“My mom repeats the same story over and over again, but she never forgets to go to Sunday services.”
“Dad misplaces things all the time but is still walking a mile every day.”
This is frequently how adult children express their concerns that their parent could have some type of memory issue when contacting Holistic Aging, A Life Care Management practice located in Pittsburgh PA, for assistance. Often, families readily acknowledge and respond appropriately to physical illnesses. Unfortunately, they also frequently fail to respond to the signs of dementia. Busy primary care practitioners (PCP) fail to recognize the early signs of cognitive decline. During the typical 15 minute office visit, many patients conceal symptoms or deny their existence.
More than a third of people over age 70 have some form of memory loss, according to a national study by a team of researchers at Duke University Medical Center, the University of Michigan, the University of Iowa, the University of Southern California and the RAND Corporation. The group performed the first population-based study to determine the number of people who have some form of cognitive impairment, with and without dementia. These findings illustrate that nearly every family will be faced with caring for a family member that has some type of memory impairment. As a Life Care Manager we need to assist families in improving the quality of life for this growing population.
Many people mistakenly use Dementia as a synonym for Alzheimer’s disease. Dementia is an umbrella-like term that can be described as any brain syndrome that causes multiple cognitive deficits, similar as saying when someone has a fever and you do not know the cause.
We will concentrate on the dementia’s most common in the elderly:
- Alzheimer’s Disease which accounts for 50-70% of all dementia cases
- Vascular Disease, which accounts for 15-20% of dementia cases and includes anything diagnosis that disrupts blood high to the brain
- Lewy Body Disease, which accounts for up to 20% of dementia cases
Families need to differentiate normal aging from Dementia. Changes in ordinary capability and attitude among the elderly are among the best warning signals that further cognitive screening should be performed.
Below is a list of signs of dementia:
- increased difficulty carrying out ordinary daily activities – initiation of getting dressed or preparing a meal from scratch
- poor or declining cognitive function
- deterioration in hygiene – no longer showering or changing clothes on a routine basis
- inability to fulfill normal responsibilities – leaving unopened mail, paying bills
- health changes – weight loss, incontinence, appetite changes, bruises suggesting a fall
- increased isolation
- loss of ordinary interest in social contacts, activities or hobbies, attitude changes including abuse of alcohol or drugs, reporting depression, unusual argumentativeness or suspiciousness
According to the DSM-IV diagnostic criteria assessment for dementia a patient must have:
Memory Loss – inability to learn new information or to recall previously learned information and two or more of the following:
1. Aphasia: language disturbances
2. Apraxia: motor activity impairment although intact function
3. Agnosia: failure to recognize/identify items despite intact sensory functioning
4. Disturbances in Executive Functioning: planning, organizing, sequencing, initiation of tasks
5. Inability to function in a social or occupational setting
Testing Cognitive Function
There are many psychological tests to measure cognitive function. I use a combination of three tests as a concrete justification of the presumed diagnosis based upon observation and family history.
The Mini-Mental State Exam is the most commonly used test for complaints of memory problems or when a diagnosis of dementia is being considered. It also serves as a base line for further testing. The MMSE test includes simple questions and problems in a number of areas: the time and place of the test, repeating lists of words, calculations such as spelling WORLD backwards, language use and comprehension, and basic motor skills. It is the standard test used to measure cognition. The MMSE is primarily used to determine if an older person has dementia of varying nature. In my experience, this test is not as accurate in assessment of the initial stages of dementia for people with a high intellectual ability.
The clock test picks up on memory issues that the MMSE can miss. I personally find it a more reliable instrument as it can pick up executive function abnormalities. Executive cognitive dysfunction can precede the memory disturbances of dementia. People with executive cognitive dysfunction can have a normal Mini-Mental State Examination (MMSE) score but still have severe functional limitations. The clock test is a moderately sensitive and specific adjunct for detecting executive cognitive dysfunction.
Such disturbances result in difficulties with instrumental activities of daily living (e.g., bathing, dressing, cooking, shopping, driving and taking medications). They produce dissociation between volition and action; for example, patients do not lose their ability to dress but, rather, are unable to initiate these tasks or choose weather-appropriate clothes. Executive function involves the ability to think abstractly, and to plan, initiate, sequence, monitor and stop complex behavior. People with executive dysfunction have difficulty with managing the household finances, taking their medications with reminders, cooking a meal, and performing their activities of daily living, or ADL’s, independently. Detection is critical to the client’s safety and ability to remain living independently.
3. Trail Making Test:
The trail making test (TMT) is a short and convenient estimate of cognitive functions, principally attention and working memory. This test consists of two parts, Part A and and Part B.. I usually administer the Part B in either oral or written form. The patient draws a line alternating between serial sequences of numbers and letters (1, A, 2, B etc.). The TMT is thought to require executive control, specifically, flexibility of thinking and greater demand for working memory. The Trail-Making Test B (TMT-B) is a neuropsychological test that may predict ability to drive safely in older adults.
This is my go to test for a comprehensive profile. The Montreal Cognitive Assessment (MoCA) is a rapid screening instrument for mild cognitive dysfunction. It assesses different cognitive domains: attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. Since the MoCA assesses multiple cognitive domains, it may be a useful cognitive screening tool for several neurological diseases that affect even the younger populations.
Cognitive testing seems to provide concrete evidence to families that the person does indeed have the cognitive issues they were identifying as concerning. If the family desires further cognitive testing, I recommend a neuropsychological evaluation.
Once the dementia is identified, we work with the family to determine the best plan of care for the client in the following areas.
