222 -Overview of Working with Alzheimer's and Dementias
Counselor Toolbox

 
 
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Alzheimer's and Dementias
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director: AllCEUs.com, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery

Objectives
~ Explore symptoms of cognitive impairment in
~ Alzheimer’s
~ Dementias
~ Review APA Treatment Guidelines for counselors working with persons with Alzheimer’s
~ Identify methods for effective communication
~ Learn how to handle difficult behaviors

Symptoms of Cognitive Impairment
~ Patients with dementia display a broad range of cognitive impairments, behavioral symptoms, and mood changes
~ The development of multiple cognitive deficits manifested by both
~ (1) Memory impairment (impaired ability to learn new information or to recall previously learned information)
~ (2) One (or more) of the following cognitive disturbances:
~ (a) Aphasia (language disturbance)
~ (b) Apraxia (impaired ability to carry out motor activities despite intact motor function)
~ (c) Agnosia (failure to recognize or identify objects despite intact sensory function)
~ (d) Disturbance in executive functioning (i.e., Planning, organizing, sequencing, abstracting)
Symptoms of Cognitive Impairment
~ Other Symptoms
~ Attention
~ Perception
~ Insight and judgment
~ Organization
~ Orientation
~ Processing speed
~ Problem solving
~ Reasoning
~ Metacognition: processes used to plan, monitor, and assess one’s understanding and performance

Symptoms of Cognitive Impairment
~ Prominent memory symptoms include all EXCEPT:
~ Difficulty learning new material
~ May lose valuables or forget food cooking on the stove
~ Forget previously learned material, including the names of loved ones
~ Difficulty with spatial tasks, such as navigating around the house or in the immediate neighborhood
~ Agitation, within the context of a diagnosis of dementia, is an umbrella term that can refer to a range of behavioral disturbances, including aggression, combativeness, hyperactivity, and disinhibition
~ Individuals with questionable cognitive impairment have Borderline functioning in several areas but definite impairment in none. Such individuals are not considered demented, but they should be evaluated over time
Causes of Cognitive Impairment
~ Vascular Dementia
~ Stroke
~ Impeded blood flow to brain
~ Alzheimer's
~ Brain Injury from a fall
~ Primary or secondary brain tumor
~ Endocrine conditions (hypothyroidism, hypercalcemia, hypoglycemia)
~ Nutritional conditions (deficiency of thiamin, niacin, or vitamin b12 (Wernike-Korsakoff’s Syndrome))
~ Infectious conditions (HIV, neurosyphilis, cryptococcus)
~ Problems with renal and hepatic function
~ Effects of medications (e.g., benzodiazepines)
~ The toxic effect of long-standing substance abuse
Diagnostic Criteria
~ Mild or Major Neurocognitive Disorder Due to Alzheimer's
~ Criteria adapted from the National Institute of Neurological and Communicative Disorders and Stroke and Alzheimer’s Disease and Related Disorders Association (NINCDS-ADRDA) include:
~ Dementia established by examination and objective testing
~ Deficits in two or more cognitive areas
~ Progressive worsening of memory and other cognitive functions
~ No disturbance in consciousness
~ Onset between ages 40 and 90
Diagnostic
~ Alzheimer’s cont…
~ Some individuals may show personality changes or increased irritability in the early stages
~ In the middle and later stages of the disease
~ Psychotic symptoms are common
~ Patients develop incontinence and gait and motor disturbances, eventually becoming mute and bedridden.
Diagnostic
~ Parkinson's
~ Insidious onset
~ Slowly progressive
~ Tremor. Rigidity. Myoclonus (sudden, involuntary jerking of a muscle or group of muscles)
~ Onset is typically in middle to late life
~ Motoric slowing
~ Executive dysfunction
~ Impairment in memory retrieval
~ Pseudodementia is a condition that occurs within the context of major depressive disorder
Diagnostic
~ Vascular Dementia
~ One or more strokes on cognitive function
~ Extensor plantar response
~ Pseudobulbar palsy
~ Gait abnormalities
~ Exaggeration of deep tendon reflexes
~ Weakness of an extremity.
~ The mode of onset, subsequent course and reversibility of dementia depend on the underlying etiology
Cognitive Deficits
~ Cognitive deficits in delirium often fluctuate
~ Cognitive deficits in dementia are stable or progress, they do not get better.
~ Cognitive deficits in schizophrenia usually occur with other psychotic features
~ Recommended assessments include evaluation of suicidality, dangerousness to self and others, and the potential for aggression, as well as evaluation of living conditions, safety of the environment, adequacy of supervision, and evidence of neglect or abuse
Screening for Cognitive Impairment
~ The AD8 (PDF, 1.2M) and Mini-Cog(PDF, 86K) are among many possible tools.
~ Patients should be screened for cognitive impairment if:
~ The person, family members, or others express concerns about changes in his or her memory or thinking
~ You observe problems/changes in the patient’s memory or thinking
~ The patient is age 80 or older
~ Low educational attainment (IQ, FASD, stroke…)
~ History of type 2 diabetes
~ Stroke
~ Depression
~ Trouble managing money or medications
~ Episodes of delirium (confusion/disorientation)

