Hot Topics In Dementia Care

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The Alzheimer's Association 2018 Dementia Care Practice Recommendations

2018 Dementia Care Practice Recommendations

Goals of quality dementia care in the following areas:

1. Person-centered care

2. Detection and diagnosis

3. Assessment and care planning

4. Medical management

5. Information, education, and support

6. Ongoing care for behavioral and psychological symptoms of dementia, and support for activities of daily living

7. Staffing

8. Supportive and therapeutic environments

9. Transitions and coordination of services

The 2018 Dementia Care Practice Recommendations: Definition

• Care partner = People supporting individuals in the early stages of dementia

• Caregivers = People supporting individuals in the middle and late stages

• Care provider = Paid professionals

Practice Recommendations for Person-Centered Care

Practice Recommendations for Person-Centered Care

1. Know the person living with dementia

2. Recognize and accept the person’s reality

3. Identify and support ongoing opportunities for meaningful engagement

4. Build and nurture authentic, caring relationships

5. Create and maintain a supportive community for individuals, families, and staff

6. Evaluate care practices regularly and make appropriate changes

Sam Fazio, Douglas Pace, Janice Flinner, Beth Kallmyer, The Fundamentals of Person-Centered Care for Individuals With Dementia, The Gerontologist, Volume 58, Issue suppl_1, February 2018, Pages S10–S19, https://doi.org/10.1093/geront/gnx122

Practice Recommendations for Person-Centered Assessment

and Care Planning

Practice Recommendations for Person-Centered Assessment and Care Planning

1. Perform regular, comprehensive person-centered assessments and timely interim assessments

2. Use assessment as an opportunity for information gathering, relationship-building, education, and support

3. Approach assessment and care planning with a collaborative, team approach

4. Use documentation and communication systems to facilitate the delivery of person-centered information between all care providers

5. Encourage advance planning to optimize physical, psychosocial, and fiscal wellbeing and to increase awareness of all care options, including palliative care and hospice

Sheila L Molony, Ann Kolanowski, Kimberly Van Haitsma, Kate E Rooney, Person-Centered Assessment and Care Planning, The Gerontologist, Volume 58, Issue suppl_1, February 2018, Pages S32–S47, https://doi.org/10.1093/geront/gnx173

Practice Recommendations for Medical Management

Practice Recommendations for Medical Management

1. Take a holistic, person-centered approach to care and embrace a positive approach to the support for persons living with dementia and their caregivers that acknowledges the importance of individuals’ ongoing medical care to their well-being and quality of life

2. Seek to understand the role of medical providers in the care of persons living with dementia and the contributions that they make to care

3. Know about common comorbidities of aging and dementia and encourage persons living with dementia and their families to talk with the person’s physician about how to manage comorbidities at home or in residential care settings

4. Encourage persons living with dementia and their families to use nonpharmacologicinterventions for common behavioral and psychological symptoms of dementia first

5. Understand and support the use of pharmacological interventions when they are necessary for the person’s safety, well-being, and quality of life

6. Work with the person living with dementia, the family, and the person’s physician to create and implement a person-centered plan for possible medical and social crises

7. Encourage persons living with dementia and their families to start end-of-life care discussions early

Mary Guerriero Austrom, Malaz Boustani, Michael A LaMantia, Ongoing Medical Management to Maximize Health and Well-being for Persons Living With Dementia, The Gerontologist, Volume 58, Issue suppl_1, February 2018, Pages S48–S57, https://doi.org/10.1093/geront/gnx147

Practice Recommendations for Information, Education, and Support for Individuals Living with Dementia and their Caregivers

Practice Recommendations for Information, Education, and Support for Individuals Living with Dementia and their Caregivers

1. Provide education and support early in the disease to prepare for the future

2. Encourage care partners to work together and plan together

3. Build culturally sensitive programs that are easily adaptable to special populations

4. Ensure education, information, and support programs are accessible during times of transition

5. Use technology to reach more families in need of education, information, and support

Carol J Whitlatch, Silvia Orsulic-Jeras, Meeting the Informational, Educational, and Psychosocial Support Needs of Persons Living With Dementia and Their Family Caregivers, The Gerontologist, Volume 58, Issue suppl_1, February 2018, Pages S58–S73, https://doi.org/10.1093/geront/gnx162

Practice Recommendations for Care of Behavioral and Psychological Symptoms of Dementia (BPSD)

Practice Recommendations for Care of Behavioral and Psychological Symptoms of Dementia (BPSD)

1. Identify characteristics of the social and physical environment that trigger or exacerbate behavioral and psychological symptoms for the person living with dementia

2. Implement nonpharmacological practices that are person-centered, evidence-based, and feasible in the care setting

3. Recognize that the investment required to implement nonpharmacological practices differs across care settings

4. Adhere to protocols of administration to ensure that practices are used when and as needed, and sustained in ongoing care

5. Develop systems for evaluating effectiveness of practices and make changes as needed

Kezia Scales, Sheryl Zimmerman, Stephanie J Miller, Evidence-Based Nonpharmacological Practices to Address Behavioral and Psychological Symptoms of Dementia, The Gerontologist, Volume 58, Issue suppl_1, February 2018, Pages S88–S102, https://doi.org/10.1093/geront/gnx167

Practice Recommendations for Support of Activities of Daily Living (ADLs)

Practice Recommendations for Support of Activities of Daily Living (ADLs)

1. Support for ADL function must recognize the activity, the individual’s functional ability to perform the activity, and the extent of cognitive impairment

2. Follow person-centered care practices when providing support for all ADL needs

3. When providing support for dressing, attend to dignity, respect, and choice; the dressing process; and the dressing environment

4. When providing support for toileting, attend to dignity and respect; the toileting process; the toileting environment; and health and biological considerations