1. Medical diagnosises
Some diagnosis’s can mimic dementia symptoms. Assuring that medical issues such as thyroid disorders, B12 deficiency, uncontrolled hypertension, depression, are not contributing to a dementia diagnosis is imperative. Completing testing and blood work can rule out these underlying medical/psychological concerns.
2. Supportive Environment:
A home safety evaluation looks at environmental factors that could put the person with cognitive impairment at risk. These include poor lighting, uneven surfaces, hand rails on steps, grab rails in bathrooms, removal of dangerous/poisonous substances, heating and electrical.
The kitchen can be a potentially dangerous place for someone who is not able to recognize the danger of a sharp knife or a gas stove left on. Therefore, it is essential to remove sharp instruments and if needed, remove the knobs to a gas oven. An environment with routine and structure as this assists in orientation and the feeling that they are safe and secure. We typically develop a medication distribution system that will assure proper adherence to prescribed medications.
Ensuring that helpful information is accessible to the client. A large white board with a calendar of daily/weekly events can help reassure the person. Posting of emergency numbers or setting the phone to pre-dialed numbers is also helpful. Physical activity is important as it helps prevent disruptive behavior or agitation. • Avoid excessive stimulation but not to the point of isolation. Encourage continued mental activity including hobbies and current events.
3. Help with managing finances:
This is the time for the Durable POA to assume responsibility for managing the person with dementias finances. Direct debits, direct deposits of income and on-line checking helps the job of the POA not be overwhelming. The POA may want to have the mail forwarded to their address to avoid the mail getting lost or misplaced in the home of the person with dementia. It is recommended to keep a detailed record of all financial transactions completed when acting as the POA and to share this information with another family member to avoid any potential problems with family members or the person with dementia may feel people are stealing from them.
4. Outside Help:
Most persons with dementia will resist in home help as they do not have the insight into their need for assistance. I recommend starting with a slow introduction of a medically supervised caretaker into the home that a Life Care Manager has developed a plan of care for the caretaker to follow. Never hire someone directly without direct supervision for a client with dementia.
If the caretaker was a good match, they will develop a relationship so that the person with dementia looks forward to the visits and assistance. The caretaker can assist with personal needs, light housework, meal preparation, laundry, providing meaningful activities, taking the person out, assuring the client takes their medication as scheduled; all dependent on the individual needs of the client. Health Insurance does not cover the cost for in-home care so if the client is low income, there are entitlement programs that may pay for their services.
The person with dementia could wonder outside and forget to close the door, may have problems finding their way home, or lock themselves out and become confused and afraid. The following are good options to help prevent those scenarios.
- Medical Alert Bracelets inscribed with the diagnosis of dementia and have a number to call for emergencies
- Good to have a space set of keys at the neighbors
- Advise the local police that the person has dementia and if there is a sutable window or door which can be opened from the outside
- Purchase an alert that signals an alarm when a door or window opens
- Although persons with dementia frequently cannot utilize a cell phone, it is a good device to track the wear location of a person using the Google map tool or other method.
- The alarms that require pushing a button on a necklace or arm bracelet are of little help with a person with dementia as the person does not remember how to use it.
Alzheimer’s drugs might be one strategy to help you temporarily manage memory loss, thinking and reasoning problems, and day-to-day function. Unfortunately, Alzheimer’s drugs don’t work for everyone, and they can’t cure the disease or stop its progression. Over time, their effects wear off.
- The Food and Drug Administration (FDA) has approved two types of drugs specifically to treat symptoms of Alzheimer’s disease.
- Cholinesterase inhibitors : Donepezil (Aricept), Galantamine (Razadyne), Rivastigmine (Exelon)
- Memantine (Namenda)
The decision to try one of these drugs should be based on whether any potential benefit is worth the cost, and the risk of side effects.
- Avoid the use of antipsychotics. In November 2015, the American Geriatrics Society’s evidence-based update of its Beers Criteria for “potentially inappropriate medication use in older adults” stated unequivocally that that antipsychotic medications should be avoided for older people, “except for schizophrenia, bipolar disorder, or short-term use as an antiemetic during chemotherapy.” Citing “increasing evidence of harm associated with antipsychotics and conflicting evidence on their effectiveness in delirium and dementia, the rationale to avoid was modified to ‘avoid antipsychotics for behavioral problems unless nonpharmacological options (e.g., behavioral interventions) have failed or are not possible, and the older adult is threatening substantial harm to self or others” Thus, there is a very limited category of people for whom the drugs could be appropriate.
7. Planning for the Future
Because dementia is usually progressive it is essential to plan for the future. When it is time to move out of the home to a more supportive environment, professionals with expertise in dementia care can make the best decision. This decision depends on many factors such as severity of the disease, behavioral issues, finances, home environment, family availability, and presence of other physical or psychological disorders impacting on the dementia. The final stages of dementia are one of the most difficult to manage in a home environment. This is especially so if associated behavioral issues arise.
When the home is no longer a safe place for the patient with dementia, the next step is to look for an assisted living that specializes in the care of those with a diagnosis of Alzheimer’s or dementia. You want to choose a dementia specific units that is equipped to handle all the physical, environmental, behavioral and psychological issues associated with end stages of dementia using primarily behavioral measures vs. primarily medication management. It’s important to recognize that Assisted livings/Personal Care Homes are not licensed to provide medical oversight.
End of Life Issues need to be addressed early on when a diagnosis of Alzheimer’s disease or dementia is determined. Families need to determine a long range plan including how they will manage the final stages of the disease. Treatment should maintain comfort rather than prolong life. Hospice should be consulted early on to assist in the management of this life limiting illness. This provides much needed support to the client and family. Beyond that it assures the final stages of this disease maintain dignity for the client and family.