CM -Dementia Case Management
Case Management Toolbox

 
 
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Case Management Toolbox
06 -Dementia Case Management
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director AllCEUs Continuing Education
Podcast Host: Case Management Toolbox, Counselor Toolbox
CEUs are available for this presentation at https://www.allceus.com/case-management-toolbox-podcast/
Objectives
Resources
– The Dementia Society of Ottawa and Renfrew Counties
– Dementia Australia
Symptoms of Dementia
– Cognitive and sensory changes:
– Memory loss
– Difficulty in communication, especially finding the right words to communicate or keeping track of a conversation.
– Reduced ability to organize, plan, reason, or solve problems
– Difficulty handling complex tasks
– Confusion and disorientation (Gets lost in familiar places)
– Difficulty with coordination and motor functions
– Loss of or reduced visual perception
– Metallic taste in mouth, decreased sense of smell
– Agnosia: loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there necessarily any significant memory loss “visual agnosia” “Auditory agnosia”

Symptoms of Dementia
– Psychological changes:
– Changes in personality and behavior
– Depression
– Anxiety
– Hallucinations
– Mood swings
– Agitation esp. with changes in routine
– Apathy
– Isolation/withdrawal

Dementia vs Normal Aging
– Normal Aging
– Occasional forgetfulness
– Can use notes as reminders
– Slower processing
– Increased time for complex tasks
– Able to follow written and verbal directions
– Longer to learn new information
– Difficulty finding the right word
– Slowed reaction time
– Able to complete ADLs*
– Some issues with balance*

Types of Dementia- Alzheimer’s
– Stage 1 means Alzheimer’s has started to develop, but there are no symptoms of memory loss yet — this stage can last up to 20 years.
– Stage 2 Mild Cognitive Impairment –MCI) involves mild changes in memory and thinking skills
– Stage 3 (Late Stage/Alzheimer’s Dementia) memory and thinking skills are so impaired that a person needs help to complete daily activities of daily living.
Types of Dementia- Korsakoff’s Syndrome
– Korsakoff’s syndrome and Wernicke/Korsakoff syndrome
– Alcohol has a direct toxic effect on the brain cells, or whether the damage is due to lack of thiamine, vitamin B1
– People with anorexia and those who have had bariatric bypass surgery are also at risk.
Types of Dementia—AIDS Dementia Complex
– 7% in people not taking anti-HIV drugs.
Types of Dementia—Vascular Dementia
– Vascular Dementia includes a very wide range of symptoms caused by a reduction in blood supply to the brain usually due to strokes or heart attack
– Symptoms can develop months after a major stroke
– The main symptom of Vascular Dementia is slowness in thinking speed, problems concentrating or difficulty planning and organizing.
– It is also common for a person with Vascular Dementia to experience mood changes
Types of Dementia- With Lewy Bodies
– Dementia with Lewy Bodies is often misdiagnosed as Alzheimer’s Disease
– Parkinson’s Disease and Dementia with Lewy Bodies produce similar brain changes
– The main symptoms include memory loss, disorientation, visual hallucinations and sleep issues
– The disease lasts an average of 5 to 8 years from the time of diagnosis to death, but the time span can range from 2 to 20 years.
Types of Dementia–Frontotemporal
– The main functions affected by Frontotemporal Dementia are language skills, the ability to focus and the ability to control impulses
– More common in those under 65
Other (Reversible-) Causes of Dementia
– Clinical hypothyroidism and hyperthyroidism have long been linked with reversible cognitive impairment in patients
– Cognitive impairment, dementia, and psychoses have been described in patients with chronic hypocalcemia, hypoparathyroidism, and hypercortisolism
– People with PTSD may exhibit hypercortisol responses to stress triggers
– Hypercortisolemia is evident in approximately 50% of depressed patients and is particularly characteristic in the melancholic subtype.
– Nearly 33% of people with Type 2 diabetes have elevated cortisol levels
– A history of recurrent severe hypoglycemic episodes was associated with a greater risk of dementia
Causes of Dementia
– Carbon monoxide (CO) poisoning can lead to a delayed onset cognitive decline beginning days to several weeks after apparent recovery from the initial insult.
– Cognitive decline, personality changes, incontinence, parkinsonism, and even mutism may occur. The majority of victims recover within 1 year.
– Carbon monoxide (CO) is a colorless, odorless gas found wherever fuel is burned including small engines, gas ranges, furnaces, fireplaces and grills
Other Causes cont…
– Sources of carbon monoxide poisoning:
– Furnace
– Chimney (closed/blocked)
– Fireplace
– Water heater
– Gas stove/oven
– Gas-powered space heaters
– Clothes dryer
– Grill
– Power tools and lawn equipment
– An attached garage that regularly houses vehicles

