Dementia and Alzheimer’s Disease – Latest Report on Alzheimer’s Disease

Dementia is an age-associated condition, causing a reduction in mental or intellectual functioning.  The most common cause of dementia is Alzheimer’s disease. It accounts for 60 to 80% of all irreversible dementias, and is characterized chiefly by difficulty remembering names and recent events, and, very often, apathy and depression in the early stages. Later stages are marked with reduced judgment and reasoning, confusion and disorientation, behavior difficulties, and communication.

This month, the Alzheimer’s Association released its latest report on this disease, 2010 Alzheimer’s Disease Facts and Figures, the latest collection of statistics on its prevalence in different racial and ethnic groups, costs of care, and mortality. The full document can be found and downloaded from Alzheimer's report.

Some of the major highlights of this report include:

• Alzheimer’s disease was the 7th leading cause of death in the U.S. for 2006, across all ages, and the 5th leading cause of death for those over age 65. Deaths from this disease increased approximately 46% from 2000 thru 2006, in contrast with reductions in other diseases (stroke, down 18%, prostate cancer, down 8%, heart disease, down 11%, and HIV, down 16%).
• African-Americans and Hispanics are at greater risk than Caucasians, with the former group being about twice as likely, and the latter group being 1.5 times as likely as Caucasians to develop the condition. Though there is no known genetic factor that would account for these racial differences, other conditions, such as high blood pressure and diabetes are being studied as increased risk factors.
• Another significant finding is that African-Americans and Hispanics are less likely to be given the diagnosis, even though the rate of the disease is higher, reflecting that diagnoses will occur later in the course of the disease than for Caucasians.
• More women than men have dementia, because women live longer, and not due to any gender differences.
• Almost 11 million people in the U.S. provide care for a person with Alzheimer’s disease or related dementia.

The full report and other valuable information can be found on the website of the Alzheimer’s Association.

The CoHealth website endeavors to provide helpful educational programs for all caregivers working with older adults, from professionals, to home care providers, to family members. See the entire range of educational programs at http://www.cohealth.org/. Two especially useful programs are the CoHealth courses on differentiating among depression, dementia, and delirium, and understanding sensory losses that occur with aging. Continuing education credit is available for many health care disciplines.

Dementia and Behavior Problems – Why Do Difficult Behaviors Occur?

We know that an illness like dementia brings with it changes in normal or routine functioning. The deficits that occur in brain function with the onset of various dementias, such as Alzheimer’s disease, vascular dementia, fronto-temporal dementia, or dementia with lewy bodies also increase the possibility of abnormal behaviors. These abnormal behaviors only add to the challenges faced by caregivers, since the verbal or physical outbursts, the inappropriate sexual behaviors, the apathy and withdrawal, the resistance to care, among others, are not intentional or purposeful. Rather, they are the result of behavior controls that weaken and eventually break down with the atrophy of the brain tissue. And with these defective controls, the person with dementia is more vulnerable to minor upsets or frustrations than the average person can tolerate.

In essence, the dementia patient is more sensitive to internal and external stimuli. These stimuli can also be thought of as triggers or causes of the problem behaviors, and can be grouped into four categories:

i. Physical causes include sensory losses (e.g., vision, hearing), acute and chronic illnesses, dehydration, constipation, pain, adverse effects from medications, and anxiety and depression;

ii. Environmental causes include too much or too little stimulation, too little structure, unfamiliar routines, and caregivers who are unfamiliar;

iii. Task-related causes include activities that are too complicated or have too many steps, or rely on previously learned information;

iv. Communication causes include inability to communicate one’s needs, word-finding difficulty, inability to comprehend spoken language.

Many of these causes are outside the control of caregivers but many can be managed or modified. The more caregivers can address potential causes and eliminate or minimize them, the fewer chances there are to tax the person with dementia beyond his capacity. And of course, reducing these potential causes of behavior difficulties can also mean reducing the number and dosages of psychotropic medications needed to control the behaviors. Reducing the need for chemical restraints is always desirable.

See the entire range of educational programs on the CoHealth website, for health care professionals, health care workers, and family caregivers. Two especially useful programs are the courses on differentiating among depression, dementia, and delirium and behavioral approaches for sensory losses in older adults.

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Understanding Dementia – Clinical Signs and Symptoms

Caregivers who work with older adults with dementia can benefit from understanding what toll the disease takes on a patient’s functioning. Earlier blogs have described many of the cognitive, behavioral and emotional changes that accompanying this dementing process. Today’s blog outlines the specific changes in mental ability that occurs, including the clinical signs of the disease.

