www.careandcompliance.com/eval

JOSH ALLEN, RN, C-AL

• National trends and statistics
• The brain
• Disease overview
• Research update
• Care trends and best practices
• Risk Management

42% of residents living in assisted living have
Alzheimer’s disease or another form of dementia
Source: National Survey of Residential Care Facilities

Source: National Survey of Residential Care Facilities

Alzheimer's disease is the sixth leading cause of death in the
United States.
More than 5 million
Americans are living with the disease.
1 in 3 seniors dies with Alzheimer's or another dementia.
In 2012, 15.4 million caregivers provided more than 17.5 billion hours of unpaid care valued at $216 billion.
Nearly 15% of caregivers for people with
Alzheimer's or another dementia are longdistance caregivers.
In 2013, Alzheimer's will cost the nation $203 billion. This number is expected to rise to $1.2 trillion by 2050.
Source: Alzheimer’s Association, Facts and Figures

www.alz.org

• An estimated 5.2 million Americans have
Alzheimer's disease
• Approximately 200,000 individuals younger than age 65 have younger-onset Alzheimer's.
• By 2025, the number of people age 65 and older with Alzheimer's disease is estimated to reach 7.1 million
• By 2050, the number of people age 65 and older with Alzheimer's disease may nearly triple to a projected 13.8 million
Source: Alzheimer’s Association, Facts and Figures

• 6th leading cause of death in the United States overall
• 5th leading cause of death for those aged 65 and older
• The only cause of death among the top 10 in America without a way to prevent it, cure it or even slow its progression
• Deaths from Alzheimer's increased 68 percent between
2000 and 2010, while deaths from other major diseases, including the number one cause of death
(heart disease), decreased
Source: Alzheimer’s Association, Facts and Figures

Source: Alzheimer’s Association, Facts and Figures

• Ambiguity about the underlying cause of death can make it difficult to determine how many people die from Alzheimer's
• There are no survivors: if you do not die from
Alzheimer's disease, you die with it
• One in every three seniors dies with Alzheimer's or another dementia
Source: Alzheimer’s Association, Facts and Figures

• In 2012, 15.4 million family and friends provided
17.5 billion hours of unpaid care
• Care valued at $216.4 billion
• 80% of care provided in the community is provided by unpaid caregivers.
• More than 60 percent of Alzheimer's and dementia caregivers rate the emotional stress of caregiving as high or very high; more than one-third report symptoms of depression
Source: Alzheimer’s Association, Facts and Figures

• In 2013, the direct costs will total an estimated
$203 billion
• Including $142 billion in costs to Medicare and
Medicaid
• Total payments for health care, long-term care and hospice for people with Alzheimer's and other dementias are projected to increase from $203 billion in 2013 to $1.2 trillion in 2050 (in current dollars)
Source: Alzheimer’s Association, Facts and Figures

Source: Alzheimer’s Association, Facts and Figures

• Cerebrum: remembering, problem solving, thinking, and feeling, also controls movement
• Cerebellum : controls coordination and balance
• Brain stem : connects the brain to the spinal cord and controls automatic functions such as breathing, digestion, heart rate and blood pressure

Frontal Lobe
Parietal Lobe
Occipital
Lobe
Temporal Lobe

Source: Alzheimer’s Association

• Fruit Fly: 100 thousand neurons
• Cockroach: One million neurons
• Mouse: 75 million neurons
• Cat: One billion neurons
• Chimpanzee: 7 billion neurons
• Elephant: 23 billion neurons

• A nerve cell that is the basic building block of the nervous system
• Specialized to transmit information throughout the body
• Communicating information in both chemical and electrical forms
• Sensory neurons carry information from the sensory receptor cells throughout the body to the brain
• Motor neurons transmit information from the brain to the muscles of the body
• Interneurons are responsible for communicating information between different neurons in the body

Dendrite
Cell body
Axon

• The information must be transmitted across the synaptic gap to the next neuron
• Neurotransmitters
• Chemical messengers that are released from the axon terminals to cross the synaptic gap and reach the receptor sites of other neurons

• Acetylcholine: Associated with memory, muscle contractions, and learning. A lack of acetylcholine in the brain is associated with Alzheimer’s disease.
• Endorphins: Associated with emotions and pain perception. The body releases endorphins in response to fear or trauma. These chemical messengers are similar to opiate drugs such as morphine, but are significantly stronger.
• Dopamine: Associated with thought and pleasurable feelings. Parkinson’s disease is one illness associated with deficits in dopamine, while schizophrenia is strongly linked to excessive amounts of this chemical messenger.

