CARING FOR CHRONICALLY ILL OLDER PERSONS

DEMENTIA,
DELIRIUM, &
DEPRESSION
VISION &
HEARING
PROBLEMS
CIRCULATION
PROBLEMS
URINARY
INCONTINENCE
& BOWEL
ELIMINATION
PROBLEMS

RESPIRATORY
PROBLEMS

CARING FOR
OLDER PERSONS
WITH MENTAL
HEALTH
CONCERNS:

DEMENTIA,
DELIRIUM &
DEPRESSION
IN AN OLDER
PERSON WITH
CHRONIC
ILLNESSES,
WHEN & WHY
DO DEMENTIA,
DELIRIUM, OR
DEPRESSION
COME TO THE
PICTURE?

HOW DO THEY
DIFFER FROM
EACH OTHER?
THE THREE DS
THE THREE DS
NO DIAGNOSTIC TESTS ARE PATHOGNOMONIC OF THE
THREE DISORDERS BUT THESE MAY HELP IN
DISTINGUISHING ONE FROM THE OTHER

DIAGNOSIS IS BEST DONE WITH GOOD CLINICAL
DIFFERENTIATION ( BUT THE THREE CAN CO-EXIST )

THESE ARE THREE DISTINCT SYNDROMES THAT CAN BE
DELINEATED THROUGH CLINICAL HISTORY, TEMPORAL
PROFILE, & CHARACTERISTIC MANIFESTATIONS ( refer to
tables / handouts )
PROGNOSIS OF THE THREE DS
DELIRIUM RESOLVES WITH PROPER TREATMENT OF
UNDERLYING MEDICAL NEUROLOGIC STATE

DEPRESSION IS SUCCESSFULLY TREATED WITH APPROPRIATE
PHARMACOTHERAPY AND PSYCHOTHERAPY

DEMENTIA MAY OR MAY NOT RECOVER DEPENDING ON THE
ETIOLOGY; DUE TO DEGENERATIVE CHANGES, EARLY
TREATMENT IS NECESSARY WHICH CAN PROVIDE SIGNIFICANT
BENEFITS IN COGNITION, FUNCTION, & BEHAVIOR.



DUE TO ITS HIGH POTENTIAL FOR BEING A
CHRONIC CONDITION, DEMENTIA HAS BECOME
ONE MOST IMPORTANT CONCERN AMONG
HEALTH PROFESSIONALS
RATIONALE FOR GIVING DEMENTIA CONSIDERABLE
ATTENTION IN HEALTH CARE
THE BRAIN STORES MEMORIES, INCLUDING THOSE ABOUT WHO WE
ARE AND OUR COMMUNITIES.

DEMENTIA AFFECTS HOW WE GET ON WITH FRIENDS AND FAMILY, OUR
PHYSICAL ABILITIES AND OUR FEELINGS.

OLDER PEOPLE ARE USUALLY AFFECTED BUT SOMETIMES, YOUNGER
PEOPLE CAN HAVE DEMENTIA, TOO.
DEMENTIA
ADVOCACIES !!!
GLOBAL
CONCERNS FOR
PEOPLE WITH
DEMENTIA
ADVOCACIES !!!
GLOBAL CONCERNS FOR
PEOPLE WITH DEMENTIA
Typical 500 bed DGH
5000 admissions over
65 each year
3000 with mental
disorder
On snapshot
220 beds mental
disorder in over 65s
96 depression
102 dementia
66 delirium
ADVOCACIES
This is first and foremost about people
and we should never forget it
But the devil is in the detail. What
happens at the bedside?
Key information,
guidance and
references on each
aspect of the care
pathway
Backed by good practice
examples from English
Hospitals
(As is acute
awareness)
Thanks to: Deborah Sturdy, Hazel Heath, Gordon Wilcock

RESPECT CULTURE AND BELIEFS
includes spiritual needs, religious customs, dietary preferences,
clothing preferences, jewellery, ways of doing hair.

THE LIFE THE PERSON LIVED
Use the name he/she prefers, support their family and friends,
recognise the importance of their possessions, clothes, letters,
handbag, photographs etc.

RESPECT IN YOUR APPROACH
Do not rush in, do not hurry the person, allow time, spend time.

PRIVACY
Privacy is something so fundamental that if we forsake it, we
demonstrate that we no longer care.




RESPECTING
Some evidence based practice approaches:
Walk in memory screening clinics

Early diagnosis

Cognitive enhancers

The Dementia Caf

Community Occupational therapist input can lead to less
dependence on Social and Heath care resources (Graff
et al. 2006).


