ALZHEIMER’S DISEASE OR LEWY BODY DEMENTIA

Alzheimer’s disease and Lewy Body dementia are similar and yet significantly different.  Those differences are the hall marks of Lewy Body dementia. Because Alzheimer’s disease represents  the largest amount of people identified as having dementia, it may be assumed early on that this is the disease process the elder has. However once the elder begins to exhibit the classic signs of Lewy Body dementia, it becomes easier to diagnose.

Lewy Body dementia can have fluctuating attention and alertness. Person’s with Alzheimer’s disease have a ongoing progression of the disease without fluctuation. Clara was assumed to have Alzheimer’s disease, when one day when entering her room in the nursing home, Clara clearly asked “Where am I?” The nursing assistant then had a nice conversation with Clara, (who before this had only spoken in non-sensical word salad) while we called her daughter, telling her to come now to visit Clara. Clara maintained this higher level of function for the rest of that day.

Persons with Lewy Body dementia will often have visual hallucinations. While the person with Alzheimer’s disease can have hallucinations they are the result of other disease processes. The person with Lewy Body dementia may or may not be disturbed by these hallucinations. Sometimes the hallucination presents in a similar way to the child who has an imaginary friend, not in any way causing alarm.

The person might also appear to  have hallucinations during sleep. However these night terrors are usually identified as a REM sleep behavior disorder. The person may start to yell, scream, punch, fight, thrash, kick, get up and pace or even run around, and at times fall out of bed all the while appearing to be asleep. This is a very difficult part of the disease process for the caregiver to still manage at home.

Lewy Body dementia will resemble Parkinson’s disease with movement problems; stiffness, slowness, rigidity and difficulty walking. A rule of thumb has always been that a person with Parkinson’s disease might not have Lewy Body dementia, but person’s with Lewy body dementia will have Parkinson symptoms.

There is a saying in healthcare when working with a patient with Lewy Body dementia to “go with the flow.” Every day might be different and it is the caregiver who needs to adjust, the patient can’t.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

 

 

6 WAYS TO MANAGE ANGRY OUTBURSTS BY THE ELDER WITH DEMENTIA

Mike was visiting his daughter Marge and her family for the 4th of July holiday. Mike had called ahead and insisted he was bringing all the food. He arrived during a heavy downpour, and Marge standing on her porch urged him to stay in the car till the rain stopped. Mike proceeded by demonstrating an inability to reason on something so simple as staying out of the rain, and then immediately becoming angry, thus began the unhappy holiday.

Mike stated “No one was going to tell him what to do.” And he proceeded to get out of his car, struggling with his walker as he tried to carry his groceries to the porch. Mike not only wasn’t going to be told what to do, but he very much wanted to direct his daughter. When Marge said she would be waiting for the rain to stop before moving groceries, Mike went right into his now frequent response of “just do what I tell you!”

Starting the visit all wet did nothing to improve Mike’s mood. From this unfortunate beginning, Mike proceeded to engage his teenage grandchildren in conversation regarding the dishonesty of the healthcare industry.  Saying everyone in healthcare is crooked and only in it for the money. Mike’s son-in-law a dentist, quickly became frustrated with Mike’s outrageous behavior and soon was asking Mike to leave.

6 Ways to manage angry outbursts by the elder with dementia:

  • realize that this is an episode of agitated behavior and that in order to manage this well you need to be in control of your own emotions
  • take care of yourself first – whether it is with taking some deep breaths or whatever you normally do that helps you to remain calm
  • be aware that arguing or trying to reason with the unreasonable person with dementia is not possible
  • remove the “audience” it is harder for Mike to back down from outrageous things he says if the whole family is there, and seeing himself as the father figure, he wants to save face
  • instead of several family members entering into this argument making Mike think everyone is against him, only one person should engage in de-escalating the situation
  • be respectful and avoid becoming defensive, the angry words even if directed at you are not about you

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

DELUSIONAL NEIGHBOR – EARLY DEMENTIA

Bob considers himself a lover of animals, he feels all the little animals in his community need him. Bob would be amazed to know he is considered a “delusional neighbor.” Bob is well known in his condo community as the owner who is bringing an unwanted amount of small critters to the property. Bob throws peanuts and bread out his 4th floor windows into trees below and onto neighbor’s patios morning. noon and night to feed his friends. Bob extends his feeding to the parking lot, putting food out every evening next to his car, resulting in bringing skunks to the property.

