Understanding the Dementias

1. Understanding the Dementias B. Heath Gordon, Ph.D.1,2,3 11.08.13

2. Disclosures • None

3. Objectives Upon completion of this 1-hour learning activity, attendants should be able to: • Identify the primary types and causes of dementing illnesses • Describe the cognitive and behavioral features of different dementing illnesses • Identify a behavioral model and techniques for managing challenging behaviors in loved ones with dementia

4. Perceptions of Cognitive Aging

5. What is Dementia? now (Major & Mild Neurocognitive Disorders)

6. DSM-IV-TR (2000) • Multiple cognitive deficits: • Memory • Impaired ability to learn new things or recall old information • Plus (one or more of the following): • Language disturbance • Difficulty performing motor activities (w/ intact motor ability) • Failure to recognize or identify objects (w/ intact senses) • Impaired planning, organizing, sequencing, or abstracting ability

7. Key Points • Symptom must interfere with daily life • Represents a decline from a higher level of functioning • Does not occur exclusively during an episode of delirium • Not better accounted for by another mental health condition

8. DSM-5 (2013) • Major and Mild Neurocogitive Disorders (NCDs) • Evidence in cognitive decline in one or more areas based on • Self-report or an informant, AND • Clinical assessment • Subtypes of NCD are specified • E.g., Probable major neurocognitive disorder due to Alzheimer disease, with behavioral disturbance, moderate • Greater alignment with consensus criteria • E.g., Probable vs. Possible Alzheimer disease

9. Causes • Progressive disease • Vascular disease • Trauma • Tumors • Substance-induced • Infection • Metabolic disorders • Endocrine disorders • Epileptic disorders • Toxic reactions • Anoxia • Vitamin deficiency

10. Primary Types of Progressive Dementia • Alzheimer disease (DAT) • Vascular dementia (VaD) • Dementia with Lewy bodies (DLB) • Frontotemporal lobar dementia (FTD)

11. Other Types • Parkinson’s disease • Huntington’s disease • Multiple sclerosis • Pick’s disease • Hydrocephalus • Creutzfeld-Jacob disease • Substance-induced persisting dementia • HIV-related dementia • Dementia pugilistica • Multiple etiologies

12. Alzheimer disease (DAT)

13. Criteria for DAT • Memory impairment: Learning & Recall • One or more impairments in the following: • Speech and/or understanding language = aphasia • Skilled movement = apraxia • Object recognition = agnosia • Judgment, planning, switching tasks, etc. = executive functioning • Cognitive deficits represent a significant decline • Gradual start and decline in cognition (vs. sudden) • Deficits cause significant impairment in social or occupational functioning

14. Features of DAT • Generally a gradual onset with initial difficulty remembering recent events (perhaps mood changes) that becomes global and affects long-term memory • Accounts for ~60-80% of all dementing illnesses • Due to neuronal atrophy, synapse loss, abnormal accumulation of neuritic plaques and neurofibrillary tangles

16. Progression

19. Vascular Dementia (VaD)

20. Criteria for VaD • Memory impairment: Learning or Recall • One or more impairments in the following: • Speech and/or understanding language • Skilled movement • Object recognition • Judgment, planning, switching tasks, etc (executive functioning) • Cognitive deficits represent a significant decline • Focal neurological signs and symptoms or lab evidence indicative of cerebrovascular disease • Deficits cause significant impairment in social or occupational functioning and are a significant decline

21. Features of VaD • Generally an abrupt onset of cognitive deficits and step-wise pattern of decline • Multiple injuries to the brain due to inadequate blood supply • Where injury occurs determine type of cognitive deficits • Impairment in memory • memory retrieval > new learning • Deficits in attention/concentration • Impairment in judgment • Personality and mood changes

22. Stroke-Related Behaviors Stroke A ≠ Stroke B

26. Frontal Lobe • Motor cortex • Motor function, fine motor coordination • Premotor cortex • Frontal eye fields, motor planning • Prefrontal cortex • “Executive functions” • Planning, organizing, monitoring, inhibiting • Motor speech area

27. Dorsolateral • Dysexecutive syndrome • Poor problem-solving, reasoning, sequencing, maintaining behaviors (perseverative) • Poor motivation • Poor insight and judgment • Slow learning, environmental dependence, poor memory attention, forgetting temporal sequence of events • Blunted and apathetic affect but anger when aroused

28. Orbitofrontal • Emotionally dysregulated • Behaviorally disinhibited • Impulsive • Poor smell discrimination • Pseudopsychopathic syndrome • Disorganized • Lack of social graces • Poor appreciation for feelings of others or negative aspects of behavior

29. Medial Frontal • Associated with anterior cingulate • Akinetic and apathetic with bilateral damage • Little initiation of movement or speech • Lack of interest and indifference • Emotional blunting • Memory impairment (amnesia with confabulation) • Incontinence • Lower extremity weakness

30. Symptom Origin?

31. Dementia with Lewy Bodies (DLB)

32. Criteria for DLB • Memory impairment: Learning & Recall • One or more impairments in the following: • Speech and/or understanding language • Skilled movement • Object recognition • Judgment, planning, switching tasks, etc (executive functioning) • Cognitive deficits represent a significant decline • Evidence from medical exam of related illness • Deficits cause significant impairment in social or occupational functioning

