)

Role of PEG Feeding Tubes in Advanced Dementia
(good slide)

When to Consider Hospice Care
* Hospice criteria for dementia are based on progression of Alzheimer’s disease.
* There are many signs and symptoms of end-stage dementia that suggest consideration of hospice.
* PLwD who cannot walk, bathe, or dress independently may be closer to hospice enrollment.