A STUDY IN HONG KONG ON DEMENTIA CARE & CARE
FOR THE CAREGIVER
( 2009129)
THE PHILIPPINE SETTING
CENTER FOR GERIATRIC HEALTH IN THE MALACANAN
COMPLEX, SAN MIGUEL, MANILA

GERIATRIC CENTER, U.P. PGH, MANILA

MEMORY CENTERS IN SOME HOSPITALS ( Ex. ST. LUKE )


ADVOCACIES OF VARIOUS ORGANIZATIONS

GERONTOLOGY NURSES ASSOCIATION
OF THE PHILIPPINES ( GNAP )
PHILIPPINE SOCIETY OF GERIATRICS &
GERONTOLOGY ( PSGG )
DEMOGRAPHIC PROFILE THAT
SUPPORTS THE GLOBAL
CONCERN
Alzheimers Society Counting the Cost 2009
Acute Awareness NHS Confed
A large proportion of people with dementia are
undiagnosed and many people with dementia go
into hospital for a reason not related to their
dementia so the dementia is not coded....as
dementia is not generally the prime reason for
admission to hospital it can often be difficult to
factor into a patients care programme, yet
improving care has the potential not only to
enhance quality of experience but also to reduce
length of stay and cost
Age Bands 65 to 74 75 to 84 85+
Cancer

Number of deaths 33305 43330 20474
Number with dementia 977 3800 5951
% with dementia 2.90% 8.80%
29.10%
Circulatory

Number of deaths 31548 71469 67962
Number with dementia 941 6319 19992
% with dementia 3.00% 8.80%
29.40%
Respiratory

Number of deaths 9615 21019 18239
Number with dementia 283 1817 5224
% with dementia 2.90% 8.60%
28.60%
From Who Cares Wins 2005
Diagnosis n (studies)
n
(participants)
Mean
Sample
Prevalence
Range
Mean
Prevalence
Depression 47
14632
311 5-58% 29%
Delirium 31
9601
309 7-61% 20%
Dementia 17 3845 226 5-45% 31%
Cognitive
Impairment
33 13882 421 7-88% 22%
Anxiety 3 1346 449 1-34% 8%
0
200000
400000
600000
800000
1000000
1200000
1400000
1600000
1800000
2000000
2011 2021 2031 2041 2051
100 & over
95-99
90-94
85-89
80-84
75-79
70-74
65-69
Numbers of people with late onset dementia
by age group
Dementia UK 2007 Results
European Context
(OECD European Union, 2010)

Prevalence of dementia - 7.3 million.
Highest prevalence: Sweden, Italy, Switzerland,
Germany.
Most common causes: Alzheimers disease (50-70%),
Vascular dementia (30%).
Rates increase with age: one-third of males (32.4%), half
of females (48.8%) at age 95 years.
Patterns of care: informal care by families and friends &
formal care at home or in institutions.

UNDERSTANDING
DEMENTIA &
DEMENTIA CARE
DEMENTIA
The acquired global
impairment of higher cortical
functions, including memory,
the capacity to solve problems
of day to day living,
performance of learned
perceptuo-motor skills, the
correct use of social skills, all
aspects of language and
communication, and the control
of emotional reactions in the
absence of gross clouding of
consciousness
WHO (1986)


THE WHO DEFINITION
DEMENTIA
THE NAME
GIVEN TO THE
CONFUSION OR
MEMORY LOSS
CAUSED BY
CHANGES IN
THE BRAIN.



MEMORY

LEARNING
CAPACITY

JUDGMENT

YOUNG &
OLD


CALCULATION


ORIENTATION


THINKING


COMPREHENSION

MALE &
FEMALE
VARIED RACES
& CULTURE

LANGUAGE
DEMENTIA - A SYNDROME OF PROGRESSIVE
NATURE, AFFECTING:


COMMON FORMS OF DEMENTIA


ALZHEIMERS DISEASE ( most
common )


VASCULAR DISEASE
Behavioural and Psychological
Symptoms of Dementia (BPSD)
Agitation,
Anxiety,
Irritability/motor
restlessness,
Wandering/pacing,
Aggression,
Shouting,
Night-time
disturbances,
Psychosis/mood
disorders.
Sexual disinhibition,
Eating problems
Ballard, OBrien, James, Swann, (2003),

Potentially harmful effects.
Depression
Cognitive decline
Emotional isolation
Confusion
Agitation
Increased
morbidity and
mortality
Injury
Strangulation
Loss of skills
Reduced appetite
Cardiac stress
Muscle wastage
Incontinence
Watson (2001)
ALZHEIMERS DEMENTIA
( named after its discoverer, Dr. Alzheimer )
Cortex most
affected.

Enlarged
ventricles.

Senile plaques.

Neurofibrillary
tangles in affected
neurones.

Reduction in
neurotransmitters -
impaired
communication
between cells.

Insidious and
progressive course
Plaques Tangles
The formation of amyloid plaques and neurofibrillary tangles are
thought to contribute to the degradation of the neurons (nerve
cells) in the brain and the subsequent symptoms of Alzheimer's
disease.

