1. Interventions to Minimize Behavioral Symptoms of Dementia:
Moving Beyond Redirection
Part I
Margaret Hoberg MSN, GNP-BC
Siobhan McMahon MSN MPH GNP-BC

2. Objectives
Learning Objectives
Explain the effects of dementia on thinking, emotions and communication
Use a theory to help explain behavioral and communication changesassociated with dementia and to guide interventions
Respond to behavioral changes with a calm, validating approach
Comprehensively assess verbal and nonverbal messages, including those that are associated with stress
Develop a plan whose non-pharmacological interventions reflect an understanding of and respectfor the person andtheirpreferences.
3. Clara

91-year-old woman 4. AD (recent MMSE score 12) 5. Severe agitation per LPN who is passing meds A few hours ago she hitanother resident. 6. CNA addsshehas been irritable and pacing. 7. The night CNA also notes she has been having trouble sleeping and has expressed feelings that others 8. She has heart disease and mild COPD. She has a history of recurrent UTIs . 9. Clara cooperates at times, but when left in her room, she wanders the hall, seeming confused. When redirected to her room, she insists that she had to go home and would refuses assistance with care.

What is the most appropriate next step in the care of Clara?
(A)Administerprn lorazepam .5mg-1 mg intramuscularly, sublingual or po
(B)Administer haloperidol 1 mg intramuscularly or po
(C)Ask family member, nurse or CNA to spend one-on-one time with her; begin a thorough assessment for acute illness and unmet physical need.
(D ) Restrain Clara to obtain a blood and urine work-up
10. What is the most appropriate next step in the care of Clara?
(A)Administer lorazepam 1 mg intramuscularly, sublingual or po
(B)Administer haloperidol 1 mg intramuscularly or po
(C)Ask family member, nurse or CNA to spend one-on-one time with her; begin a thorough assessment for acute illness and unmet physical emotional or social needs.
(D)Restrain the patient to obtain a blood and urine work-up
11. Dementia Statistics

5.3 million 12. 7th leading cause of death 13. Risk >65: 14. 9.1 % men/ 15. 17.2% women 16. Risk: Over age 85 17.12.1% men 18. 20.3% women 19. Long term care 20. AL 45-67 % with some dementia 21. 41 % with moderate to severe cognitive impairment

Memory / Cognitive Changes

Normal aging 22. Mild cognitive impairment 23. Delirium (e.g. acute infection) 24. Other medical / health causes (B12 deficiency; thyroid dysfunction) 25. Depression 26. Alzheimers disease 27. Vascular (multi-infarct) dementia 28. Dementia associated with Lewy bodies 29. Other (alcohol, frontotemporal dementia, Parkinsons Disease, Neurosyphilis)

Dementia
persistent and progressive
30. Alzheimers disease
Alzheimers disease (AD) is an irreversible, progressive brain disease that slowly destroys memory and thinking skills and the ability to carry out the simplest tasks of daily living. In most people with AD, symptoms first appear after age 60.
AD is the most common cause of dementia among older people, but it is not a normal part of aging.
31. Cause of Alzheimers Dementia

Amyloidplaques and neurofibrillary tangles which start in area of brain affecting memory and spread to other areas 32. Gradual loss of connections between nerve cells (neurons) in the brain. This loss leads to diminished cell function and cell death. 33. Read more about Alzheimers Disease by connecting to this link: 34. Alzheimer's Association Web Page with Description of Alzheimer's Dementia

Causes of Vascular Dementia
Complete blockage of blood vessels in the brain. The complete blockage of an artery in the brain usually causes a stroke, but some blockages don't produce stroke. These "silent brain infarctions" increase a person's risk of vascular dementia. The risk increases with the number of infarctions experienced over time. One variety of vascular dementia is called multi-infarct dementia. Heart disease and irregular heart rhythms, such as atrial fibrillation, can increase your risk of stroke.
Narrowing of the blood vessels in the brain. Vascular dementia also can occur without a complete blockage of an artery. Portions of the brain can be starved for oxygen and food by reduced blood flow from arteries narrowed by vascular disease.
Vascular dementia can also be caused by: very low blood pressure, bleeding brain, blood vessel damage from such disorders as lupus erythematosus or temporal arteritis
35. Other conditions that cause memory loss or dementia
medication side effects
chronic alcoholism
certain tumors and infections in the brain
blood clots in the brain
vitamin B12 deficiency
dehydration
high fever
some thyroid, kidney, or liver disorders
36. Dementia symptoms
Memory impairment- getting lost in familiar settings, forgetting previous conversations, names, faces
Language impairment- difficulty finding words or following conversation, inability to communicate needs and preferences through verbal means
Apraxia-unable to perform previously learned tasks such as not knowing how to drink from a cup even though person may have sensory and physical ability intact
Agnosia-unable to recognize objects or other sensory stimuli
Impaired executive function- poor planning and judgement, difficulty solving problems
37. Mild
Moderate

Memory problems 38. Getting lost 39. Difficulty handling money or medications 40. Taking a longer time than usual completing a task 41. Poor judgment 42. Losing things 43. Mood changes 44. Increased memory loss 45. Problems recognizing family and friends 46. Inability to learn new things 47. Difficulty carrying out routine multi-step tasks 48. Problems coping with new situations 49. Impulsive 50. Delusions and paranoia

Progressive Symptoms of AD
51. Severe
Difficulty recognizing one selfor family
Inability to verbally communicate
Weight loss
Seizures
Difficulty swallowing
Groaning
Moaning
Increased sleeping
Loss of bladder and bowel control
Progressive Symptoms of AD