Dementia is a syndrome or collection of symptoms that result in a global, or diffuse deterioration of intellectual abilities. It is important to recognize that the term dementia, in and of itself, does not say anything about the cause, or whether it is reversible. Of course, we are most familiar with primary degenerative dementias, which are caused by specific disease processes, such as Alzheimer’s disease, vascular conditions, Parkinson’s disease, and many others.

However, there are also secondary, or reversible (i.e., treatable) causes of dementia, including medications and dietary factors that can produce the same losses in intellectual functioning that we may see with a primary degenerative dementia. Pseudo-dementia (or false dementia) is the term for the dementia-like condition that is caused by severe depression. These treatable dementias are more common in community-dwelling elderly, especially those living alone, than in long term care settings, where treatable conditions have generally been ruled out.

One of the hallmarks of dementia is a loss of memory, especially memory for recent events (such as where an individual parked her car, or what she had for breakfast). More remote, or long term memory is generally intact. There is a loss of comprehension ability, which over time, limits how much the person understands what is being communicated. There is a loss of general information, that is, everyday facts and details that are commonly known by unimpaired individuals, such as the season, or major local or world events. We often see changes in attention and concentration ability, limiting the ability to stay on task for more than a few minutes. Judgment and common sense gradually decline with this condition, as do executive functions, such as reasoning ability and decision making.

There is a gradual loss of orientation, or what is also referred to as changes in sensorium. Cognitively-intact individuals are generally oriented in the temporal sphere (i.e., time), spatial sphere (i.e., place), and personal sphere (i.e., person). However, dementia results in a gradual loss of this orientation, first in the temporal, then spatial, and finally in the personal sphere. The remaining major cognitive changes we see in dementia are those related to verbal and language skills, first seen in word-finding difficulty and the ability to put ideas, thoughts, and needs into words. This progresses over time to severe deficits in the ability to communicate.

These changes occur insidiously, or cumulatively over time, and do not follow the same exact course for each individual affected. This makes it hard for caregivers to know what to expect, and how to adapt to the new losses in functioning. However, as we better understand these changes, and learn approaches that make up for or re-supply what is missing, there are fewer altercations and power struggles, and more time to focus on the individual’s residual strengths and capacities. These caregiving approaches will be discussed in coming weeks.

For more insights into these issues, see the CoHealth online programs on differentiating among depression, dementia, and delirium and on managing problem behaviors in dementia patients.  Useful, informative programs for families on facing Alzheimer's disease is also available on our website.  Visit the CoHealth website for more details about us, or mission, and our programs.

Principles of Behavior Management with Dementia – Don’t Take it Personally – Principle No. 9

It is easy to misunderstand or misinterpret the actions of someone with dementia, to wonder why he is saying hurtful things, or to feel offended when his interpersonal behavior and communications are so uncharacteristic for him. Whether in a residential setting or a nursing home, the effects of dementia can produce unpredictable and often offensive emotions, behaviors, and attitudes. Regardless of how long we may have known, loved, and cared for someone, there will be occasions when a coarse, crude comment, a striking out with a clenched fist, or a distasteful act like spitting is directed at the caregiver.

The damaging effects of the dementing illness can present an even greater burden if we take these unpleasant or aggressive behaviors personally. How could the patient be so unkind and ungrateful, after all I have done for him? Why would he try to hurt me, when I’m only trying to get him to finish his meal? Where did that foul language come from – I never heard him say things like that before! Questions like these reflect our disbelief and puzzlement about the sudden changes. But, we have to remember that the loss of emotional and emotional controls that accompany this illness is usually not intentional or purposeful. Yes, these outbursts can be provoked or triggered, as discussed in previous articles, but we can’t expect the outburst to be tamed just because we care so much.

The controls are gone, or at least weakened and erratic. As a result, our interpretation or explanation of the event should be more realistic and objective. To interpret the event as intentional is to perceive the person as capable of controlling his own behaviors. Generally, this is not the case.

Yes, it does bother or hurt us, as caregivers, that the patient has lost these emotional and behavioral controls. There is even some sadness as we see the real person slipping away from our grasp. Someone once described Alzheimer’s disease as a funeral that never ends. Being an effective caregiver means to never lose that sense of caring and empathy for the patient. But, it also means understanding that the threats and problem behaviors are not intended to hurt us, but rather they surface simply because we are there.

For more insights into these issues, see the CoHealth online courses on differentiating among depression, dementia, and delirium and on managing problem behaviors in dementia patients.  Nurses and other health care providers may be interested in leaning more about S-BAR as an effective tool when communicating with other caregivers. Visit our website at http://www.cohealth.org/.