Live Counseling and Social Work CEU Webinar: 1-25-2018 at 1pm EST 1.5 CEUs for $10 Register here: https://www.allceus.com/member/cart/index/index?c=30 Objectives Explore symptoms of cognitive impairment in Alzheimer’s Dementias Review APA Treatment Guidelines for counselors working with persons with Alzheimer’s Learn how to handle difficult behaviors An on-demand CEU course can be found here: https://www.allceus.com/member/cart/index/product/id/53/c/ Also see our 2 CEU course on communicating with the cognitively impaired https://www.allceus.com/member/cart/index/product/id/796/c/

1. Alzheimer's and
Dementias
Instructor: Dr. Dawn-Elise Snipes, PhD
Executive Director: AllCEUs.com, Counselor Education and Training
Podcast Host: Counselor Toolbox & Happiness Isn’t Brain Surgery
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 1

2. Objectives
 Explore symptoms of cognitive impairment in
 Alzheimer’s
 Dementias
 Review APA Treatment Guidelines for counselors
working with persons with Alzheimer’s
 Learn how to handle difficult behaviors
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 2

3. Symptoms of Cognitive Impairment
 Patients with dementia display a broad range of cognitive
impairments, behavioral symptoms, and mood changes
 The development of multiple cognitive deficits manifested
by both
 (1) Memory impairment (impaired ability to learn new information
or to recall previously learned information)
 (2) One (or more) of the following cognitive disturbances:
 (a) Aphasia (language disturbance)
 (b) Apraxia (impaired ability to carry out motor activities despite
intact motor function)
 (c) Agnosia (failure to recognize or identify objects despite intact
sensory function)
 (d) Disturbance in executive functioning (i.e., Planning,
organizing, sequencing, abstracting)
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89
3

4. Symptoms of Cognitive Impairment
 Other Symptoms
 Attention
 Perception
 Insight and judgment
 Organization
 Orientation
 Processing speed
 Problem solving
 Reasoning
 Metacognition: processes used to plan, monitor, and
assess one’s understanding and performance
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 4

5. Symptoms of Cognitive Impairment
 Prominent memory symptoms include all EXCEPT:
 Difficulty learning new material
 May lose valuables or forget food cooking on the stove
 Forget previously learned material, including the names of loved ones
 Difficulty with spatial tasks, such as navigating around the house or in
the immediate neighborhood
 Agitation, within the context of a diagnosis of dementia, is an
umbrella term that can refer to a range of behavioral
disturbances, including aggression, combativeness,
hyperactivity, and disinhibition
 Individuals with questionable cognitive impairment have
Borderline functioning in several areas but definite impairment
in none. Such individuals are not considered demented, but
they should be evaluated over time
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 5

6. Causes of Cognitive Impairment
 Vascular Dementia
 Stroke
 Impeded blood flow to brain
 Alzheimer's
 Brain Injury from a fall
 Primary or secondary brain tumor
 Endocrine conditions (hypothyroidism, hypercalcemia, hypoglycemia)
 Nutritional conditions (deficiency of thiamin, niacin, or vitamin b12
(Wernike-Korsakoff’s Syndrome))
 Infectious conditions (HIV, neurosyphilis, cryptococcus)
 Problems with renal and hepatic function
 Effects of medications (e.g., benzodiazepines)
 The toxic effect of long-standing substance abuse
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 6

7. Diagnostic Criteria
 Mild or Major Neurocognitive Disorder Due to
Alzheimer's
 Criteria adapted from the National Institute of Neurological
and Communicative Disorders and Stroke and Alzheimer’s
Disease and Related Disorders Association (NINCDS-ADRDA)
include:
 Dementia established by examination and objective testing
 Deficits in two or more cognitive areas
 Progressive worsening of memory and other cognitive functions
 No disturbance in consciousness
 Onset between ages 40 and 90
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 7

8. Diagnostic
 Alzheimer’s cont…
 Some individuals may show personality changes or
increased irritability in the early stages
 In the middle and later stages of the disease
Psychotic symptoms are common
Patients develop incontinence and gait and motor
disturbances, eventually becoming mute and bedridden.
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 8