As neighbors try to reason with Bob, pointing out the heavily treed grounds with many walnut trees for the squirrels and natural sources of food for all, Bob continues to throw out food. And that is the problem, you cannot reason away a delusion. A delusion is a fixed false belief that isn’t able to be changed by presenting facts or explanations.

Bob has lived in this condo, with these neighbors for 18 years. To all outward appearances Bob hasn’t changed much over these years. He has always lived alone here in his condo. Bob drives a car, maintains his property, even investing in upgrades as needed. Bob always appears clean and well groomed, wearing clean clothes. Bob does his own grocery shopping and prepares his own food.

However for the last year Bob has been so sure that the animals need him and need food, that he has gone against all the established rules of the condo association. He argues with his neighbors and although he has been fined multiple times for feeding the animals he has vowed not to stop.

Recently Bob has solved his own problem by deciding to move. He is relocating about 15 miles away from the condo and interestingly from his beloved critters. I can only wonder if he will leave this delusion behind and in the new and strange environment develop a new delusion. Suspicions and delusions are common in people with early memory loss. When the memory loss makes the person feel like something is wrong, but they cannot identify what the problem is, they will create a new explanation that, for them fits the facts.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

REASONS FOR SUDDEN DEMENTIA – DELIRIUM AND DEMENTIA Part II

The Center for Medicare requires healthcare professionals to investigate causes and reasons for sudden dementia including these changes:

SIGNS OF POSSIBLE DEHYDRATION

  • recent decrease in volume of urine, more concentrated urine or a darker color
  • recent decrease in eating habits, skipping meals, leaving food uneaten, weight loss
  • nausea, vomiting, diarrhea, or blood loss
  • receiving IV drugs
  • receiving diuretics or drugs that might cause electrolyte imbalance

FUNCTIONAL DECLINE

  • falls or increased risk for falls
  • recent decline in the ability for self-care in hygiene, dressing, walking, eating, etc.

MEDICATION REVIEW

This area requires the services of the pharmacist. A medication review would first focus on new or recent medications and possible interactions with other medications the patient is taking. All narcotics need to be investigated, the elderly may become unreasonable, angry, or argumentative on narcotic medications. All behaviors that are different for the patient since beginning a new medication must be explored. Especially so for any drugs used to change or modify  behaviors such as anti-anxiety, antidepressants, sleep medications and of course anti-psychotic medications.

SOCIAL CHANGES

  • social withdrawal – recent loss of a family member or friend
  • recent changes in mood – crying or anxious\
  • a recent move – out of state or from home to facility

UNUSUAL BEHAVIORS

  • recent change in sleep habits, sleeplessness at night and sleeping during the day – nightmares
  • unusual, inappropriate or unsafe movements
  • hyper-active or hypo-active, a recent change to the extreme in a person’s level of activity

 

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

REASONS FOR SUDDEN DEMENTIA – DELIRIUM AND DEMENTIA – Part I

The increase number of people experiencing sudden dementia has caused delirium to be a focus of Medicare. As with everything else the way to capture attention is to create a monetary connection. In this case, Medicare reimbursement for sudden dementia is tied to identifying the cause of the patient’s delirium. The list of possible reasons, is to be a guide for consideration for every patient on Medicare with sudden dementia or delirium. Or any person admitted to a nursing facility who has sudden dementia as a diagnosis.

The basic physical changes that can cause a person to become delirious:

CHANGES IN VITAL SIGNS – COMPARED TO BASELINE (baseline, you always want to compare with what is usual)

  •  elevated temperature – 2.4 degrees higher than baseline
  • pulse rate less than 60 or higher than 100 beats per minute
  • breathing slower than 16 breaths a minute or higher than 25
  • a significant drop in blood pressure compared to baseline
  • a significant increase in blood pressure compared to baseline

ABNORMAL LABORATORY VALUES

  • electrolytes
  • kidney function
  • liver function
  • blood sugar
  • thyroid function
  • arterial blood gases (this is blood tested from an artery instead of a vein to check the ph of the blood as well as to see how well the lungs are moving oxygen into the blood and removing carbon dioxide out of the blood)

PAIN

  • how often is the pain, how intense, how long does it last, what is the quality of the pain?
  • how is the pain affecting the patient’s ability to function?