5. When providing support for eating, attend to dignity, respect and choice; the dining process; the dining environment; health and biological considerations; adaptations and functioning; and food, beverage and appetite

Lindsay P Prizer, Sheryl Zimmerman, Progressive Support for Activities of Daily Living for Persons Living With Dementia, The Gerontologist, Volume 58, Issue suppl_1, February 2018, Pages S74–S87, https://doi.org/10.1093/geront/gnx103

Practice Recommendations for Supportive and Therapeutic Environments

Practice Recommendations for Supportive and Therapeutic Environments

1. Create a sense of community within the care environment

2. Enhance comfort and dignity for everyone in the care community

3. Support courtesy, concern, and safety within the care community

4. Provide opportunities for choice for all persons in the care community

5. Offer opportunities for meaningful engagement to members of the care community

Margaret P Calkins, From Research to Application: Supportive and Therapeutic Environments for People Living With Dementia, The Gerontologist, Volume 58, Issue suppl_1, February 2018, Pages S114–S128, https://doi.org/10.1093/geront/gnx146

Key Summary in Dementia Care From AAIC 2018

New technology uses in training• “Bringing Art to Life”

• Virtual reality program presenting two scenarios through continuum of AD

• Among a group of high school students working with seniors• Improved empathy

• Increased enthusiasm

• Decreased stigma and negative attitudes

• Expanded awareness about what it is like to have Alzheimer's disease and dementia• Ongoing project with medical and pharmacy students

Special Populations: LGBT Seniors (Fazio et al)

• 2.7 million LGBT people over age 50, with that number doubling over next 15 years

• 200,000 LGBT individuals with dementia in the US, but almost nothing was known about the prevalence of dementia among people without HIV/AIDS dementia

• LGBT community faces similar health concerns as the general public, but LGBT with dementia face uniquely challenges• Even with recent advances in LGBT rights, LGBT older adults often marginalized and face discrimination• 2X as likely to age without a spouse or partner, 2X as likely to live alone, and 3-4X times less likely to have

children –limiting their support• 40% of LGBT older people in their 60s and 70s say their healthcare providers don‘t know their sexual

orientation

• Pressing health issues for LGBT people:• Lower rates of accessing care (up to 30%)• Increased rates of depression• Higher rates of obesity in the lesbian population• Higher rates of alcohol and tobacco use for LGBT persons• Higher risk factors of cardiovascular disease for lesbians

Special Populations: Oldest Old (Leung et al.)

• “Conventional wisdom” • If you reach age 90+ without dementia, you are very unlikely to get it

• Studied 4,100 persons aged 95-110 in 11 countries1. Prevalence increased with age in all countries

2. Risk of dementia and cognitive/functional decline varied significantly between countries (i.e., cultural and lifestyle factors play a role in remaining physically and cognitively healthy)

3. Persons with higher levels of education had lower prevalence of dementia and cognitive impairment

4. Women in this age group had a higher risk of dementia and cognitive impairment

Special Populations: Caregivers, the “Second Patient”

• Many Studies in AAIC 2018

• Negative effects• High levels of stress

• Physical health suffers e.g., ↓immunity, ↑mortality

• Social isolation

• Financial hardship

• Positive effects• Increased reciprocity• Increased altruism

FDA Guidelines for Treatment of Behavioral Symptoms

• Behavioral symptoms of dementia often cause the greatest caregiving challenges and leading causes for placement in assisted living or a nursing home• Agitation, anxiety, insomnia, depression, wandering, incontinence, disinhibition

• No approved drug treatments are available

• Psychotropic medications may need to be considered when behaviors have not responded to non-pharmacologic approaches, especially if causing physical or emotional harm to the person with dementia or caregiver

• Must be used with extreme care and must be regularly evaluated to determine the appropriate time to stop

• Using antipsychotics to treat these behaviors was associated with increased mortality

• Need for new research on new medication (e.g., Nuedexta, Mibrampator, Nabilone)

Possible Treatment of Non-Cognitive Symptoms(Lanctôt et.al.)

• Nabilone is a synthetic form of THC, the psychoactive element in marijuana

• 39 participants with average age of 87 received Nabilone

• Agitation improved significantly compared to placebo• But, more people in the study experienced sedation on nabilone (45%)

compared to placebo (16%)

• Marijuana is, essentially, an untested drug in Alzheimer’s and yet no clinical trial data supporting the use

Treatment of Non-Cognitive Symptoms: Sleep (Figueiro et al.)

• AD/ADRD leads to changes in sleep, patterns, insomnia, and daytime sleepiness

• Light/dark patterns are typically experienced by people living in residential care facilities & may underlie sleep pattern disturbances

• Circadian Stimulus Metric (Lighting Research Center)• How well does a light source stimulate the circadian system (i.e., suppressing the

body’s production of the hormone melatonin, well-established marker of the circadian system) after a 1-hour exposure

• Short term study of 43 people in 10 nursing homes• Participants who had high-circadian stimulus showed significant decrease in sleep

disturbance, depression and agitation• Ongoing long-term study

Treatment of Non-Cognitive Symptoms: Sleep (Fox et al.)

• Non-benzodiazepine hypnotic “Z-drugs,” (e.g., zolpidem, zopicloneand zaleplon) often prescribed to help treat insomnia

• Analyzed existing data from the UK Clinical Practice Research for persons newly prescribed Z-drugs vs persons not prescribed

• Use of Z-drugs was associated with a 40% increased risk of any type of fracture (dose dependent)

• Z-drugs also associated with a greater risk of hip fractures, but not falls, infections, or stroke

• Consider non-pharmacological alternatives, and when Z-drugs are prescribed, care should be given to reduce or prevent falls

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