9. Diagnostic
 Parkinson's
 Insidious onset
 Slowly progressive
 Tremor. Rigidity. Myoclonus (sudden, involuntary jerking of a
muscle or group of muscles)
 Onset is typically in middle to late life
 Motoric slowing
 Executive dysfunction
 Impairment in memory retrieval
 Pseudodementia is a condition that occurs within the
context of major depressive disorder
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 9

10. Diagnostic
 Vascular Dementia
 One or more strokes on cognitive function
 Extensor plantar response
 Pseudobulbar palsy
 Gait abnormalities
 Exaggeration of deep tendon reflexes
 Weakness of an extremity.
 The mode of onset, subsequent course and
reversibility of dementia depend on the
underlying etiology
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 10

11. Cognitive Deficits
 Cognitive deficits in delirium often fluctuate
 Cognitive deficits in dementia are stable or progress,
they do not get better.
 Cognitive deficits in schizophrenia usually occur with
other psychotic features
 Recommended assessments include evaluation of
suicidality, dangerousness to self and others, and the
potential for aggression, as well as evaluation of
living conditions, safety of the environment,
adequacy of supervision, and evidence of neglect or
abuse
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 11

12. Screening for Cognitive Impairment
 The AD8 (PDF, 1.2M) and Mini-Cog(PDF, 86K) are among
many possible tools.
 Patients should be screened for cognitive impairment if:
 The person, family members, or others express concerns about
changes in his or her memory or thinking
 You observe problems/changes in the patient’s memory or thinking
 The patient is age 80 or older
 Low educational attainment (IQ, FASD, stroke…)
 History of type 2 diabetes
 Stroke
 Depression
 Trouble managing money or medications
 Episodes of delirium (confusion/disorientation)
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 12
https://www.nia.nih.gov/ne
ws/dilemma-delirium-older-
patients

13. Course of Treatment
 Demographic and social factors that may impact
course or treatment include:
 Age
 Gender
 Social support
 Resource availability
 Ethnic background
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 13

14. Important Aspects of Management
 Counselor Goals
 Establish and maintain an alliance with the patient and
family
 Perform a diagnostic evaluation and refer the patient
for any needed general medical care
 Assess and monitor psychiatric status for the presence
of noncognitive psychiatric symptoms and progression
of cognitive symptoms.
 Educate the patient and family about future symptoms
and the care likely to be required
 Help patients and their families think about financial
and legal issues due to the patient's incapacity
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 14

15. Important Aspects of Management
 Counselor Goals
 Help patients and their families think about financial
and legal issues due to the patient's incapacity
 Educate the patient and family about the illness, its
treatment, and available sources of care and support
 Monitor safety and intervene when required
 Improving quality of life
 Maximizing function in the context of existing deficits
 Improvement of cognitive skills, mood, or behavior
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 15

16. Important Aspects of Management
 Counselor Goals
 Goals for treatments for cognitive and functional losses
include:
 Restoring cognitive abilities
 Preventing further decline
 Increasing functional status
 Goals for treatments for psychosis and agitation include:
 Decrease psychotic symptoms (including paranoia, delusions,
and hallucinations)
 Decrease independent agitation, screaming, combativeness
 Increase the comfort and safety of patients and their families
and caregivers
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 16

17. Side Effects
 Side effects of psychotherapies include:
 Frustration
 Catastrophic reactions
 Agitation
 Depression
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 17

18. Important Aspects of Management
 Important aspects of psychiatric management
include
 Educating patients and families about:
The illness
Treatment
Sources of additional care and support (e.g. Support
groups, respite care, nursing homes, and other long-
term-care facilities)
The need for financial and legal planning due to the
patient’s eventual incapacity (e.g. Power of attorney for
medical and financial decisions, an up-to-date will, and
the cost of long-term care)
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 18

19. Management..
 Patients with dementia require a treatment plan
that is individualized, multimodal, evolving
 Frequency of visits is determined by:
 The patient's clinical status
 The likely rate of change
 The current treatment plan
 The need for any specific monitoring of treatment
effects
 The reliability and skill of the patient's caregivers
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 19