• Not a specific disease
• A general term that describes a wide range of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities
• Alzheimer's disease accounts for 60 to 80 percent of cases
• Vascular dementia, which occurs after a stroke, is the second most common dementia type
Source: Alzheimer’s Association

Alzheimer’s Disease
Frontotemporal
Mixed Dementia
Vascular Dementia
Lewy Body
Parkinson’s
Disease

• Symptoms of dementia can vary greatly
• At least two of the following core mental functions must be significantly impaired to be considered dementia:
• Memory
• Communication and language
• Ability to focus and pay attention
• Reasoning and judgment
• Visual perception
Source: Alzheimer’s Association

• Depression
• Medication side effects
• Infection
• Excess use of alcohol
• Thyroid problems
• Vitamin deficiencies
Source: Alzheimer’s Association

• There is no one test to determine if someone has dementia.
• Medical history
• Physical examination
• Laboratory tests
• Characteristic changes in thinking, day-to-day function and behavior associated with each type
• Can determine dementia with a high level of certainty
• Harder to determine the exact type
Source: Alzheimer’s Association

Symptoms:
• Difficulty remembering names and recent events
• Apathy and depression
• Impaired judgment
• Disorientation
• Confusion
• Behavior changes
• Difficulty speaking, swallowing and walking
Source: Alzheimer’s Association

Brain changes:
• Deposits of the protein fragment beta-amyloid
(plaques) that build up between brain cells
• Twisted strands of the protein tau (tangles) that build up inside cells
• Evidence of nerve cell damage and death in the brain
Source: Alzheimer’s Association

Stage 1 No impairment
The person does not experience any memory problems. An interview with a medical professional does not show any evidence of symptoms of dementia.
Stage 2 Very mild cognitive decline
The person may feel as if he or she is having memory lapses — forgetting familiar words or the location of everyday objects. But no symptoms of dementia can be detected during a medical examination or by friends, family or co-workers.
Stage 3 Mild cognitive decline
Friends, family or co-workers begin to notice difficulties. During a detailed medical interview, doctors may be able to detect problems in memory or concentration.
Source: Alzheimer’s Association

Stage 4 Moderate cognitive decline
At this point, a careful medical interview should be able to detect clear-cut symptoms in several areas: forgetfulness of recent events, greater difficulty performing complex tasks, such as planning dinner.
Stage 5 Moderately severe cognitive decline
Gaps in memory and thinking are noticeable, and individuals begin to need help with day-to-day activities.
Stage 6 Severe cognitive decline
Memory continues to worsen, personality changes may take place and individuals need extensive help with daily activities.
Source: Alzheimer’s Association

Stage 7 Very severe cognitive decline
In the final stage of this disease, individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement.
Source: Alzheimer’s Association

Symptoms:
• Impaired judgment or ability to plan steps needed to complete a task is more likely to be the initial symptom, as opposed to the memory loss often associated with the initial symptoms of Alzheimer's
• Occurs because of brain injuries such as microscopic bleeding and blood vessel blockage
• The location of the brain injury determines how the individual's thinking and physical functioning are affected
Source: Alzheimer’s Association

Brain changes:
• Brain imaging can often detect blood vessel problems implicated in vascular dementia
• In the past, evidence for vascular dementia was used to exclude a diagnosis of Alzheimer's disease
(and vice versa)
• That practice is no longer considered consistent with pathologic evidence, which shows that the brain changes of several types of dementia can be present simultaneously
Source: Alzheimer’s Association

Symptoms:
• Often have memory loss and thinking problems common in Alzheimer's
• More likely than people with Alzheimer's to have initial or early symptoms such as sleep disturbances, well-formed visual hallucinations, and muscle rigidity or other parkinsonian movement features
Source: Alzheimer’s Association