Other Causes Cont…
– Symptoms of CO2 Poisoning
– Dizziness
– Blurred vision
– Weakness/Fatigue
– Confusion
– Shortness of breath during mild activity
– Nausea
– Headache

Dementia Progression
– Dementia is a progressive disease
– The speed of progression varies depending on
– The type of dementia
– The person
– Early interventions
– Medical complications
– Genetics
Dementia Primary Prevention
– Authors estimate that as much as 35% of dementia cases could be prevented by targeting nine modifiable risk factors
• Early life education
• Midlife hypertension (Vascular dementia)
• Obesity
• Diabetes
• Hearing loss
• Old-age smoking
• Depression (Hypercortisolism, unstimulating environments)
• Physical inactivity
• Social isolation
Dementia Primary Prevention
– Regular Physical Activity
– The protective effective was increased as the number of activities increased
– Higher levels of intellectual activities and an intellectually stimulating environment may reduce the risk of cognitive decline later in life
– A lower level of education increases the risk of having AD by approximately 30%**
– Social engagement. Degree of loneliness, decreased social networking and activities seem to be associated with a higher risk
– Dietary modulation (Omega-3, antioxidants, B-Vitamins) serves only to bolster normal health mechanisms that are a natural deterrent of chronic health conditions such as AD without really possessing any discrete disease specificity
Dementia Secondary Prevention/EI
– Reduction or cessation of symptom progression once the symptoms have appeared
– cholinesterase inhibitors and NMDA Antagonists (Ketamine*)
– May improve acute symptoms but does not slow progression
– Physical Activity
Dementia Tertiary Prevention/EI
– Prevent the development of complications from the disorder
– Depression
– Falls
– Nutritional deficiencies
– Diabetes

Multidisciplinary Team
– Physical therapists can help with movement problems through exercises, gait training, and general physical fitness programs.
– Speech therapists may help with voice volume and projection, and swallowing difficulties.
– Occupational therapists help find ways to more easily carry out everyday activities, such as eating and bathing.
– Music or expressive arts therapists may provide meaningful activities that can reduce anxiety and improve well-being.
– Mental health counselors can help people with LBD and their families learn how to manage difficult emotions and behaviors and plan for the future.
– Palliative care specialists can help improve a person's quality of life by relieving disease symptoms at any stage of illness.
Goals
– Goals
– Independence
– Safety
– Sense of meaning
– Happiness/contentment
– General methods
– Safety from falls, wandering, burns, guns, and CO2
– Adequate quality sleep
– Adequate nutrition
– Medication compliance
– Physical Activity
– Social Interactions
– Meaningful Daily Activity
Special Issues for People with Dementia
– The needs of a person with Early Onset Dementia can be very different from traditional onset dementia because they may be actively working and raising a family and be otherwise healthy and strong
– Early stage of dementia, a person can still function rather independently and requires little care assistance.
– Appointment reminders
– Daily to-do list and / or a schedule of when medications
– Hang complete outfits
– Go shopping together (or auto-deliver)
– Regular check-ins while the person is still living independently
– Family counseling to deal with grief issues related to the diagnosis
– Financial planning
– Note on microwave (i.e. no metal, duration for common foods)
– Coffee maker that automatically shuts off

Special Issues for People with Dementia
– Middle Stage Dementia
– No longer able to function as independently
– Greater difficulty communicating (see communication tips)
– Assistance with activities of daily living, such as bathing, grooming, and dressing, is often required
– Initially, an individual may only need prompts or cues to perform these tasks, such as reminders of the need to shower or clothes laid out on the bed
– Transportation will be required
– Supervision is necessary
Special Issues for People with Dementia
– Late Stage Dementia
– Requires a significant amount of care 24-hours / day.
– Mobility issues
– Swallowing becomes an issue in late stage dementia, and caregivers have to make sure food is cut into small pieces, is soft, such as yogurt and applesauce, or is pureed.
– Options for care, such as hiring a part time caregiver or moving your loved one to a nursing home.
Monitoring Tools
– Functional Assessment Staging Test
– Stage-Expected Untreated Duration-Mental Age-MMSE-A Score
– Weight
– Infections/Pain/Illness (60% may have untreated issues)
– Falls and injuries
– Behavior changes
– Medication compliance, effects/side-effects and changes
– Mood and ADLs: Ambulation, hygiene, feeding, toileting
– May indicate disease progression or another acute issue
– Social engagement
– Note: Abilities may fluctuate
General
– Review medications
– Consider whether any might be contributing to cognitive deficits, especially anticholinergics, antihistamines, narcotics, sedatives, and benzodiazepines*
– Address treatment compliance
– Add social activities
– Add intellectual stimulation and meaningful daily activities
– Focus on activities with tangible results
– Painting
– Life-story book
– Gardening
– Playing or listening to music
– Picture books