33. Features of DLB • Associated with abnormal structures called Lewy Bodies in the brain • Gradual start and progression of cognitive decline • Fluctuating cognition and variability in alertness/attention • Abrupt confusion • Memory deficits (memory retrieval more than learning new information) • Parkinsonism • Bradykinesia (loss of spontaneous movement) • Rigidity (muscle stiffness) • Tremor • Shuffling gait • Visual hallucinations (well-formed, detailed, recurrent) • Frequent falls

34. Frontotemporal Dementia (FTD)

35. Criteria for FTD • Memory impairment: Learning & Recall • One or more impairments in the following: • Speech and/or understanding language • Skilled movement • Object recognition • Judgment, planning, switching tasks, etc (executive functioning) • Cognitive deficits represent a significant decline • Evidence from medical exam of related illness • Deficits cause significant impairment in social or occupational functioning

36. Features of FTD • Loss of brain tissue in frontal and temporal lobes • Associated with abnormal structures in the brain (Pick’s Bodies) • Gradual start and progression of cognitive decline: • Behavioral & personality changes are significant • loss of personal (hygiene) and social (tact) awareness • Disinhibited and impulsive • Loss of initiative, indecision, lack of spontaneity • Impairment in speech and/or understanding language • Object recognition impairment • Impairment in skilled movement

37. Positive Behavior Approach

38. Introduction • Models for Understanding Behavior • Different types of disruptive behavior/agitation • Mixing three models • Matching Interventions to Disruptive Behaviors • Based on environmental links • Individualized to ability and preference

39. Behavior Symptoms Behavioral Disturbances: Behaviors we don’t want to see but are present. Verbal Aggression Cursing Screaming Threatening Verbally Non-Aggressive Crying Repeated Questions Constant Requests • Physically Aggressive • Hitting • Kicking • Biting • Physically Non-Aggressive • Pacing • Inappropriate disrobing

40. Behavior Symptoms Behavioral Deficits: Behaviors we do want to see but are not present. • Decreased social skills • Apathy/Decreased display of emotion • Physical dependency/ADL limitations greater than indicated by illness/disease • Unable to interact with their surroundings

41. Behaviors Rated by Dimension VERBAL/VOCAL VERBALLY NONAGGRESSIVEVERBALLY AGGRESSIVE -complaining -cursing and verbal aggression -negativism -making strange noises -repetitive questions -verbal sexual advances -constant, unwarranted requests -screaming for attention NONAGGRESSIVE AGGRESSIVE PHYSICALLY NONAGGRESSIVEPHYSICALLY AGGRESSIVE -repetitious mannerisms -physical sexual advances -inappropriate robbing and disrobing -hurting self or others -eating inappropriate substances -throwing things -handling things inappropriately -tearing things -pacing, aimless wandering -grabbing -intentional falling -pushing -general restlessness -spitting -hoarding things -kicking and hitting -hiding things -biting PHYSICAL (Cohen-Mansfield, 2000)

42. Model for Understanding Behavior • Role of Individual Qualities • Personal History, Habits, Preferences • Personality Style • Neurological/Brain structure and chemistry • Mental & Physical Abilities, Deficits • Role of Environmental Qualities INTERNAL NEEDS: EXTERNAL DEMANDS: Physical Physical Surroundings Emotional Social Surroundings

43. Learning Behavior Model • A connection occurs between antecedents, behavior, and consequences • Disruptive behavior is learned through reinforcement from others • Goal: reinforce positive, appropriate behavior and do not reinforce negative, disruptive behavior

44. Based on Cohen-Mansfield, 2000 Unmet Needs Model Life long habits & Personality Unmet needs and Direct effects of dementia Environment Physical Psychosocial Need-Driven Behavior Current abilities Physical & Mental Learning Behavior Model Person Environment Fit Model

45. Benefit of Behavioral Models • All models focus on the reason or cause for the behavior. • Need to understand behavior before you act • Does not decrease the person’s ability to interact, which is already difficult. • Focuses on psychosocial interventions, and does not have the drawbacks of medication. • Side effects • Drug interactions • Limited value (does not increase positive behavior)

46. Assumptions • All behavior has meaning • Behavior is a way of communicating • Behavior can be a demonstration of a person’s abilities, disabilities, and challenges they face • Understanding the reason or cause is the best way to manage disruptive behaviors • Try psychosocial approaches before medications • Interventions must be person-centered

47. Learning Behavior Model: ABCs of Behavior “A” Antecedents “B” Behavior “C” Consequences

48. ABCs of Resident Behavior • The ABCs of Behavioral Management • A = Antecedent • B = Behavior • C = Consequence • Antecedent: what happens before the behavior • Consequence: what happens after the behavior (Burgio & Stevens)

49. ABCs of Resident Behavior • To identify the Antecedents and Consequences, ask the ‘W’ questions • What • Why • When • Where • Who (Burgio & Stevens)

50. Behavior Logs: Charting Behavior • Time & Date: • Behavior: List & Describe: • With whom? Number of people: • Where?: • Trigger Event(s): • Interventions Tried: List & Describe: • End Result(s): • Effective?: