 This episode was prerecorded as part of a live continuing education webinar. On-demand CEUs are still available for this presentation through All CEUs. Register at allceus.com slash counselor toolbox. I'd like to welcome everybody to today's presentation. This is the third in a three-part series working with older adults. Today we're going to be talking about sort of differential diagnosis of Alzheimer's and dementia. Remembering that we as mental health clinicians a lot of times are in a place to identify potential problems, but a lot of times older adults or anyone struggling with something that's causing cognitive decline will also need to be evaluated and the official diagnosis will come from their medical doctor. So we're going to explore symptoms of cognitive impairment in Alzheimer's and dementias. We'll review the APA treatment guidelines for counselors working with persons with Alzheimer's and talk about how to handle some difficult behaviors. So when we're talking about cognitive impairment, that is a really broad category. Patients with dementia display a broad range of cognitive impairments, behavioral symptoms, and mood changes. And not all cognitive impairment rises to the level, if you will, of dementia. So it was important to, again, remember that if there seems to be some cognitive impairment, we need to take a look at what's going on. Is the person under the influence, are they, and I think we'll get to this in a minute, is their blood sugar too low? If they have undiagnosed or uncontrolled diabetes, sometimes if their blood sugar gets really low, they may become, have some difficulty with cognitive impairment. So the development of multiple cognitive deficits needs to be evaluated by both memory impairment, so impaired ability to learn new information or recall previously learned information. And, you know, stuff, my kids are homeschooled and my daughter is working on Algebra 2 right now. Oh my gosh, I didn't do well in Algebra 2 when I took it in high school. I haven't taken it in 30 years or something. So it's something that I don't even remember. So yeah, I don't have a memory impairment. I just didn't commit that to memory. But we want to look at previously learned information, stuff that the person did know before, like how to drive or, you know, some tasks like cooking or something that may indicate that there's been some sort of cognitive change and or an impaired ability to learn new information. So you seem to be going over the same stuff over and over again. Now, again, I want to caution people that sometimes people don't learn new information because it's being presented in a way that doesn't fit, you know, not everybody. And I'm one of them, you know, I say kudos to y'all for being able to listen to a webinar and really glean a bunch from it. I learn a lot more if I read. So, you know, if I listen to a webinar once, I'm probably not going to learn a bunch. I'm probably going to have to listen to it multiple times in order to really digest all that information. That's why I don't like conferences so much because a lot of times, conferences is just a lecture at you that's not interactive. It's not application groups and breakout things. So I have a hard time translating that knowledge into anything useful. So we want to look at is the person having difficulty learning new information because of the way it's presented or because of the information, or are they just having difficulty learning. Now, we also have to remember that there are certain things that people are going, or may have difficulty kind of wrapping their head around. My mother, you know, God lover, really does not like technology. You know, she's not that old, but you know, she grew up long before computers were ever invented. So this whole tablets and wireless internet and everything and TVs with multiple remote controls kind of freaks her out. And she still has difficulty figuring out how to change inputs on the TV. It's just one of those, we call it a mental block she has. It's not that she can't learn new information. She learns new stuff all the time. But there are certain categories of information that for some reason her brain just does not want to wrap around. So we don't want to pathologize something that may just be sort of a cultural, if you will, challenge. You know, something somebody's not been exposed to before. One or more of the following cognitive disturbances also has to be present if we're going to be diagnosing dementia. Aphasia or language disturbance. Apraxia inability to carry out motor activities despite intact motor function like brushing your teeth or catching a ball as well as they could catch a ball. You know, it's another one of those things. You want to individualize what you're looking at. I can catch a beach ball. If you throw a tennis ball my way. Yeah, it's about a 20% chance I'll catch it. Aphasia or failure to recognize or identify objects despite intact sensory function. So somebody can see me holding up my eyeglasses, but they may not be able to identify or recognize what they are. And that's a common object or a fork or something that they should know what it is, but they're not able to recognize it. They're like, what is that? And disturbance and executive functioning, planning, organizing, sequencing, abstracting. You know, this is kind of the general stuff. You know, what do you have to do to get ready when my grandfather was getting older and he didn't have Alzheimer's or anything, but he was gosh, 78, I think. When he started having difficulty with some executive functioning. My father would show up to pick him up for lunch and he'd walk outside and in his socks, he'd forget that he needed to put on shoes in order to go to a restaurant. You know, it wasn't that he wasn't ready. He just forgot that shoes were necessary. So you