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.

Principles of Behavior Management and Reality Orientation with Dementia – Principle 8

The information in this blog series is intended to help paid and unpaid caregivers manage problem behaviors caused by dementia. The slow insidious decline that we see in dementia is characterized by losses in mental, emotional, behavioral, and self-care capacities. The recommended interventions offered are considered milieu-based, or environmentally-based because they help to create an environment that is structured and anxiety-reducing, settings that reinforce appropriate behaviors while avoiding interactions that trigger unwanted behaviors.

This blog describes the need for extraordinary structure, explanation, and cues to make up for what is missing due to the loss of general awareness and information that accompanies dementia. This loss is manifested in little or no awareness of everyday events, like holidays, important facts, seasons, local or world events, anything that you and I may take for granted. Because the person with dementia is unaware of these facts, it is essential to communicate these to the patient, and repeating as often as necessary. This is referred to as reality orientation, and should take place whenever interacting with the person. We want to communicate what’s happening to the individual: explain what is going to happen, what just happened, what the daily schedule is, what the day and date and seasons and upcoming holidays are, when the next meal is, even what we’re having for the next meal or had for the last meal, and so on. We see this on the activity boards in the nursing home, though the verbal interaction between caregiver and patient is much more effective.

We take this information all around us for granted, but for the confused, disoriented person, it is necessary to replace this missing information. And, the need for this information sharing is not short term or temporary, but permanent. The term “prosthetic environment” is used to describe the permanent, extraordinary atmosphere that we want to create: multiple cues and reminders, continually offering explanations, facts, everyday information, in short, anything and everything that helps to orient the person, and helps her feel safe and secure. This is called a prosthetic environment for good reason: a prosthesis is a device used to replace a missing part of the body, such as a leg. And, just as a prosthetic leg is needed permanently, a prosthetic environment is also needed permanently for those with brain impairment to minimize confusion, disorientation, anxiety, and distress. Whatever structure, communication, and reality orientation we can provide, the better. In the absence of this, the person gets more anxious because she cannot tolerate uncertainty, ambiguity, or the unknown. The more the anxiety level escalates, the more likely she is to engage in problem behaviors.

As we learn the many ways that dementia impairs a person’s functioning, we can be better prepared to anticipate, make up for, or replace some of the losses that the patient experiences. This means better management of potential behavior problems, and helping the person function at her highest possible level.

Many of these concepts can be found in the caregiver educational programs on our website, http://www.cohealth.org/. Some of the titles include behavior management, understanding Alzheimer’s disease, nursing home placement, and end of life decision making.

Principles of Behavior Management with Dementia – Principle No. 3

This is the third in a series about managing problem behaviors with older adults due to dementing illnesses, in nursing homes, assisted living facilities, or those residing in their own homes. These principles are based on proven methods to modify or change behaviors, or prevent them from worsening.  The approaches are based on the cognitive, behavioral, and emotional impairments that accompany dementia.

The third principle is to keep expectations realistic.  Do not be deceived by how much we think the person with dementia follows what we are saying. One of the hallmarks of this condition is the tendency to deny, or disguise the extent of cognitive changes occurring from the disease. The individual does not complain or emphasize the various problems he is experiencing, such as with memory, concentration, or attention to details. On the contrary, we can expect this person to minimize or mask these problems. Consequently, if we do not lower our expectations, it is very easy to overestimate what the person is understanding or comprehending in our communications. So we might think the person is perfectly okay with the explanation that we are giving, but in fact, it will probably be too complicated to process. For example, we might quickly explain why there is a change in the meal schedule or eating location. We assume the person follows our explanation, by nodding and agreeing, but eventually, the person’s distress builds because of the change from the familiar, from the routine. Even though she acts as though she is understanding and following what we are saying, the result is a lot of frustration on both the caregiver’s part and the patient’s part because of that inability to fully understand and follow that communication.  If we tax the person too much beyond her capabilities, we might trigger a catastrophic reaction, which is an intense outburst and strong emotional reaction to the task demands.  These reactions can quickly cascade into behavioral outbursts and severe behavior problems.

The lesson here is to not assume the dementia person is understanding us just because she is superficially agreeing. In fact, in the next minute, it may appear as though no explanation was given at all, and we have to start the conversation all over again, from the beginning.

As we better understand the various losses that occur with a dementing illness, we can minimize the triggers or causes of problem behaviors, and how to de-escalate the problem after it has occurred. 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.

Principles of Behavior Management with Dementia – Principle No. 2

This is a second in a series about managing problem behaviors with older adults due to dementing illnesses, whether residing in nursing homes, independent or assisted living facilities, or their own homes. There are many sound, proven approaches for managing these problem behaviors. Psychotropic medications are one choice, but other approaches that are milieu or environmentally-based can complement the psychoactive interventions, and may allow for a reduction or elimination of the drugs altogether.

These caregiving approaches are formulated around the impairments that come with dementia, especially in the areas of cognitive, behavioral, and interpersonal functioning. These approaches recognize that the most effective interventions incorporate an understanding of why the person is behaving the way he is. For example, this blog discusses the need for consistency in all interactions and routines with these individuals, whenever possible. Because the dementia patient is unable to learn and process new information, it becomes necessary to rely on previously learned knowledge and information as much as possible. In long term care settings, this means providing familiar caregivers, familiar rooms for activities and seating arrangements in the dining room, and familiar roommates. Anything that is being provided for this individual should be the same, predictable and consistent as possible. In private homes, meal times, preferred seating locations, and even dressing and hygiene activities should be consistent from one day to the next.

When there are changes in routine, as with new caregivers, or changes in a schedule, roommates, or meal times, those familiar to the person should take extra time to explain the change, as unimportant as it may seem. Without the explanation and extra structuring of the event, we can tax the person’s feelings of security and safety, something that can easily lead to increases in anxiety and agitation. Even when we might think a little change of pace might be enjoyable or refreshing, the person whose neurons in the brain are not firing normally will likely not appreciate the unfamiliar change. And she may become more distressed by it.

As we better understand the various losses that occur with a dementing illness, we can minimize the triggers or causes of these behaviors, and how to de-escalate the problem after it has occurred. For more insights into these issues, see my online courses on differentiating among depression, dementia, and delirium and on managing problem behaviors in dementia patients, and families facing Alzheimer's disease.