Brain changes:
• Lewy bodies are abnormal aggregations (or clumps) of the protein alpha-synuclein
• Alpha-synuclein also aggregates in the brains of people with Parkinson's disease, but the aggregates may appear in a pattern that is different from dementia with Lewy bodies
Source: Alzheimer’s Association

Symptoms:
• As Parkinson's disease progresses, it often results in a progressive dementia similar to dementia with
Lewy bodies or Alzheimer's
• Problems with movement are a common symptom early in the disease
• If dementia develops, symptoms are often similar to dementia with Lewy bodies.
Source: Alzheimer’s Association

Symptoms:
• Typical symptoms include changes in personality and behavior and difficulty with language
• Nerve cells in the front and side regions of the brain are especially affected.
• Generally develop symptoms at a younger age (at about age 60) and survive for fewer years than those with Alzheimer's
Source: Alzheimer’s Association

• Creutzfeldt-Jakob disease
• Normal pressure hydrocephalus
• Huntington's Disease
• Wernicke-Korsakoff Syndrome

• An acute confusional state
• Medical condition that results in confusion and other disruptions in thinking and behavior, including changes in perception, attention, mood and activity level
• Individuals living with dementia are highly susceptible to delirium
• Can easily go unrecognized

Onset
Depression Delirium
Weeks to months Hours to days
Dementia
Months to years
Mood Low/apathetic Fluctuates Fluctuates
Course Chronic; responds to treatment.
Acute; responds to treatment
Chronic, with deterioration over time
Source: American Medical Association

Depression Delirium Dementia
Self-
Awareness
Likely to be concerned about memory impairment
May be aware of changes in cognition; fluctuates
Likely to hide or be unaware of cognitive deficits
ADLs May neglect basic self-care
May be intact or impaired
IADLs May be intact or impaired
May be intact or impaired
May be intact early, impaired as disease progresses
May be intact early, impaired before ADLs as disease progresses
Source: American Medical Association

• Scientists know Alzheimer's disease involves progressive brain cell failure
• The reason cells fail isn't clear
• Experts believe that Alzheimer's develops as a complex result of multiple factors rather than any one overriding cause
Source: Alzheimer’s Association

Age and Alzheimer’s:
• Although Alzheimer's is not a normal part of growing older, the greatest risk factor for the disease is increasing age
• After age 65, the risk of Alzheimer's doubles every five years
• After age 85, the risk reaches nearly 50 percent
Source: Alzheimer’s Association

Family History and Alzheimer’s:
• Research has shown that those who have a parent, brother, sister or child with Alzheimer's are more likely to develop the disease
• The risk increases if more than one family member has the illness
• Either heredity (genetics) or environmental factors or both may play a role
Source: Alzheimer’s Association

VIDEO:
THE ROLE OF GENETICS IN
ALZHEIMER’S
Instructors: Click on the link to the movie to begin.
The movie will open in Media player. Double click on the playing video to make it full-screen.
When movie is complete, hit escape. Then, close Media player to return to PowerPoint.
Source: Alzheimer’s Association

• Amyloid precursor protein (APP) , discovered in
1987, is the first gene with mutations found to cause an inherited form of Alzheimer's.
• Presenilin-1 (PS-1) , identified in 1992, is the second gene with mutations found to cause inherited
Alzheimer's. Variations in this gene are the most common cause of inherited Alzheimer's.
• Presenilin-2 ( PS-2) , discovered 1993, is the third gene with mutations found to cause inherited
Alzheimer's.
• Apolipoprotein E-e4 (APOE4) , discovered in 1993, is the first gene variation found to increase risk of
Alzheimer's and remains the risk gene with the greatest known impact. Having this mutation, however, does not mean that a person will develop the disease.
Source: Alzheimer’s Association

Drug Name donepezil galantamine memantine rivastigmine tacrine
Brand Name Approved For FDA Approved
Aricept All stages 1996
Razadyne
Namenda
Exelon
Cognex
Mild to moderate
Moderate to severe
Mild to moderate
Mild to moderate
2001
2003
2000
1993
Source: Alzheimer’s Association

Source: Alzheimer’s Association

Cholinesterase inhibitors
• Slowing down the disease activity that breaks down a key neurotransmitter
• Donepezil, galantamine, rivastigmine and tacrine are cholinesterase inhibitors
Source: Alzheimer’s Association

