case management

1. Case Management Toolbox
Dementia Case Management
Dr. Dawn-Elise Snipes PhD, LPC-MHSP, LMHC
Executive Director AllCEUs Continuing Education
Podcast Host: Case Management Toolbox, Counselor Toolbox
CEUs are available for this presentation at https://www.allceus.com/case-management-toolbox-podcast/
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2. Objectives
 Review the symptoms of dementia
 Differentiate between dementia and normal aging
 Review the types of dementia
 Identify possible causes and preventative factors
for dementia
 Explore biopsychosocial needs of people with
dementia and their caregivers at each stage
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3. Resources
 The Dementia Society of Ottawa and Renfrew
Counties
 Dementia Australia
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4. Symptoms of Dementia
 Cognitive and sensory changes:
 Memory loss
 Difficulty in communication, especially finding the right words to
communicate or keeping track of a conversation.
 Reduced ability to organize, plan, reason, or solve problems
 Difficulty handling complex tasks
 Confusion and disorientation (Gets lost in familiar places)
 Difficulty with coordination and motor functions
 Loss of or reduced visual perception
 Metallic taste in mouth, decreased sense of smell
 Agnosia: loss of ability to recognize objects, persons, sounds,
shapes, or smells while the specific sense is not defective nor is
there necessarily any significant memory loss “visual agnosia”
“Auditory agnosia”
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5. Symptoms of Dementia
 Psychological changes:
 Changes in personality and behavior
 Depression
 Anxiety
 Hallucinations
 Mood swings
 Agitation esp. with changes in routine
 Apathy
 Isolation/withdrawal
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6. Dementia vs Normal Aging
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 Normal Aging
 Occasional forgetfulness
 Can use notes as reminders
 Slower processing
 Increased time for complex tasks
 Able to follow written and verbal directions
 Longer to learn new information
 Difficulty finding the right word
 Slowed reaction time
 Able to complete ADLs*
 Some issues with balance*

7. Types of Dementia- Alzheimer’s
 Stage 1 means Alzheimer’s has started to develop,
but there are no symptoms of memory loss yet —
this stage can last up to 20 years.
 Stage 2 Mild Cognitive Impairment –MCI) involves
mild changes in memory and thinking skills
 Stage 3 (Late Stage/Alzheimer’s Dementia)
memory and thinking skills are so impaired that a
person needs help to complete daily activities of
daily living.
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8. Types of Dementia- Korsakoff’s Syndrome
 Korsakoff’s syndrome and Wernicke/Korsakoff
syndrome
 Alcohol has a direct toxic effect on the brain cells, or
whether the damage is due to lack of thiamine, vitamin
B1
 People with anorexia and those who have had bariatric
bypass surgery are also at risk.
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9. Types of Dementia—AIDS Dementia Complex
 7% in people not taking anti-HIV drugs.
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10. Types of Dementia—Vascular Dementia
 Vascular Dementia includes a very wide range of
symptoms caused by a reduction in blood supply to
the brain usually due to strokes or heart attack
 Symptoms can develop months after a major stroke
 The main symptom of Vascular Dementia is slowness
in thinking speed, problems concentrating or
difficulty planning and organizing.
 It is also common for a person with Vascular Dementia
to experience mood changes
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11. Types of Dementia- With Lewy Bodies
 Dementia with Lewy Bodies is often misdiagnosed
as Alzheimer’s Disease
 Parkinson’s Disease and Dementia with Lewy
Bodies produce similar brain changes
 The main symptoms include memory loss,
disorientation, visual hallucinations and sleep
issues
 The disease lasts an average of 5 to 8 years from
the time of diagnosis to death, but the time span
can range from 2 to 20 years.
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12. Types of Dementia--Frontotemporal
 The main functions affected by Frontotemporal
Dementia are language skills, the ability to focus
and the ability to control impulses
 More common in those under 65
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13. Other (Reversible?) Causes of Dementia
 Clinical hypothyroidism and hyperthyroidism have long
been linked with reversible cognitive impairment in
patients
 Cognitive impairment, dementia, and psychoses have
been described in patients with chronic hypocalcemia,
hypoparathyroidism, and hypercortisolism
 People with PTSD may exhibit hypercortisol responses to stress
triggers
 Hypercortisolemia is evident in approximately 50% of depressed
patients and is particularly characteristic in the melancholic
subtype.
 Nearly 33% of people with Type 2 diabetes have elevated cortisol
levels
 A history of recurrent severe hypoglycemic episodes was
associated with a greater risk of dementia
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14. Causes of Dementia
 Carbon monoxide (CO) poisoning can lead to a
delayed onset cognitive decline beginning days to
several weeks after apparent recovery from the
initial insult.
 Cognitive decline, personality changes, incontinence,
parkinsonism, and even mutism may occur. The
majority of victims recover within 1 year.