Course of Treatment
~ Demographic and social factors that may impact course or treatment include:
~ Age
~ Gender
~ Social support
~ Resource availability
~ Ethnic background
Important Aspects of Management
~ Counselor Goals
~ Establish and maintain an alliance with the patient and family
~ Perform a diagnostic evaluation and refer the patient for any needed general medical care
~ Assess and monitor psychiatric status for the presence of noncognitive psychiatric symptoms and progression of cognitive symptoms.
~ Educate the patient and family about future symptoms and the care likely to be required
~ Help patients and their families think about financial and legal issues due to the patient's incapacity
Important Aspects of Management
~ Counselor Goals
~ Help patients and their families think about financial and legal issues due to the patient's incapacity
~ Educate the patient and family about the illness, its treatment, and available sources of care and support
~ Monitor safety and intervene when required
~ Improving quality of life
~ Maximizing function in the context of existing deficits
~ Improvement of cognitive skills, mood, or behavior
Important Aspects of Management
~ Counselor Goals
~ Goals for treatments for cognitive and functional losses include:
~ Restoring cognitive abilities
~ Preventing further decline
~ Increasing functional status
~ Goals for treatments for psychosis and agitation include:
~ Decrease psychotic symptoms (including paranoia, delusions, and hallucinations)
~ Decrease independent agitation, screaming, combativeness
~ Increase the comfort and safety of patients and their families and caregivers
Side Effects
~ Side effects of psychotherapies include:
~ Frustration
~ Catastrophic reactions
~ Agitation
~ Depression
Important Aspects of Management
~ Important aspects of psychiatric management include
~ Educating patients and families about:
~ The illness
~ Treatment
~ Sources of additional care and support (e.g. Support groups, respite care, nursing homes, and other long-term-care facilities)
~ The need for financial and legal planning due to the patient’s eventual incapacity (e.g. Power of attorney for medical and financial decisions, an up-to-date will, and the cost of long-term care)
Management..
~ Patients with dementia require a treatment plan that is individualized, multimodal, evolving
~ Frequency of visits is determined by:
~ The patient's clinical status
~ The likely rate of change
~ The current treatment plan
~ The need for any specific monitoring of treatment effects
~ The reliability and skill of the patient's caregivers
Important Aspects of Management
~ Behavior oriented treatments
~ Identify the antecedents and consequences of problem behaviors
~ Reduce the frequency of behaviors by changing the environment to alter these antecedents and consequences.
~ Stimulation-oriented treatments
~ Recreational activity, art therapy, music therapy, and pet therapy, along with other formal and informal means of maximizing pleasurable activities for patients
~ Emotion-oriented treatments
~ Supportive psychotherapy can be employed to address issues of loss in the early stages of dementia
~ Reminiscence therapy has some modest research support for improvement of mood and behavior
~ Tolerate, Anticipate, Don’t Agitate
Management cont…
~ A Particular concern in long-term care is the use of physical restraints and antispychotics
~ Restraint use in this population can be decreased by
~ Environmental changes that reduce the risk of falls or wandering
~ Careful assessment and treatment of possible causes of agitation.
~ Bed and chair monitors that alert nursing staff when patients may be climbing out of bed or leaving a chair
~ Prompted voiding schedules through the day and night to decrease the urge for unsupervised trips to the bathroom
Management
~ Antipsychotics, Benzodiazepines, Anticonvulsants (carbamazepine), Trazadone, Buspirone, Beta blockers, notably propranolol are used to treat agitation and psychosis
~ Benzodiazepine
~ Most useful for treating patients with prominent anxiety
~ Perform better than placebo but not as well as antipsychotics
~ Usually not recommended other than for brief use because of the risk of daytime sedation, tolerance, rebound insomnia, worsening cognition, disinhibition, delirium, risk of falls, worsening of sleep disordered
~ Antipsychotic medications, when over used can lead to worsening of the dementia, over-sedation, falls, and tardive dyskinesia.
~ Elderly and patients with dementia are more sensitive to certain medication side effects including anticholinergic effects and orthostasis

Management
~ Psychostimulants (d-amphetamine, methylphenidate) are associated with tachycardia, restlessness, agitation, sleep disturbances, and appetite suppression
~ SSRIs have favorable results in treating depression, but can produce nausea and vomiting, agitation and akathisia, parkinsonian side effects, sexual dysfunction, and weight loss
~ Special considerations for elderly and demented populations include all EXCEPT:
~ Elderly individuals may have decreased renal clearance and slowed hepatic metabolism
~ Elderly individuals are more likely to have a variety of general medical problems and take multiple medications
~ Elderly and demented patients are more likely to be noncompliant with treatment