Memantine
• NMDA (N-methyl-D-aspartate) receptor antagonist
• Works by regulating the activity of glutamate, a chemical messenger involved in learning and memory
• Protects brain cells against excess glutamate, a chemical messenger released in large amounts by cells damaged by Alzheimer's disease and other neurological disorders
Source: Alzheimer’s Association

VIDEO:
ADVANCES IN BRAIN
DAMAGE
Instructors: Click on the link to the movie to begin.
The movie will open in Media player. Double click on the playing video to make it full-screen.
When movie is complete, hit escape. Then, close Media player to return to PowerPoint.
Source: Alzheimer’s Association

• Brain Atrophy Linked With Cognitive Decline in
Diabetes
• Mediterranean Diet Is Good for the Mind, Research
Confirms
•
Alzheimer’s risk raised by high blood sugar, even for those without diabetes
•
Exercise May Be the Best Medicine for Alzheimer‘s
Disease

VIDEO:
THE BENEFIT OF DIET AND
EXERCISE IN ALZHEIMER’S
Instructors: Click on the link to the movie to begin.
The movie will open in Media player. Double click on the playing video to make it full-screen.
When movie is complete, hit escape. Then, close Media player to return to PowerPoint.
Source: Alzheimer’s Association

• Behavior management
• Communication
• Wandering and elopement
• Co-morbidities
• Changes in condition
•
Tips and tricks…

• Can be one of the most challenging aspects of caring for residents with dementia
• The key is to have an established management technique
• Behaviors are not resolved, they are managed.
• Caregivers will find caring for residents with dementia less stressful if they accept that difficult, and even bizarre behaviors are a normal part of the illness

1.
2.
3.
4.
5.
Try not to take behaviors personally
Remain patient and calm
Explore pain as a trigger
Don't argue or try to convince
Accept behaviors as a reality of the disease and try to work through it
•
Source: Alzheimer’s Association

• Step 1: Is the behavior a problem?
• Step 2: What is the problem?
• Step 3: Who, when and where?
• Step 4: Why?
• Step 5: How will you manage the behavior?
• Step 6: Reassessment

• A behavior is not a problem unless it negatively affects the resident with the behavior or other residents
• If a behavior does not negatively affect the resident or other residents, management of the behavior is not necessary

• Specifically identify what the problem behavior is

• Identify with whom the problem behavior occurs, when it occurs, and where it occurs
• This can identify specific triggers that may be causing the problem behaviors
• Such as specific times of day, specific residents or staff, or specific places or situations

• This step can be difficult but attempt to identify why the problem behavior occurs
• If a specific reason for the behavior cannot be identified, it can be related to a symptom of dementia

STEP 5: HOW WILL YOU MANAGE THE BEHAVIOR?
• This step must be done as a team effort
• All members of the staff and caregivers in your community can contribute
• Remember, problem behaviors in dementia are managed, not resolved

• It is vital that the problem behavior is regularly reassessed
• Is it getting better?
• Has it become worse?
• Should your management solution be changed or updated?
• Establish a regular time frame for reassessments, such as; every day, every week, etc.

• Pain
• Frustration
• Demoralizing or infantilizing approach
• Misunderstanding a request
• Fatigue
• Communication barriers
• Inability to perform a task
• Inability to express needs
• Rapid change in the environment

• Be patient and supportive
• Offer comfort and reassurance
• Avoid criticizing or correcting
• Avoid arguing
• Offer a guess
• Encourage unspoken communication
• Limit distractions
• Focus on feelings, not facts
•
Source: Alzheimer’s Association

• Try to identify the immediate cause
• Rule out pain as a source of stress
• Focus on feelings, not the facts
• Don't get upset
• Limit distractions
• Try a relaxing activity
• Shift the focus to another activity
• Decrease level of danger
• Avoid using restraint or force
•
Source: Alzheimer’s Association

• Keep the home well lit in the evening
• Make a comfortable and safe sleep environment
• Maintain a schedule
• Avoid stimulants and big dinners
• Plan more active days
• Try to identify triggers
•
Source: Alzheimer’s Association