 Carbon monoxide (CO) is a colorless, odorless gas found
wherever fuel is burned including small engines, gas
ranges, furnaces, fireplaces and grills
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15. Other Causes cont…
 Sources of carbon monoxide poisoning:
 Furnace
 Chimney (closed/blocked)
 Fireplace
 Water heater
 Gas stove/oven
 Gas-powered space heaters
 Clothes dryer
 Grill
 Power tools and lawn equipment
 An attached garage that regularly houses vehicles
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16. Other Causes Cont…
 Symptoms of CO2 Poisoning
 Dizziness
 Blurred vision
 Weakness/Fatigue
 Confusion
 Shortness of breath during mild activity
 Nausea
 Headache
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17. Dementia Progression
 Dementia is a progressive disease
 The speed of progression varies depending on
 The type of dementia
 The person
Early interventions
Medical complications
Genetics
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18. Dementia Primary Prevention
 Authors estimate that as much as 35% of dementia cases could
be prevented by targeting nine modifiable risk factors
1. Early life education
2. Midlife hypertension (Vascular dementia)
3. Obesity increases the risk of dementia in general by 42 percent,
Alzheimer's by 80 percent and vascular dementia by 73 percent
4. Diabetes
5. Hearing loss
6. Old-age smoking
7. Depression (Hypercortisolism, unstimulating environments)
8. Physical inactivity
9. Social isolation
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19. Dementia Primary Prevention
 Regular Physical Activity
 The protective effective was increased as the number of activities
increased
 Higher levels of intellectual activities and an intellectually
stimulating environment may reduce the risk of cognitive
decline later in life
 A lower level of education increases the risk of having AD by
approximately 30%**
 Social engagement. Degree of loneliness, decreased social
networking and activities seem to be associated with a higher
risk
 Dietary modulation (Omega-3, antioxidants, B-Vitamins) serves
only to bolster normal health mechanisms that are a natural
deterrent of chronic health conditions such as AD without really
possessing any discrete disease specificity
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20. Dementia Secondary Prevention/EI
 Reduction or cessation of symptom progression
once the symptoms have appeared
 cholinesterase inhibitors and NMDA Antagonists
(Ketamine*)
May improve acute symptoms but does not slow
progression
 Physical Activity
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21. Dementia Tertiary Prevention/EI
 Prevent the development of complications from
the disorder
 Depression
 Falls
 Nutritional deficiencies
 Diabetes
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22. Multidisciplinary Team
 Physical therapists can help with movement problems through
exercises, gait training, and general physical fitness programs.
 Speech therapists may help with voice volume and projection,
and swallowing difficulties.
 Occupational therapists help find ways to more easily carry out
everyday activities, such as eating and bathing.
 Music or expressive arts therapists may provide meaningful
activities that can reduce anxiety and improve well-being.
 Mental health counselors can help people with LBD and their
families learn how to manage difficult emotions and behaviors
and plan for the future.
 Palliative care specialists can help improve a person's quality of
life by relieving disease symptoms at any stage of illness.
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23. Goals
 Goals
 Independence
 Safety
 Sense of meaning
 Happiness/contentment
 General methods
 Safety from falls, wandering, burns, guns, and CO2
 Adequate quality sleep
 Adequate nutrition
 Medication compliance
 Physical Activity
 Social Interactions
 Meaningful Daily Activity
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24. Special Issues for People with Dementia
 The needs of a person with Early Onset Dementia can be very
different from traditional onset dementia because they may be
actively working and raising a family and be otherwise healthy
and strong
 Early stage of dementia, a person can still function rather
independently and requires little care assistance.
 Appointment reminders
 Daily to-do list and / or a schedule of when medications
 Hang complete outfits
 Go shopping together (or auto-deliver)
 Regular check-ins while the person is still living independently
 Family counseling to deal with grief issues related to the diagnosis
 Financial planning
 Note on microwave (i.e. no metal, duration for common foods)
 Coffee maker that automatically shuts off
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25. Special Issues for People with Dementia
 Middle Stage Dementia
 No longer able to function as independently
 Greater difficulty communicating (see communication
tips)
 Assistance with activities of daily living, such as
bathing, grooming, and dressing, is often required
 Initially, an individual may only need prompts or cues
to perform these tasks, such as reminders of the need
to shower or clothes laid out on the bed
 Transportation will be required
 Supervision is necessary
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26. Special Issues for People with Dementia
 Late Stage Dementia
 Requires a significant amount of care 24-hours / day.
 Mobility issues
 Swallowing becomes an issue in late stage dementia,
and caregivers have to make sure food is cut into small
pieces, is soft, such as yogurt and applesauce, or is
pureed.
 Options for care, such as hiring a part time caregiver or
moving your loved one to a nursing home.
