Alzheimer’s Disease and Dementia Care for Health Plan Case Managers

1. Alzheimer’s Disease and Dementia Care for Health Plan Case Managers Karen Bugg RN LMSW Institute for Health Care Studies Michigan State University August 16th & 17th 2010

2. What does “dementia” mean?

3. Dementia and the Brain • Injury to brain cells causes dementia. • Dementia causes a decline in a person’s ability to think, understand, and remember and affects a person’s function. • Dementia gets worse over time.

4. Dementia Because of memory loss: • no longer self-sufficient • requires ongoing help or supervision • functional dependency

5. Bathing Dressing Feeding Self Toileting Transferring Telephone Driving Shopping Meal Preparation Managing Finances Managing Medications Activities of Daily Living

6. Causes of Dementia • Alzheimer’s disease is the most common cause of dementia. • Other common causes are: • Vascular dementia • Dementia with Lewy bodies

7. Alzheimer’s definition A progressive degenerative neurological disease. Most common form of dementia in the elderly. Nearly 75% of all dementia cases.

8. Alzheimer’s in the United States 5.3 million people One person is newly diagnosed every 70 seconds 7th leading cause of death Rates are expected to double every 20 years

9. Alzheimer’s Disease - Statistics • 6-8% of all persons age 65 and older • 30-50% of all persons age 85 and older • By 2029, all baby boomers will be at least 65 years old • 5.3 million cases currently, will increase to 18 million by 2040

10. Race & Ethnicity • Older African Americans and Hispanics are much more likely than older whites to have Alzheimer’s disease and other dementias.

11. Michigan In 2008, sixty-eight percent of nursing home residents were cognitively impaired.

13. Current Dilemmas in Dementia Care • Alzheimer’s disease is under diagnosed, particularly among patients who do not speak English as their primary language. • Pre-Alzheimer’s impairments are often attributed to “normal” aging. • Denial and fear often delay evaluation. • Typical lag time between symptom onset and diagnosis is two years. • Most patients are not diagnosed by their primary care physicians.

14. Impact on health care Today, there are about 4,700 providers, up from about 3,300 five years ago.    Alzheimer's disease now accounts for 10.1 percent of hospice admissions nationwide, up from 5.5 percent in 2000.    ALH’s beds have tripled over the decade from 600,000 to 2,000,000..   

15. The Future of Alzheimer’s Disease Treatment with current FDA approved drugs Disease modifying drugs to induce remission Medications to reverse memory loss Cure

16. Brain Anatomy & Function Related to Memory

17. Healthy Brain Cells • Billions of neurons • Axons = message transmitters • Dendrites = message receivers • Groups of neurons have special functions

18. Healthy Brain Processes • Communication • Metabolism • Repair

19. Brain Communication • Neurotransmitters • A chemical messenger between neurons that excite or inhibit.

20. Brain Metabolism • Brain needs lots of blood to nourish cells with oxygen and glucose. • Or death to cells.

21. Brain Repair • Neurons can live 100 years or more. • They must maintain and repair. • Injury and illness can destroy. • New neurons can be generated in some areas.

23. The Frontal Lobes • Help you to do more than one thing at once. • Prioritize what to focus on. • Sense how much time is passing.

24. When dementia affects the frontal lobes, you may: • Have difficulty focusing on a task and paying attention to what is going on. • Be overwhelmed when a caregiver talks and touches at the same time. • Have difficulty following the logic of an argument. • Need the most important words said first in a sentence.

25. You may also: • Need short and simple words and sentences. • Refuse a bath because you can’t think of how to do it. • Be unable to stop striking or grabbing someone because you can’t control impulses.

26. Temporal Lobes • The temporal lobes help you: • Understand language • Speak • Read and write.

27. When dementia affects the temporal lobes, you may: • Make non-sense words. • Use the wrong sounds when talking. • Substitute words or use fewer words. • Say “yes” when you mean “no”. • Not understand what someone tells you. • Not understand what you read. • Use swear words without realizing it.

28. Parietal Lobes • The parietal lobes: • Help you locate and arrange objects in space. • Tell your brain to pay attention to everything that is in the space you see.

29. When dementia affects the parietal lobes, you may: • Use excessive energy putting an arm into a shirt sleeve. • Put a glass down on the edge of a plate, rather than beyond it. • Have difficulty responding to objects on the left side of your visual field. • Have difficulty tolerating clutter, many objects, and movement in the room.

30. You may also: • Feel angry, frustrated, and tired from all of the confusing objects and sounds in the environment. • Respond better when a caregiver approaches from the front. • Resist stepping into a tub or shower because you can’t see: the side of the tub, where your feet or hands should go, or how deep the water is.

31. Hippocampus • The hippocampus creates your memory of recent events such as: • What someone just said. • What you had for lunch. • Who just visited you an hour ago. • Where you parked your car.

32. When dementia affects the hippocampus, you may: • Repeat a question over and over again. • Forget that a family member just visited. • Be surprised or angry when a caregiver begins to remove clothing when you just agreed to take a shower. • Lose items repeatedly or store them in the wrong place.

33. The Aging Brain And Memory

34. Namenesia “Hi. I’m, I’m, I’m…. You’ll have to forgive me, I’m terrible with names.”

35. Roomnesia Now why did I come in here?

36. Fleeting thought syndrome A.K.A…. “the senior moment”

37. Memory loss is not a normal part of aging

38. Decline in mental ability is not inevitable as people age Neuroplasticity Cognitive reserve

39. Cognitive Reserve Relationship between brain pathology and cognitive effect moderated by CR CR markers: education, occupation, leisure interests Greater CR causes less impact on function with similar level of pathology Greater CR leads to steeper decline once pathology overwhelms Yaakov Stern

40. Types of Memory Episodic memory Semantic memory Working memory Procedural memory

41. The Aging Brain • Brain tissue volume decreases with age due to white matter loss. • Regional loss may be gender specific. • Frontal regions are more vulnerable to decline. • Neurogenesis = growth of new brain cells.

42. Aging: Vulnerable Processes Processing speed Working memory Divided attention Complex visual processing Long term memory Episodic memory Source recall

43. Preserved Abilities with Aging Priming - an unconscious influence of past experience on current performance or behavior.

44. Visual Priming C H _ _ M _ _ K O _ T _ _ U S D _ N O _ _ U R P R _ _ T I _ _ _ I T _ _ _

45. Preserved Abilities with Aging Priming - an unconscious influence of past experience on current performance or behavior. Inhibition of stimulus-bound responding.

46. Stroop test

47. Common Causes of Poor Memory Insomnia and impaired sleep (apnea) Drug side effects (antihistamines) Menopause Depression Attention Deficit Disorder Head injury Chemotherapy

48. Problem Medications • Antiarrythmics • Antiemetics • Antihistamines • Antiparkinson Agents • Antipsychotics • Antispasmotics • Skeletal Muscle Relaxants • Tricyclic Antidepressants

49. Uncommon Causes of Poor Memory • Young onset Alzheimer’s disease • Mosquito and tick born disease • Brain tumors • Toxin and heavy metal exposure • Anesthesia • Seizures

50. Early Warning Signs of Dementia Frequent repeating / defensive answers Word finding difficulty Mistakes with bills / checkbook Changes in hygiene / grooming Mistakes with medications Geographic disorientation