• Carry out daily activities
• Identify the most likely times of day that wandering may occur
• Reassure the person if he or he feels lost, abandoned or disoriented
• Ensure all basic needs are met
• Avoid busy places that are confusing and can cause disorientation
• Place locks out of the line of sight
• Camouflage doors and door knobs
• Use devices that signal when a door or window is opened
• Provide supervision
• Keep car keys out of sight
•
Source: Alzheimer’s Association

• Ensure safety of residents and staff
• Resident rights
• Ability to consent
• Communicate with family
• Relocate if needed

• Dysphagia: Occurs when there is a problem with any part of the swallowing process.
• Aspiration: Occurs when liquids or solids are breathed into the respiratory system instead of properly being swallowed into the stomach.

• Choking on foods, liquids or medication
• Coughing during or after eating
• Wet sounding voice
• Extra effort to chew or swallow
•
“Pocketing” food

• Have resident sit upright when eating.
•
Tilt the resident’s head slightly forward when eating.
• Ensure the resident remains sitting or standing upright for at least 15-20 minutes after finishing a meal.
• Minimize distractions in dining area.

• Do not encourage residents to talk until he/she has swallowed his/her food.
• Cut food into small pieces.
• Encourage swallowing more than once after each bite or drink.
• Modified diets if physician ordered.
• Request a speech therapy evaluation from the physician to evaluate swallowing.

•
•
•
•
Thick liquids
Soft foods
Pureed
Minced, ground and chopped

• Poor nutrition
• Dehydration
• Lack of ability to ambulate or move about easily
• Inability to turn in bed or from side to side in chair
• Decreased sensation
• Poor circulation
• Shearing
• Loss of bladder and/or bowel control
• Decreased activity
• Poor cognitive function

• Meticulous incontinence care
• Adequate hydration and nutrition
• Turn and reposition minimally every 2 hours
• Hydrate skin with topical application of lotions/creams
• Utilization of a barrier cream/ointment for incontinence

• More than 1/3 of adults 65 and older fall each year in the US.
• Men are more likely to die from a fall. However, women are 67% more likely than men to have a nonfatal fall injury.
• When an older adult falls, the effects go beyond physical injury.

Resident
• Effects of medications
• Eyesight problems
• Hip, leg and foot disorders
• Disease and illness
Environment
• Elevated Bed Heights
• Low-seated chairs
• Poor lighting
• Slippery floors or nonsecured rugs
• Clutter
• Poorly maintained ambulatory aides

• Condition of resident
• Medications
• History of falls
• Gait and balance
• Ambulatory aide assessment
• Medical history
• Evaluation by physical therapist

• Remind resident to request assistance as needed.
• Ensure all pathways are free from obstacles.
• Provide adequate lighting.
• Provide appropriate chairs with arms that are solid and secure.

• Remind resident to request assistance as needed.
• Ensure all pathways are free from obstacles.
• Provide adequate lighting.
• Provide appropriate chairs with arms that are solid and secure.
• Observe environment for potentially unsafe conditions.
•
Identify residents who are “at risk” for falling and implement specific fall risk reduction strategies for that resident

• Physical aggression
• Physical symptoms, non-aggressive
• Verbal aggression
• Verbal symptoms, non-aggressive
• Social withdrawal
• Depression
• Source: www.interact2.net

• New symptoms or signs of increased confusion
(e.g. disorientation, change in speech)
• Decreased level of consciousness
• Inability to perform usual activities (due to mental status change)
• New or worsened physical and/or verbal agitation
• New or worsened delusions or hallucinations
• Source: www.interact2.net

• Physician
• Family
• Licensing agency
• Your staff

• Indicated for persons with mental illness (e.g. schizophrenia, bipolar, etc.)
• Primarily used to manage psychosis
• Delusions
• Hallucinations

Traditional
• Haldol
• Thorazine
• Mellaril
• Serentil
Atypical
• Zyprexa
• Risperdal
• Seroquel
• Geodon

Associated with significant side effects
• Extrapyramidal effects
• Tardive dykinesia
• Hypotension
• Lethargy

Risk of Death
• Increased risk of death when used for residents with dementia
• FDA: 1.6 - 1.7 times increase in death rates
• Specific causes of death showed that most were due to heart related events or infections (e.g., pneumonia)