20. Important Aspects of Management
 Behavior oriented treatments
 Identify the antecedents and consequences of problem behaviors
 Reduce the frequency of behaviors by changing the environment to
alter these antecedents and consequences.
 Stimulation-oriented treatments
 Recreational activity, art therapy, music therapy, and pet therapy,
along with other formal and informal means of maximizing
pleasurable activities for patients
 Emotion-oriented treatments
 Supportive psychotherapy can be employed to address issues of
loss in the early stages of dementia
 Reminiscence therapy has some modest research support for
improvement of mood and behavior
 Tolerate, Anticipate, Don’t Agitate
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 20

21. Management cont…
 A Particular concern in long-term care is the use of
physical restraints and antispychotics
 Restraint use in this population can be decreased by
 Environmental changes that reduce the risk of falls or
wandering
 Careful assessment and treatment of possible causes of
agitation.
 Bed and chair monitors that alert nursing staff when
patients may be climbing out of bed or leaving a chair
 Prompted voiding schedules through the day and night to
decrease the urge for unsupervised trips to the bathroom
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 21

22. Management
 Antipsychotics, Benzodiazepines, Anticonvulsants (carbamazepine),
Trazadone, Buspirone, Beta blockers, notably propranolol are used to treat
agitation and psychosis
 Benzodiazepine
 Most useful for treating patients with prominent anxiety
 Perform better than placebo but not as well as antipsychotics
 Usually not recommended other than for brief use because of the risk of daytime
sedation, tolerance, rebound insomnia, worsening cognition, disinhibition, delirium, risk
of falls, worsening of sleep disordered
 Antipsychotic medications, when over used can lead to worsening of the
dementia, over-sedation, falls, and tardive dyskinesia.
 Elderly and patients with dementia are more sensitive to certain medication
side effects including anticholinergic effects and orthostasis
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 22

23. Management
 Psychostimulants (d-amphetamine, methylphenidate) are associated
with tachycardia, restlessness, agitation, sleep disturbances, and
appetite suppression
 SSRIs have favorable results in treating depression, but can produce
nausea and vomiting, agitation and akathisia, parkinsonian side
effects, sexual dysfunction, and weight loss
 Special considerations for elderly and demented populations include
all EXCEPT:
 Elderly individuals may have decreased renal clearance and slowed hepatic
metabolism
 Elderly individuals are more likely to have a variety of general medical
problems and take multiple medications
 Elderly and demented patients are more likely to be noncompliant with
treatment
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 23

24. Management
 Safety measures include:
 Evaluation of suicidality and the potential for violence
 Recommendations regarding adequate supervision
 Vigilance regarding neglect or abuse
 Restrictions on driving and use of other dangerous equipment
 Specific psychosocial treatments for dementia can be divided
into four broad groups:
 Behavior oriented
 Emotion oriented
 Cognition oriented
 Stimulation oriented
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 24

25. Management
 Basic principles of care to be remembered by counselors
and family include
 Keeping requests and demands relatively simple and avoiding
overly complex tasks that might lead to frustration
 Avoiding confrontation and deferring requests if the patient
becomes angered
 Remaining calm, firm, and supportive if the patient becomes upset
 Being consistent and avoiding unnecessary change
 Providing frequent reminders, explanations, and orientation clues
 Recognizing declines in capacity and adjusting expectations
appropriately
 Bringing sudden declines in function and the emergence of new
symptoms to psychiatrist
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 25

26. Management
 Behavioral symptoms can be precipitated by both
over and understimulation
 Cholinesterase inhibitors (tacrine and donepezil),
A-tocopherol (vitamin e), Selegiline (deprenyl),
ergoloid mesylates (hydergine) are used to treat
Alzheimer’s
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 26

27. Depression
 Depression
 Depression is common in patients with dementia.
 Patients with depression should be carefully evaluated
for suicide potential.
 Depressed mood may respond to improvements in the
living situation or stimulation-oriented treatments.
 Patients with severe or persistent depressed mood with
or without a full complement of neurovegetative signs
should be treated with antidepressant medications.
 SSRIs are the first-line treatment.
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 27

28. Management
 Treatment plan for mildly impaired patients includes
 Patients and their families are often dealing with recognition
of the illness and associated limitations, and they may
appreciate suggestions for how to cope with these
limitations (e.g., making lists, using a calendar).
 Identify specific impairments and highlight remaining
abilities.
 Caregivers should be made aware of the availability of
support groups and social agencies.
 Patients with moderate to severe major depression who do
not respond to or cannot tolerate antidepressant
medications should be considered for ECT.
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 28