Amyloid Plaques

One of the hallmarks of Alzheimer's disease is the
accumulation of amyloid plaques between nerve
cells (neurons) in the brain. Amyloid is a general
term for protein fragments that the body produces
normally.Beta amyloid is a protein fragment snipped
from an amyloid precursor protein (APP). In a healthy
brain, these protein fragments are broken down and
eliminated. In Alzheimer's disease, the fragments
accumulate to form hard, insoluble plaques.
Neurofibrillary Tangles


Neurofibrillary tangles are insoluble twisted
fibers found inside the brain's cells. These tangles
consist primarily of a protein called tau, which
forms part of a structure called a microtubule. The
microtubule helps transport nutrients and other
important substances from one part of the nerve
cell to another. In Alzheimer's disease, however,
the tau protein is abnormal and the microtubule
structures collapse.
CLINICAL
MANIFESTATIONS OF
ALZHEIMERS DISEASE
SIGNIFICANT FORGETFULNESS
CLIENT HAS PROBLEMS WITH LONG-TERM & SHORT-TERM MEMORY
SHORT-TERM- CAN RECALL ONLY 4-5 ITEMS FROM 5- 9 ITEMS ( BASED ON
NORMALRETENTION OF 7 PLUS OR MINUS )

IMPAIRED COGNITIVE FUNCTIONING
IMPAIRED EXECUTIVE JUDGMENT ( DIFFICULTY IN ABSTRACT
THINKING OR IMPAIRED JUDGMENT )
ALTERED HIGHER CORTICAL FUNCTIONS
APHASIA PROBLEMS EXPRESSING SPEECH OR UNDERSTANDING SOUND
APRAXIA INABILITY TO TRANSFORM THOUGHTS INTO ACTION
AGNOSIA - INABILITY TO RECOGNIZE OBJECTS

DIFFICULTY IN PERFORMING FAMILIAR TASKS; MISPLACING
OBJECTS CONSTANTLY

DECLINE IN SOCIAL FUNCTIONS ( Reisbergs 7 Stages )


Alzheimers Trajectory
Stage I- 2-4 years
Memory loss short-term in particular
Mild changes in personality
Stage II - 2-5 years
Cognitive decline language, problem solving.
Depression, Disorientation, Wandering
Stage III 1-2 years
Apathy, Disinterest in food
Urinary and faecal incontinence
Difficulty recognise family or friends
Can develop seizures


CARE APPROACHES TO MEET VARIED NEEDS OF
PERSONS WITH ALZHEIMERS DISEASE
PHYSIOLOGIC PSYCHOSOCIAL
LIMITING &
MANAGING
COMPLICATIONS
ADDRESSING PHYSIOLOGIC NEEDS
KEEP CLIENT AMBULATORY AS LONG AS POSSIBLE & MAINTAIN DAILY
EXERCISE REGIMEN

MAINTAIN OPTIMAL NUTRITIONAL/ VITAMIN STATUS

PROTECT FROM SOURCES OF INFECTION

MAINTAIN BOWEL AND BLADDER ELIMINATION THROUGH ROUTINE
CONSISTENT TOILETING

PROVIDE ADEQUATE TIME FOR REST & SLEEP

INSTITUTE SAFETY MEASURES

ADDRESSING PSYCHOSOCIAL NEEDS
PROVIDE COGNITIVE STIMULI TO ENHANCE MEMORY & ORIENTATION
USE REALITY ORIENTATION & REALITY TESTING SKILLS
PROVIDE REGULAR SOCIAL INTERACTION
MAINTAIN SELF-ESTEEM THROUGH INVOLVEMENT IN ADL SKILLS
MAINTAIN A STRUCTURED MILIEU OR SOCIAL ENVIRONMENT
PAY PARTICULAR ATTENTION TO THE USE OF NON-VERBAL
COMMUNICATION TECHNIQUES AS WELL AS VERBAL CUES TO MAINTAIN
EFFECTIVE COMMUNICATION PATTERNS
USE BEHAVIOR MODIFICATION TECHNIQUES TO MODIFY NEGATIVE
BEHAVIOR
CONDUCT ASSESSMENT & EVALUATION OF THE NEED FOR MEDICATIONS
LIMITING & MANAGING COMPLICATIONS
FOR DIFFICULTY IN COMMUNICATING WITH PATIENT ESPECIALLY DURING
THE ADVANCED STAGES OF ALZHEIMERS DISEASE
Do not stop communicating; keep interacting with client
Use actions, which have more impact than words