want to look at some of those things, something that somebody previously knew and was something that they did regularly. Have they forgotten how to do it now or does it not make sense to them now? And again, you know, as we said in the other presentations and we're going to continue to say, don't assume that it's normal aging. Don't assume that it's going to get worse. You want to, if you see something a little bit wonky, let's have it evaluated to figure out if there's something that needs to be treated. Or if there are preventative or early intervention steps we can take to slow the cognitive decline. Other symptoms of cognitive impairment include problems with attention. You know, they're with you for one second and then they're off and la la land the next and you can't hold their attention no matter what. I mean, boring discussion aside, you know, nothing really holds their attention. They bounce around, you know, can't watch a television show. Their perception may be changing. Their perceptive abilities may change. Inside and judgment, you know, what's the right thing to do? What's helpful? What do you need to do to plan to get ready for this? Or do you need to go to sleep? Or you know, if you're sick, do you need to go to the doctor? My grandmother, bless her heart, you know, when she would get sick, she wouldn't want to bother anybody. So she wouldn't call. And there was one time that her illness got so bad that both ears were completely clogged and she couldn't hear anything. And but she couldn't, so she couldn't call anybody on the phone to go, hey, I need to go to the doctor. And nobody could reach her. So eventually my uncle went over there to check in on her and she's like, oh, I'm so sick. And so her judgment wasn't really on par because she could have walked outside over to her neighbors over to Mr. Manny's house. And probably had him make the phone call. So, you know, that was kind of the indication of, you know, maybe there might be something going on with her. Organization. You know, I am not the most organized person in the world. But if they're having difficulty with basic organizational skills, you know, putting their clothes away, things like that. And it's not something they used to have a problem with. Pay attention to that. Their orientation to person, place, time, you know, your general mental health evaluation, their processing speed. Now, remember, we said that processing speed as people get older is going to tend to slow down a little bit. But we shouldn't see huge jumps in declines and processing speed. And you shouldn't expect somebody to be super slow. That's not normal aging. So we want to look at, you know, what's going on with this person. If their processing speed is slow, you know, they may not realize that they've got some hearing impairment going on. And then my grandmother again, she's always been deaf in one ear. And as she got older, she started losing hearing even when she wasn't sick in the other ear. And she didn't really realize it. And then after we were able to get her some hearing aids, convince her to go to the doctor to get hearing aids. She was like, Oh, wow, it's amazing how much more I can hear. And then when my kids would talk to her on the phone and stuff, instead of them saying something to her and her saying something back that may completely, completely no sense. It was like, I have no idea what you're talking about, grandma. They were on the same level because she was trying to interpret before kind of like trying to hear somebody when you're underwater and figure out what they're saying and respond to them. So, you know, if their problem solving or their processing speed is not what it should be, we want to look and see are there sensory things going on, not cognitive, but sensory things going on that are keeping them from being able to take in and understand the information. If their reasoning gets poor, you know, take a look at that if you notice a marked change and we're really looking in terms of somebody's ability to live happy, healthy and independently. You know, you may not agree with their reasoning, but if it's done in a way, you know, if whatever their reasoning or thought processes are is safe and healthy and whatever, then really none of our business. And metacognition or processes used to plan, monitor and assess one's understanding of performance so they can, you know, look back and say this was a good day. I did a lot of stuff today and monitor how much they accomplished. You know, you're really going to notice differences between people with cognitive symptoms because they're going to have differences in their impairments in the different areas. You want to look for prominent memory symptoms, which include all of the following. Whoops, I didn't mean to include except. Difficulty learning new material. They may lose valuables or forget food cooking on the stove. They may forget previously learned material, including the names of loved ones, or have difficulty with spatial tasks such as navigating around the house or in the immediate neighborhood. So those are all things that you want to pay attention to if somebody has prominent memory symptoms. You know, that should be a clue that they need to be evaluated. If there's agitation within the context of dementia, agitation is an umbrella term that can refer to a range of behavioral disturbances, including aggression, competitiveness, hyperactivity, and just plain old disinhibition. You know, they're willing to tell you exactly what they think about it. So we want agitation doesn't necessarily mean being irritable and agitated. There's a range of behaviors and things that this describes individuals with questionable cognitive impairment have borderline functioning in several areas, but definite impairment in none. So it's those. This is one