A complete pain assessment must be conducted at this time.

SIGNS OF INFECTION

  • fever
  • cloudy or foul smelling urine
  • congested lungs or cough
  • shortness of breath – or painful breathing
  • diarrhea
  • abdominal pain
  • wound draining pus
  • any redness around an incision or wound

Some of these symptoms may be present but if there isn’t a good reason for something such as a slow pulse –  that is related to a medication the patient is on, then this symptom must be considered as a cause for the sudden dementia, and investigated further.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

 

AGGRESSIVE DEMENTIA BEHAVIORS PUSHING, YELLING AND SPITTING

Persons with dementia may at times have difficult behaviors. Behaviors that may cause harm to themselves or others. Aggressive dementia behaviors, apply to pushing, yelling, hitting, grabbing, spitting or even trying to bite the caregiver. Persons with dementia who have these combative or harmful behaviors are considered to have aggressive behaviors. Some aggressive dementia behaviors are predictable and follow a pattern of actions or events. While other aggressive behaviors are isolated one time, events.

There are three basic types of aggressive behavior triggers:

  • Something is affecting the person with dementia internally such as a medical, social or psychological cause. This could be anything from pain, fear, frustration, hunger, thirst, unable to communicate, or needing to go to the bathroom.
  • Environmental triggers have to do with items, actions or events that cause over stimulation which turns into aggression. It might be that the environment is too noisy, temperature is too hot or cold, lighting is to bright or too dark, or maybe the person just doesn’t recognize any of the people around him.
  • The “caregiver trigger” applies to whomever is providing care for the person with dementia. It could be that the caregiver is tired or over stressed and not using the best communication techniques. They might not be providing care the way the person prefers or they just don’t know the likes and dislikes of the person they are caring for and, because of their poor care,  cause the behavior.

Knowing the person you are caring for can prevent those aggressive behaviors that follow a pattern and are predictable. Observe  the person’s body language, watch for wringing of the hands, rubbing their body, clenching fists, gritting teeth or the person can become extremely quiet before an episode of aggression. Knowing the person can prevent injury from aggressive dementia behaviors.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing 

DEMENTIA STAGES – TIME LINE

While every person with dementia has a different experience and progression. For dementia symptoms that follow the decline due to Alzheimer’s disease, these changes can be tracked in the following way.

Mild Cognitive Impairment: Very early changes noted in areas of forgetfulness, problems in locating lost/misplaced objects and loss of words. Changes cause concern yet mild cognitive impairment does not always progress to dementia. Many elderly people never experience an increase in this level of confusion. (this lose can occur very gradually over up to 10 years)

Very Early Dementia: No longer able to be gainfully employed, may becoming lost in familiar community, experiences anxiety due to having trouble always understanding environment.   Very important at this time to have hearing and vision checked to support the elder in understanding the environment. (2 years)

Early Dementia: Now diagnosed with dementia, possibly of the Alzheimer’s type, no longer able to handle finances, trouble identifying money, no longer able to do meal planning, no longer driving, unable to live independently, flattening of expression  (most noticeable in family group photos), emotional problems, withdrawn, tearfulness and sometimes anger. Starting to have problems with appropriate clothing choices and hygiene. (2 years)

Mid-Dementia Stage: Now need caregiver support for hands on assistance in hygiene, bathing, dressing, toileting, brushing teeth, significant problems with communication uses few words, is now incontinent of urine and beginning to be incontinent of bowel as well. Continues to be able to eat independently but totally dependent in all other areas of eating even cutting food and pouring beverages. (2 years)

Late Stage Dementia: Total care in all areas of life, need to be physically fed all foods, non-verbal, few people can walk at this point,  and requiring to be re-positioned when in bed, no longer moves independently.

Dementia stages vary depending on the disease causing the dementia, most notably in dementia caused by delirium or early onset dementia. The person with early onset dementia who is diagnosed at a young age goes through the dementia stages at a much faster pace.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing 

 

WHAT DOES THE PERSON WITH DEMENTIA NEED?

The person with dementia needs to feel safe, but not in a way that they feel restricted. The person with dementia has a need to understand. The person with dementia has a need to be understood. The person with dementia has a need to be healthy and physically fit. The person with dementia has a need to be spoken to like an adult.