General
– Assess mobility issues
– In house
– Getting out of bed
– Getting in and out of the shower/tub
– Stairs
– Slick floors
– Tripping hazards
– With preferred activities (walk the dog, woodwork, crochet, painting)
– To get supplies (driving, shopping)
– Address long-term care planning
– Advanced directives
– Power of attorney
– Living transitions
General
– Evaluate behavioral issues and safety
– Driving, wandering, cooking, bathing, shopping
– Sundowning—confusion and agitation increase throughout the day
– Mitigate vulnerabilities/triggers
– Recognize the function of the agitation
– Use visual cues for orientation and comfort
– Avoid arguing
– Consider bright light therapy to adjust circadian rhythms—Full spectrum light at least 100 watts (not soft) within 3 ft. or sitting by a sunny window
– Increase daytime activity and limit day naps
– Avoid stimulants after noon
– Minimize stress (TV or reading might be too difficult) painting, pets, baking with assistance, gardening
– Address caregiver stress
Addressing Behavioral Issues
– Functional assessments
– Preferred activities
– Problem behaviors
– Aromatherapy (esp. Lemon Balm, rose, lavender, bergamot)
– Music therapy
– Animal assisted therapy
– Relaxation training
– Reminiscence therapy helps recall past happy times despite current issues with short term memory
– Difference between reminiscing and remembering
– Use favorite music, keepsakes/ornaments/jewelry, magazines, familiar scents or foods
Addressing Behavioral Issues
– Validation therapy
– Often prevents argumentative and agitated behaviors. Validation may require you to agree and validate with a statement that has been made, even though the statement is neither true or real, because to the person with dementia, it may actually be both true and real
– Light therapy (sundowning)
– Activities of Daily Living
– Strategies may include verbal or visual cues, demonstration, physical guidance, partial physical assistance and problem solving
Addressing Behavioral Issues
– The reasons that underlie the problem behaviors can be one or more of the following basic human needs:
– Resolution of unfinished issues, in order to die in peace
– To live in peace
– Adjusting to new normal when sight, hearing, mobility and memory fail
– To make sense out of an unbearable reality
– For recognition, status, identity and self-worth
– To be useful and productive
– To be listened to and respected
– To express feelings and be heard
– To be loved and to belong
– To be nurtured, feel safe and secure, rather than immobile or restrained
– For sensory stimulation as well as sexual expression
– Reduce pain and discomfort
Caregiver Needs
– Resources
– The signs and symptoms of dementia
– The course and prognosis of the condition
– Treatments
– Knowledge of how to help their loved-one
– Communication
– Behavior issues
– Safety—wandering, falling, hazards
– Local care and support
– Sources of financial and legal advice, and advocacy
– Medico-legal issues, including driving
– Local information sources, including libraries and voluntary organizations.
– Respite care—In home or clubhouse/day care
Communicating with People with Dementia
– Get their attention
– Remove distractions
– Ensure they have glasses or hearing aids
– Be patient. Allow enough time for them to respond, and be careful not to interrupt
– Use visual reminders (memory books and charts)
– Keep questions and requests to one at a time
– Break larger tasks into smaller chunks
– Empathize with frustration
– Anticipate misunderstandings
– Enjoy the good times

Communicating with People with Dementia
– Reduce input late in the day
– Do not talk to the person with Alzheimer’s like a baby or speak about them as if they weren’t there.
– If they struggle to find a word or communicate a thought, gently try to provide the word(s) they are looking for.
– Frame questions and instructions in a positive way.
– Be open to the person’s concerns, even if he or she is hard to understand.
– If you can’t understand what they are trying to say, look for clues in their emotions and body language and take their surrounding environment into consideration.

Summary
– Dementia can be permanent or temporary and caused by a variety of factors including
– Diabetes
– HIV
– Stroke/Heart attack
– Depression
– Thiamine deficiency
– CO2 poisoning
– Lewy bodies
– Genetics

Summary
– A variety of interventions can be used to assist the person with dementia and their caregivers
– Ensure sufficient sleep
– Assist with communication
– Conduct functional assessments of preferred and problem behaviors