FOR DIFFICULTY IN MANAGING THE PATIENTS BEHAVIOR ESPECIALLY
WHEN THE ENVIRONMENT IS MISPERCEIVED AND APPEARS THREATENING
Do not let the client see your anger or irritation when the client increases
voice volume, or with increased restlessness, agitation, & hostility
Make sure that you do not put extra demands on he client
Distract the clients attention during agitated moments
Palliative care needs of people with dementia
Assessment of pain and other symptoms
Carer of people with dementia
Decisions about end-of-life care
What do we mean by palliative care?
Palliative care is an approach that improves the quality of life
of patients and their families facing the problems associated
with life-threatening illness, through the prevention and relief
of suffering by means of early identification and impeccable
assessment and treatment of pain and other problems,
physical, psychosocial and spiritual
(WHO, 2002)
Safe Environment
Installation of Alarm System
Safe Environment cont.
Use of Signs
This Is Your
Life Book
Permission granted by
Alzheimers Association of Victoria
This is your life
Past interests & hobbies
Present skills
Favourite music & TV programs
Special friends and pets
The Value of Memories
Life Story Work - find out as much as possible about
the persons background, their culture, their life
history what that person liked to do, the music
preferred, favourite movie, hobbies etc.

The Memory Box have you started yours?
What would you put in your memory box?

Thanks to Bendigo Health for
use of their Communication
with Dementia Clients
Pamphlet.
Dos & Donts of
Dealing With
Dementia
Diversional Therapy
MUSIC MUSIC MUSIC
MUSIC cont.
Emotional wellbeing
Communication
Behaviour Management
Sleep
Other Diversional Therapies
Old movies
Memorabilia
Reminiscences
Craft/games
Touch/tactile/comfort objects
Utilization of previous skills
Old Movies
Memorabilia
Reminiscing
Craft and Memory Games
Tactile Diversion
Utilizing Previous Skills
Strategies For Restless
Hands
IV Line Decoy Part I
IV Line Decoy Part II
Occupying Restless Hands
Management of BPSD.


The use of restraint amongst
institutionalised elderly with
dementia and problem behaviour
not only remains widespread, but
also appears to be accepted as
inevitable
Testad, Aasland, Aarsland (2005)
Restraint!
The intentional
restriction of a
persons
voluntary
movement or
behaviour
Counsel and Care
(2002).

RESTRAINT is a RESTRICTIVE PRACTICE
The only legitimate reason for
using restraint is therapeutic
that is, to ensure the safety and
well being of the resident or
patient
Braun and Lipson (1993).
Something to Remember!
Mental Capacity Act, 2005
Restraint is only permitted:
To prevent harm to the incapacitated
person,
The restraint used is proportionate to
the likelihood and seriousness of the
harm.


ISSUES &
CHALLENGES
Bad Language
People with dementia are
Demented
Dementing
Victims
Sufferers
Wanderers (without
purpose)


1. Make dementia everybodys business rather than
somebody elses business
2. Focus on prevention physical health check vascular
checks to prevent vascular events
3. Improve awareness and recognition of dementia amongst
GPs, health and social care professionals, including care
homes
4. Increase the number of people receiving an early diagnosis
and an annual health check.





5) Treat dementia as long-term condition and focus on case
management and anticipatory care to
Prevent or defer care home admissions
Prevent of defer hospital admission (especially from care homes)
Reduce length of stay in care homes and community hospitals
6) Invest in low-intensity treatment and support options and
make better use of existing options e.g. Whole System
Demonstrator Dementia Package
7) Share specialist expertise with mainstream parts of system
8) Share mainstream expertise with specialist parts of system


Human Rights Based Approach.
A human rights based
approach offers one method
for facilitating positive risk
management.
Whitehead, Greenhill, Carney, (Print pending.)


Human Rights Based Approach.
FREDA Principles;
Fairness
Respect
Equality
Dignity
Autonomy


Issues and Challenges
Low expectations of staff of the persons ability to
function, leading to an enforced reliance and
dependence on support.

Assumed vulnerability, leading to risk averse responses.

Rewarding dependent responses

Negative and guilt laden language: burden on carers,
bed blockers, global financial burden.

Over prescription of anti-hypnotics (Banerjee 2009).

Negative social context
Stigma
Malignant social psychology
Social exclusion

All impact on the quality of life and cognitive
functioning of older people, particularly those with
dependency on others for care
(Kitwood and Bredin 1992, Kitwood 1997, Brooker 2007)

Value the PERSON with dementia
Please dont call us dementing we are still people separate
from our disease, we just have a disease of the brain. If I had
cancer, you would not refer to me as cancerous would you?
Our labels seem to mean so much am I Alzheimers Disease
or fronto-temporal dementia, or simply someone with a
dementing illness.
All these terms labels us as someone without capacity,
without credibility as a member of the community. How
about separating us from the illness in some way? How
about remembering we are a person with progressive brain
damage
Christine Bryden, Dancing with Dementia, 2005
HOW WILL WE RESPOND TO THE
CHALLENGES?

?????????
Dementia will affect all of us:

We may develop a dementia or a
parent or relative or our
husband/wife, or friend !!!

ACT NOW!