of those people who's obviously questionable if we were still doing the old five axis diagnosis you would do a rule out here for cognitive impairment. Because there's nothing that quite rises to the level of diagnostic criteria. Such individuals are not considered demented hate that term, but they should be evaluated over time. So what causes cognitive impairment. And this is really important for us to pay attention to because we can identify symptoms of cognitive impairment in younger people as well as older people. Vascular dementia from stroke stroke can be caused by high blood pressure. It can be caused by anything that cuts off blood supply to the brain, whether it's, you know, autoerotic asphyxiation or overdose on system depressants where kind of the heart stops beating or is beating so slowly that enough oxygen is not getting up there. Any of anything that impedes blood flow to the brain, it can also be caused by severe head injuries that may cause like a blood clot or something. So you want to kind of be aware. Alzheimer's, you know, that's the first thing people default to when you see an older person starting to have cognitive impairment issues, but it's not, you know, that's not necessarily the diagnosis we're looking at. It's actually probably not nearly as likely as some of these others. And the strokes can also cause, well, I already mentioned, vascular dementia and people can have a lot of mini strokes and not realize it. Sometimes when you think of strokes you think of somebody who had a major incident and half their bodies paralyzed or something. But mini strokes, especially multiple mini strokes can be just as harmful, cognitively speaking. If they have brain injury from a fall, it could cause cognitive impairment. It could actually injure parts of the brain. And we know that people who are older may tend to get hypotensive or get dizzy easier and fall more. Primary or secondary brain tumor, you know, it's a possibility. Is it probable? No, but it's a possibility. Endocrine conditions such as hypothyroidism. Thyroid gets too low, things get a little bit wonky. Maybe the blood's, the heart's not pumping as much as it should because the person is hypothyroid. That means they're slowed way down. Hypercalcemia and hypoglycemia. And hypercalcemia is too much calcium. And hypoglycemia is too little blood sugar. So that's what we're talking about with diabetes. Nice thing, hypothyroidism, hypocalcemia and hypoglycemia are almost always like 100% treatable. So it's another reason we want to make sure, you know, we don't assume that this is just grandma's lot in life. Nutritional conditions. A deficiency of thiamine, niacin, or vitamin V12 can cause cognitive impairment. So if your older adult client is not eating well or has, you know, the flu or something for a long period of weeks, probably not going to do anything. But, you know, pay attention to this. And as we talked about before, if somebody rapidly detoxes from alcohol and they've been drinking, you know, pretty consistently, it can cause a deficiency in thiamine and cause cognitive impairment. This is usually reversible when it's because of alcohol withdrawal. But it has to be done immediately. The person has to get a shot of, I believe, thiamine in order to reverse the problem, otherwise it can become permanent. So another reason we want to be alert. Infectious conditions such as HIV. If you're working with a client who's HIV positive, be aware that cognitive impairment may become a symptom. Neurocephalus or cryptococcus. I always say, you know, if somebody presents in my office, I want to know that they've had a physical and lab work done, you know, preferably within six months or, you know, if the symptoms just recently started, you know, the last two or three months, it would be nice if they would go and get some of that stuff evaluated so we can make sure that there's no underlying physiological cause that could be easily treatable. Problems with renal, kidney, and hepatic liver functioning also can cause cognitive impairment. Your kidneys and your liver get all the toxins out of your body. So if they're not working well, then toxic levels of stuff can build up, whether it's medications or other stuff and can cause cognitive impairment. Effects of medications such as benzodiazepines, barbiturates, and alcohol can cause cognitive impairment. And the toxic effect of long standing substance abuse. If you've ever worked with anybody or seen anybody who's been using methamphetamine, people who huff paint. Those are, those are two very stark examples of the toxic effects of long standing substance abuse on the brain. Paint can do some really wicked stuff. And you see in some people who are really heavy chronic users of marijuana that they may have some cognitive changes as well. So we look at mild or major neurocognitive disorders due to Alzheimer's. And this is the one, like I said, everybody just automatically says, oh my gosh, we need to worry about this. Criteria adapted from the National Institute of Neurological and Communicative Disorders and Stroke and Alzheimer's Disease and Related Disorders Association include, the person has to have dementia, which is established by examination and objective testing. So we're not just going to say, oh yeah, you got some cognitive stuff going on, but it's Alzheimer's. No, there's stuff that we need to do that's objective. They will likely do a scan to look for Lewy bodies in the brain. You know, there are things they're going to do. Deficits in two or more cognitive areas. Progressive worsening of memory and other cognitive functions. No disturbance in consciousness through all this. So they're not passing out, which would indicate maybe they're having many strokes. And the onset can be between ages 40 and 90. So we want to, you know, widen our scope