Alzheimer’s disease & Dementias

by Robin Fenley, CSW

DirectorAlzheimer’s and Long-term Care

UnitNYC Department for the Aging

What is Dementia?

The term given to changes experienced in cognition, behavior and self-careReversible

MetabolicPhysiologic

IrreversibleAlzheimer’s disease ~75% of all dementias

Alzheimer’s Disease (AD)

Not a normal part of agingProgressive decline in executive functioning

Memory loss Inability to learn new tasks

Behavioral changesDeterioration in self-care abilities

Ten Warning Signs(Alzheimer’s Assoc.)1. Recent memory loss that effects job performance

2. Difficulty performing familiar tasks

3. Problems with language

4. Disorientation of time and place

5. Impaired judgment

6. Problems with abstract thinking

7. Misplacing things

8. Changes in mood or behavior

9. Personality changes

10. Loss of initiative

Medical Work-up

Neurological and physical examinationLab tests, EKG, chest X-rayBrain scans CT, MRI, PETEEGPsychiatric evaluationNeuropsychological tests for mental status and cognitive functioning

Disease Course of ADPrognosis

Insidious onsetAvg 8-10 years after diagnosisUp to 20 years

RetrogenesisBarry Reisberg, MD, NYU Silberstein Dementia Research Center20 year reversal in abilities

Risk factorsAgeFamily history

< 10%Before age 60

High cholesterolHigh blood pressureHead injury

Speculative:Exposure to aluminumAspartame (artificial sweetner)

TreatmentsMedication

Early stage• Aricept, Exelon, Reminyl

Moderate to late stage• Namenda

AntipsychoticsAntidepressants

VaccineElan Pharmaceutical, 2002 and 2004

Alternative Treatments Vitamin E

400 IU 2x day 1200 IU 2x day in 1997 study

Ginkgo biloba1997 study showed ~improved cognition, ADLs, social behaviorCurrent study with 3000 participants

ExerciseNYU’s study

Facts & Figures

4 million persons with AD nationallyEstimated 200,000 in NYC

Projected to grow to 14-16 million by 20501 in 10 people 65+Almost 50% for those 85+

(Source: Alzheimer’s Association)

Facts & Figures cont’d

4th leading cause of death in the elderly (heart disease, cancer, diabetes)

75% of individuals with AD are cared for at home

(Source: Alzheimer’s Association; National Institute on Aging)

The Price of ADNationally

$100 billion/year• Direct and indirect care

$61 billion/year to business• Lost productivity, absenteeism, replacement(Source: Alz Assoc., Nat’l Institute on Aging)

Average lifetime costs per person$174,000

(Source: Ernst,RL & Hay,JW. The U.S. economic & social costs of Alzheimer’s disease revisited. American Journal of Public Health. 1994. Cited in Nat’l Institute of Health, 2003.)

Challenging BehaviorsPsychosis

50-70% incidence rate•Theft•Intruders•Misidentification•Infidelity

(Source: J.Cummings, MD, UCLA Alzheimer’s Disease Research Center)

Depression

25% incidence rate•Decreased appetite•Decreased interest in life activities

•Lethargy•Apathy

(Source: J.Cummings, MD, UCLA Alzheimer’s Disease Research Center)

Agitation60-80% incidence rate

•Resistance to care•Aggression, striking out•Shouting

٠Disinhibition ٠Irritability٠Anxiety

(Source: J.Cummings, MD, UCLA Alzheimer’s Disease Research Center)

Impact of Behavioral Changes

Distressing to caregiversDistressing to person with ADCan precipitate abuseCan lead to earlier institutionalization

BUTCan respond to medical intervention

Engaging the Person with Dementia

Respect the dignity of the individual

Approach the individual in their

direct line of vision Identify yourself in reassuring tone If appropriate, use touch to get their attention Avoid sudden movements that may startle

Be Aware of the Environment

Reduce background noise and distraction Sundowning

Simplify Verbal Communication

Convey ideas one step at a timeSelect concrete words when possibleAvoid abstractions or generalizationsUse yes/no questionsRepeat as necessaryPerson may ‘mask’ responses

Active Listening

Be patient. Allow time for the individual to find the wordsDo not interrupt or finish the sentenceUnderstand what the person is saying before responding

Nonverbal Communication

Communication skills deteriorate from verbal to nonverbal Watch body language and facial expression for signs of agitation, discomfort or pain

Communicating with the Caregiver

Allow time to ventListen for veiled or overt expressions of exhaustion, frustration, angerBe sensitive to caregiver/care receiver confidentiality If possible, interview separately

Resistance in Alzheimer’s

If the person becomes agitated, stop the activity Schedule enough time Do not force the issue unless there is an immediate threat to health and safety

Service Options

Diagnostic centersSafe Return ProgramClinical trialsNYC Caregiver Program

Community Care Options

Home careHome delivered mealsTransportationAdult day service

Social modelMedical model

Taking a Break

RespiteIn-homeCongregateOvernight respite

Residential Continuum

Adult homeAssisted livingNursing home

Considerations

Available social supportsAwareness of community servicesUtilization of servicesFinancial resourcesInvolvement of APS where appropriate

The Multidisciplinary Team

Family membersSocial workersGeriatricians, psychiatristsElder law attorneysLaw enforcementGeriatric care managersFaith-based community

Useful Contacts311 for all city services in NYC

NYC Dept for the Aging(212) 442-1000www.nyc.gov/agingwww.nyccaregiver.org

Alzheimer’s Association, NYC Chapter(212) 973-0700www.alznyc.org

Useful Contacts, cont’d

U.S. Administration on Agingwww.aoa.gov

Fisher Foundationwww.alzinfo.org