29. Management
 Treatment plan for moderately impaired patients should
include:
 Increased supervision
 Families should be advised regarding the possibility of accidents
due to forgetfulness (e.g., fires while cooking), of difficulties
coping with household emergencies, and wandering
 Patients should be strongly urged not to drive
 As patients' dependency increases, respite care (e.g., home health
aid, day care, or brief nursing home stay) may be helpful
 At this stage, families should begin to consider and plan for
additional support at home or possible transfer to a long-term care
facility.
 Delusions and hallucinations often develop in moderately impaired
patients.
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 29

30. Management
 Combativeness, and physical violence
 Often associated with frustration, misinterpretations, delusions, or
hallucinations
 Pose a particular problem for patients cared for at home
 Hospitalization and/or nursing home placement must be
considered
 When treating psychosis and agitation the clinician should:
 Consider the safety of the patient and those around him or her
 Conduct a careful evaluation for a general medical, psychiatric, or
psychosocial problem that may underlie the disturbance
 If the symptoms do not cause undue distress to the patient or
others, they are best treated with reassurance and distraction
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 30

31. Handling Troubling Behaviors
 Try to accommodate the behavior, not control the behavior
 For example, if the person insists on sleeping on the floor, place a
mattress on the floor to make him more comfortable.
 Remember that we can change our behavior or the physical
environment.
 Changing our own behavior will often result in a change in our loved
one’s behavior. (Frustration -> frustration)
 Check with the doctor first.
 Behavioral problems may have an underlying medical reason, i.e. pain or
experiencing an adverse side effect from medications.
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89
31

32. Handling Troubling Behaviors
 Behavior has a purpose. People with dementia typically
cannot tell us what they want or need. They might do
something, like take all the clothes out of the closet on a
daily basis, and we wonder why.
 To be busy and productive
 Because they are too hot or cold, uncomfortable
 Always consider what need the person might be trying to
meet with their behavior—and, when possible, try to
accommodate them.
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 32

33. Handling Troubling Behaviors
 What works today, may not tomorrow because:
 Multiple factors influence troubling behaviors
 Natural progression of the disease process
 The key to managing difficult behaviors is being creative and flexible
in your strategies to address a given issue.
 Behavior is triggered. It occurs for a reason.
 It might be something a person did or said
 It could be a change in the physical environment.
 The root to changing behavior is disrupting the patterns that we
create.
 Try a different approach
 Try a different consequence. (Positive redirection)
 Sundowing can best be described as a peak period of agitation
or other behavioral disturbances during the evening hours
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 33
https://www.caregiver.
org/caregivers-guide-
understanding-
dementia-behaviors

34. Issues for Caregivers
 Challenges in home-care settings often include :
 Family care providers to work at jobs outside the home
during the day
 The adverse emotional impact on caregivers and
children or grandchildren
 The psychological stress on families from Alzheimer's
disease appears to be more complex than simply the
burden of caring for a disabled family member
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 34

35. Summary
 Many different conditions can cause cognitive
impairment
 The key to managing difficult behaviors is being
creative and flexible in your strategies to address a
given issue
 Patients with severe or persistent depressed mood
with or without a full complement of
neurovegetative signs should be treated with
antidepressant medications.
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 35

36. Summary
 10 Counselor Goals
 Establish and maintain an alliance with the patient and
family
 Perform a diagnostic evaluation and refer the patient
for any needed general medical care
 Assess and monitor psychiatric status for the presence
of noncognitive psychiatric symptoms and progression
of cognitive symptoms.
 Educate the patient and family about future symptoms
and the care likely to be required
 Help patients and their families think about financial
and legal issues due to the patient's incapacity
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 36

37. Summary
 10 Counselor Goals
 Help patients and their families think about financial
and legal issues due to the patient's incapacity
 Educate the patient and family about the illness, its
treatment, and available sources of care and support
 Monitor safety and intervene when required
 Improve quality of life and maximize function in the
context of existing deficits
 Improve of cognitive skills, mood, or behavior
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 37

38.  University of Kentucky FREE CEs for nurses, social
workers and CNAs
 Alzheimer’s Care Curriculum
AllCEUs Unlimited CEUs $59 | Addiction Counselor Certificate Training $149 | Specialty Certificates $89 38