Management
~ Safety measures include:
~ Evaluation of suicidality and the potential for violence
~ Recommendations regarding adequate supervision
~ Vigilance regarding neglect or abuse
~ Restrictions on driving and use of other dangerous equipment
~ Specific psychosocial treatments for dementia can be divided into four broad groups:
~ Behavior oriented
~ Emotion oriented
~ Cognition oriented
~ Stimulation oriented
Management
~ Basic principles of care to be remembered by counselors and family include
~ Keeping requests and demands relatively simple and avoiding overly complex tasks that might lead to frustration
~ Avoiding confrontation and deferring requests if the patient becomes angered
~ Remaining calm, firm, and supportive if the patient becomes upset
~ Being consistent and avoiding unnecessary change
~ Providing frequent reminders, explanations, and orientation clues
~ Recognizing declines in capacity and adjusting expectations appropriately
~ Bringing sudden declines in function and the emergence of new symptoms to psychiatrist
Management
~ Behavioral symptoms can be precipitated by both over and understimulation
~ Cholinesterase inhibitors (tacrine and donepezil), A-tocopherol (vitamin e), Selegiline (deprenyl), ergoloid mesylates (hydergine) are used to treat Alzheimer’s

Depression
~ Depression
~ Depression is common in patients with dementia.
~ Patients with depression should be carefully evaluated for suicide potential.
~ Depressed mood may respond to improvements in the living situation or stimulation-oriented treatments.
~ Patients with severe or persistent depressed mood with or without a full complement of neurovegetative signs should be treated with antidepressant medications.
~ SSRIs are the first-line treatment.
Management
~ Treatment plan for mildly impaired patients includes
~ Patients and their families are often dealing with recognition of the illness and associated limitations, and they may appreciate suggestions for how to cope with these limitations (e.g., making lists, using a calendar).
~ Identify specific impairments and highlight remaining abilities.
~ Caregivers should be made aware of the availability of support groups and social agencies.
~ Patients with moderate to severe major depression who do not respond to or cannot tolerate antidepressant medications should be considered for ECT.
Management
~ Treatment plan for moderately impaired patients should include:
~ Increased supervision
~ Families should be advised regarding the possibility of accidents due to forgetfulness (e.g., fires while cooking), of difficulties coping with household emergencies, and wandering
~ Patients should be strongly urged not to drive
~ As patients' dependency increases, respite care (e.g., home health aid, day care, or brief nursing home stay) may be helpful
~ At this stage, families should begin to consider and plan for additional support at home or possible transfer to a long-term care facility.
~ Delusions and hallucinations often develop in moderately impaired patients.
Management
~ Combativeness, and physical violence
~ Often associated with frustration, misinterpretations, delusions, or hallucinations
~ Pose a particular problem for patients cared for at home
~ Hospitalization and/or nursing home placement must be considered
~ When treating psychosis and agitation the clinician should:
~ Consider the safety of the patient and those around him or her
~ Conduct a careful evaluation for a general medical, psychiatric, or psychosocial problem that may underlie the disturbance
~ If the symptoms do not cause undue distress to the patient or others, they are best treated with reassurance and distraction
Handling Troubling Behaviors
~ Try to accommodate the behavior, not control the behavior
~ For example, if the person insists on sleeping on the floor, place a mattress on the floor to make him more comfortable.
~ Remember that we can change our behavior or the physical environment.
~ Changing our own behavior will often result in a change in our loved one’s behavior. (Frustration -> frustration)
~ Check with the doctor first.
~ Behavioral problems may have an underlying medical reason, i.e. pain or experiencing an adverse side effect from medications.
Handling Troubling Behaviors
~ Behavior has a purpose. People with dementia typically cannot tell us what they want or need. They might do something, like take all the clothes out of the closet on a daily basis, and we wonder why.
~ To be busy and productive
~ Because they are too hot or cold, uncomfortable
~ Always consider what need the person might be trying to meet with their behavior—and, when possible, try to accommodate them.
Handling Troubling Behaviors
~ What works today, may not tomorrow because:
~ Multiple factors influence troubling behaviors
~ Natural progression of the disease process
~ The key to managing difficult behaviors is being creative and flexible in your strategies to address a given issue.
~ Behavior is triggered. It occurs for a reason.
~ It might be something a person did or said
~ It could be a change in the physical environment.
~ The root to changing behavior is disrupting the patterns that we create.
~ Try a different approach
~ Try a different consequence. (Positive redirection)
~ Sundowing can best be described as a peak period of agitation or other behavioral disturbances during the evening hours

Issues for Caregivers
~ Challenges in home-care settings often include :
~ Family care providers to work at jobs outside the home during the day
~ The adverse emotional impact on caregivers and children or grandchildren
~ The psychological stress on families from Alzheimer's disease appears to be more complex than simply the burden of caring for a disabled family member

Summary
~ Working with people with cognitive impairment can be frustrating
~ It is important not to confuse chronological age with communicative age
~ KISS
~ Eliminate distractions
~ Don’t expect short-term memory
~ Use pictures, lists, storyboards
~ Spaced retrieval training has shown effectiveness in improving memory in people with cognitive impairments
~ Many clients who misuse alcohol and/or try to self detox can precipitate a cognitive impairment through
~ Thiamine deficiency
~ Stroke
~ Conduct ongoing assessments for cognitive impairments

~ University of Kentucky FREE CEs for nurses, social workers and CNAs
~ Alzheimer’s Care Curriculum