The need to feel safe, means feeling comfortable and accepted. Many times when a person with dementia moves into a nursing home, they will talk about “going home.” Home is where you are comfortable, accepted and you will not be forced into doing something. In the nursing home setting it takes about a month for many to no longer ask to go home. It is not that they are now resigned to being in the nursing home. It is that they finally feel that acceptance and feel at home.

The need to understand, and be understood. Persons with dementia have lost their normal forms of communication. They no longer can communicate verbally or non-verbally their needs. Even the person who still has words has trouble expressing their thoughts and feelings. Misinterpretation of their environment causes more misunderstanding and results in fear.

The person with dementia has a need for nutritious food and exercise.  Nutritious meals, no junk food, supplement with B vitamins for stress and brain health, fresh air and exercise results in better sleep. (B vitamins should only be taken in the morning so they do not disrupt sleep)

The person with dementia needs to be included in conversations. They need to be addressed by their preferred name or title.

The person with dementia struggles all day long to understand their world and make their needs known.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

SUDDEN CONFUSION – Part III

May is 89 years old and suffers from sudden confusion and dementia. While her story is sad and even tragic, it really demonstrates how the combination of extreme life stressors and the smaller brain can lead to equally extreme confusion. Until recently May was functioning on a very high level for someone her age. In fact she was providing some of the care for her aged husband.

Then due to the care she was providing she required back surgery. May suffered from excruciating pain prior to her surgery as well as following the procedure. This required her to be on narcotics, something that was certainly an assault to her brain. And one of those things known to cause elderly brains to shrink.

While recovering from her surgery, her husband of so many years died. Before May could adjust to the loss of her husband she received the news that her granddaughter had suddenly and tragically died as well. May then began to mentally spiral down, with the combination of grief, pain and narcotic medications, she could no longer cope.

May became delirious causing her to now be medicated with high powered psychotropic medications. She was physically restrained in a hospital bed, confused, agitated, delirious  and manic to the point of chewing on her fingers. Resulting in chewing off 1/3 rd of one of her fingers, in her extreme mental distress.

While the story of May demonstrates how extremes can result in sudden confusion, dementia and delirium. Her life tragedies could not have been for-seen nor avoided. The loss of her husband was expected but not the loss of a much loved granddaughter. Her back problems were possibly predictable depending on how much physical support she was providing for her ailing husband. However, that she would need back surgery and be on narcotics for the pain was not predictable.

But what we don’t know about May is how good of a job she had done taking  care of her brain during those 89 years. Our assumption is that she was doing a good job taking care of her health and her brain, due to the fact that at her advanced age she could participate in her husbands care.

So for May as well as many other elderly, sudden confusion and delirium are not all that unexpected or sudden when the tragedies of life arrive.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing

 

DEMENTIA – BAD BEHAVIOR AND HOLIDAYS

Children act out in the days leading up to holidays and parents shake their heads and say ” he has had too much sugar.” That may very well be true, yet children are certainly impacted by the hustle and bustle of holidays. And just as children are overwhelmed by the activities and anticipation, even more so is the elder with dementia.

However when the elder with dementia becomes angry and uncooperative, no one says “he has just had too much sugar.” And very often the solution proposed is some form of isolation, where what the elder may need is just the opposite. The elder with dementia may push family away with angry behaviors such as yelling, screaming, even pushing and at times throwing things.

There are also behaviors that are not as physical but equally as troubling such as, pacing, complaining, repeating themselves and general restlessness. What is important to remember is that the elder with dementia is not acting this way on purpose. The elder with dementia is always trying to understand his environment. Where he is, who is there, what is going on and most of all what might be expected of him.

While holidays are great is so many ways for the person with dementia, the music, colors, food, smells and decorations reinforce what is happening. The increase in  people, excitement, noise can push an already stressed elder over the edge. This is a good time for old fashion remedies. Activities that are calm, quiet and one on one.

  • a hand massage helps with anxiety, worry, sadness, and fearfulness
  • the old fashion back rub works wonderfully for those  in chronic pain or exhibiting irritability and anger
  • a foot massage provides calming for those with hyperactive behaviors, restlessness and pacing
  • massaging the forehead, temples and scalp help with tension and headaches

Added to the calming effect of the physical-therapeutic touch, some light smelling aroma, and you might be giving the best gift.

Virginia Garberding RN

Certified in Gerontology and Restorative Nursing