1) Work with the physician/prescriber
•
Don’t just ask the doctor for a prescription
• Ask him/her for alternative solutions to manage the issue
•
Don’t be afraid to advocate for your resident

2) Focus on Resident-Centered Care
• Use alternative interventions
• Physical activity
• Increased engagement
• Creating calm environments
• Identifying behavioral triggers
• Reminiscence therapy

3) Educate your staff
• Direct care staff, med aides, and nurses
• Dangers of overuse
• How to avoid it
• Address burnout and caregiver stress

4) Track and trend
• Quality improvement efforts
• Track and trend usage among your residents
• Establish realistic goals for reduction
• NCAL: Reduce off-label use of antipsychotics by
15 percent

www.ncal.org

Incidence
• % of residents who have an antipsychotic drug initiated for an off-label use within the first 90 days in your community

Incidence
# of residents with antipsychotic drug use indicated on medical records over the first 90 days
# of residents who have been at AL for 90 days or less

Prevalence
• % of residents with off-label use of an antipsychotic drug

Prevalence
# of residents (over 90 days) with antipsychotic drug use indicated on medical records
# of residents (over 90 days)

Exclusions: FDA Approved Uses
• Schizophrenia
• Bipolar disorder
• Major depressive disorder
•
Tourette’s disorder
• Irritability associated with autistic disorder
• Treatment of resistant depression

Which of the following is a good intervention for a resident with Dementia?
a) b) c) d)
3-5 medication prescriptions
Atkins diet
Regular exercise
Isolation

Which of the following is a good intervention for a resident with Dementia?
a) b) c) d)
3-5 medication prescriptions
Atkins diet
Regular exercise
Isolation

A swallowing disorder is NOT considered a comorbidity when experienced by a person with
Dementia.
a) b)
True
False

A swallowing disorder is NOT considered a comorbidity when experienced by a person with
Dementia.
a) b)
True
False

High blood pressure increases the risk of
Alzheimer’s disease.
a) b)
True
False

High blood pressure increases the risk of
Alzheimer’s disease.
a) b)
True
False

When redirecting a resident who is wandering, you should never: a) b) c) d)
Attempt change of face
Argue with or pull the resident
Allow them to wander in a safe area
All of the above

When redirecting a resident who is wandering, you should never: a) d)
Attempt change of face b)
Argue with or pull the resident c)
Allow them to wander in a safe area
All of the above

When conducting a pre-admission appraisal, it is best to: a.
b.
c.
d.
Not allow the resident to answer questions, as they are not a reliable source of information
Interview only the resident, as they are the person you will care for
Interview both the family members and the resident
All of the above

When conducting a pre-admission appraisal, it is best to: a.
b.
c.
d.
Not allow the resident to answer questions, as they are not a reliable source of information
Interview only the resident, as they are the person you will care for
Interview both the family members and the resident
All of the above

Studies how that a history of diabetes has no impact on the likelihood of developing dementia.
a.
b.
True
False

Studies how that a history of diabetes has no impact on the likelihood of developing dementia.
a.
b.
True
False

Alzheimer’s disease is the ______ leading cause of death in the United States a.
b.
c.
d.
1 st
3 rd
5 th
6 th

Alzheimer’s disease is the ______ leading cause of death in the United States a.
b.
c.
d.
1 st
3 rd
5 th
6 th

A lack of which of the following neurotransmitters is associated with Alzheimer’s disease?
a.
b.
c.
d.
Acetylcholine
Endorphins
Dopamine
Serotonin

A lack of which of the following neurotransmitters is associated with Alzheimer’s disease?
a.
b.
c.
d.
Acetylcholine
Endorphins
Dopamine
Serotonin

The main difference between delirium and dementia is that delirium is a chronic problem that develops slowly over time.
a.
b.
True
False

The main difference between delirium and dementia is that delirium is a chronic problem that develops slowly over time.
a.
b.
True
False

Which of the following are effective methods to reduce off-label use of antipsychotic medications?
a.
b.
c.
d.
Work with the physician
Educate staff
Track and trend
All of the above

Which of the following are effective methods to reduce off-label use of antipsychotic medications?
a.
b.
c.
d.
Work with the physician
Educate staff
Track and trend
All of the above

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