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27. Monitoring Tools
 Functional Assessment Staging Test
 Stage-Expected Untreated Duration-Mental Age-MMSE-A Score
 Weight
 Infections/Pain/Illness (60% may have untreated issues)
 Falls and injuries
 Behavior changes
 Medication compliance, effects/side-effects and changes
 Mood and ADLs: Ambulation, hygiene, feeding, toileting
 May indicate disease progression or another acute issue
 Social engagement
 Note: Abilities may fluctuate
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28. General
 Review medications
 Consider whether any might be contributing to cognitive deficits,
especially anticholinergics, antihistamines, narcotics, sedatives, and
benzodiazepines*
 Address treatment compliance
 Add social activities
 Add intellectual stimulation and meaningful daily activities
 Focus on activities with tangible results
 Painting
 Life-story book
 Gardening
 Playing or listening to music
 Picture books
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29. General
 Assess mobility issues
 In house
 Getting out of bed
 Getting in and out of the shower/tub
 Stairs
 Slick floors
 Tripping hazards
 With preferred activities (walk the dog, woodwork, crochet,
painting)
 To get supplies (driving, shopping)
 Address long-term care planning
 Advanced directives
 Power of attorney
 Living transitions
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30. General
 Evaluate behavioral issues and safety
 Driving, wandering, cooking, bathing, shopping
 Sundowning—confusion and agitation increase throughout the day
 Mitigate vulnerabilities/triggers
 Recognize the function of the agitation
 Use visual cues for orientation and comfort
 Avoid arguing
 Consider bright light therapy to adjust circadian rhythms—Full spectrum
light at least 100 watts (not soft) within 3 ft. or sitting by a sunny window
 Increase daytime activity and limit day naps
 Avoid stimulants after noon
 Minimize stress (TV or reading might be too difficult) painting, pets,
baking with assistance, gardening
 Address caregiver stress
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31. Addressing Behavioral Issues
 Functional assessments
 Preferred activities
 Problem behaviors
 Aromatherapy (esp. Lemon Balm, rose, lavender,
bergamot)
 Music therapy
 Animal assisted therapy
 Relaxation training
 Reminiscence therapy helps recall past happy times
despite current issues with short term memory
 Difference between reminiscing and remembering
 Use favorite music, keepsakes/ornaments/jewelry, magazines,
familiar scents or foods
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32. Addressing Behavioral Issues
 Validation therapy
 Often prevents argumentative and agitated behaviors.
Validation may require you to agree and validate with a
statement that has been made, even though the
statement is neither true or real, because to the
person with dementia, it may actually be both true and
real
 Light therapy (sundowning)
 Activities of Daily Living
 Strategies may include verbal or visual cues,
demonstration, physical guidance, partial physical
assistance and problem solving
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33. Addressing Behavioral Issues
 The reasons that underlie the problem behaviors can be one or
more of the following basic human needs:
 Resolution of unfinished issues, in order to die in peace
 To live in peace
 Adjusting to new normal when sight, hearing, mobility and memory fail
 To make sense out of an unbearable reality
 For recognition, status, identity and self-worth
 To be useful and productive
 To be listened to and respected
 To express feelings and be heard
 To be loved and to belong
 To be nurtured, feel safe and secure, rather than immobile or restrained
 For sensory stimulation as well as sexual expression
 Reduce pain and discomfort
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34. Caregiver Needs
 Resources
 The signs and symptoms of dementia
 The course and prognosis of the condition
 Treatments
 Knowledge of how to help their loved-one
 Communication
 Behavior issues
 Safety—wandering, falling, hazards
 Local care and support
 Sources of financial and legal advice, and advocacy
 Medico-legal issues, including driving
 Local information sources, including libraries and voluntary
organizations.
 Respite care—In home or clubhouse/day care
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35. Communicating with People with Dementia
 Get their attention
 Remove distractions
 Ensure they have glasses or hearing aids
 Be patient. Allow enough time for them to respond, and
be careful not to interrupt
 Use visual reminders (memory books and charts)
 Keep questions and requests to one at a time
 Break larger tasks into smaller chunks
 Empathize with frustration
 Anticipate misunderstandings
 Enjoy the good times
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36. Communicating with People with Dementia
 Reduce input late in the day
 Do not talk to the person with Alzheimer’s like a baby or
speak about them as if they weren’t there.
 If they struggle to find a word or communicate a thought,
gently try to provide the word(s) they are looking for.
 Frame questions and instructions in a positive way.
 Be open to the person’s concerns, even if he or she is hard
to understand.
 If you can’t understand what they are trying to say, look
for clues in their emotions and body language and take
their surrounding environment into consideration.
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37. Summary
 Dementia can be permanent or temporary and
caused by a variety of factors including
 Diabetes
 HIV
 Stroke/Heart attack
 Depression
 Thiamine deficiency
 CO2 poisoning
 Lewy bodies
 Genetics
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38. Summary
 A variety of interventions can be used to assist
the person with dementia and their caregivers
 Ensure sufficient sleep
 Assist with communication
 Conduct functional assessments of preferred and
problem behaviors
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