and not just say, well Alzheimer's only hits people who are, you know, retirement age. No, it can hit or can be diagnosed when you're 40 or so. And, you know, a good point one of you makes that those who suffer from dementia or Alzheimer's may exhibit aggressive behaviors, but others don't. You know, not everybody who becomes, has a cognitive impairment is going to behave aggressively. And they may not all disinhibit. So we don't want to assume any of these criteria really are true for all people, which is, again, if you see something that seems off with a patient, a colleague, you know, a friend, family member, it's good to have a full assessment done by somebody. Some individuals may show personality changes or increased irritability in the early stages, but not all. My uncle was passive is all get out in the early stages. It wasn't until he got into the very late stages that he became somewhat combative. In the middle and later stages of the disease, psychotic symptoms are common. So remember, we want to rule out late onset schizophrenia. Psychotic symptoms are common and patients may develop incontinence and gait and motor disturbances, eventually becoming mute and bedridden. We know that Alzheimer's is going to have a progressive effect on the brain. And we know that eventually becoming mute and bedridden is probably going to happen. But how the course of it from beginning to end is so different for every person that we don't want to assume we want to prepare and support the family as much as possible. Parkinson's is another problem that can have cognitive impairment associated with it. And it's obviously different than Alzheimer's disease. It has an insidious onset and it's slowly progressive. The person may have tremor, rigidity or myoclonus, which is a sudden involuntary jerking of a muscle or group of muscles. And, you know, I have talked over the past few days about how my grandfather developed Parkinson's disease. And it was very slow onset at first. At first he thought he had just had too much coffee. And then he was like, well, maybe, you know, the shaking is just part of aging or, you know, he kept looking for other explanations until it started being persistent. And much more than just not being able to focus on something that was minuscule, but having difficulty holding his coffee cup. Onset is typically in middle to late life and is accompanied by motoric slowing. So it's harder to do things because the muscles and nerves aren't talking as well. Executive dysfunction and impairment in memory retrieval. So, again, just like with any other diagnosis we make, the DSM gives us this laundry list of symptoms. Not everybody's going to have every symptom. The key that you're really looking at in Parkinson's is your tremor and rigidity. If you start seeing that in somebody or they're complaining about that, we want to look for side effects of medications. Yes, they probably should have a blood workup at their physician because when your blood sugar gets really low, you can get the shake some. So let's rule out some easy stuff. But then there are other things that the physician can do or the neurologist can do to help figure out what you're dealing with. Now, one thing that we don't talk about a lot is pseudo dementia. It's a condition that occurs within the context of major depressive disorder. So if somebody is really, really depressed, hence major depressive disorder, it's not uncommon to see problems with attention, perception, insight and judgment, organization, orientation, problem solving and processing speed. You know, I would expect that in any adult that is experiencing really major depressive episode. So we do want to be aware of that. And in the older population and among the American Psychiatric Association guideline, this is sometimes referred to as pseudo dementia. So just being aware of that if you see it in a clinical record. Bascular dementia comes on because of one or more strokes which can impair cognitive function. You may have people have an extensor planter response, pseudo-bulbular policy, gait abnormalities, exaggeration of deep tendon reflexes and weakness of an extremity. Why am I going through all these? Because we're not going to test these. This is not our ball game. But if we're working with a client who's talking about they've had sudden weakness, they can't pick things up like they used to, we notice they've got gait abnormalities. They're shuffling or hiccuping when they walk a little bit. And especially if we also notice that there are cognitive disturbances, then we're going to start being concerned about some sort of dementia, possibly vascular dementia. The mode of onset, subsequent course and reversibility of dementia depends on the underlying etiology. Some you can't reverse. It's just not the way it's. You may be able to slow it down a little bit. A lot of medications and treatments have come out even for Alzheimer's over the past 15 years. But you're not going to reverse it. Some of them you can arrest and reverse like the dementia brought on from alcohol withdrawal. Cognitive deficits in delirium often fluctuate. So be aware of that. Somebody may have a good moment. They may be lucid for a little bit and then not so much. Cognitive deficits in dementia are stable or progressed. They don't get better. So it could help you identify whether you're dealing more with delirium or dementia. Cognitive deficits in schizophrenia usually occur with other psychotic features. So we've got delirium, we've got dementia, and then we've got, oh, that late onset schizophrenia. Well, could it be schizophrenia or Alzheimer's psychotic symptoms? And you want to look at the history of the person, the family history of the person, and the psychiatrist is going to probably rule out or rule in schizophrenia. Recommended assessments include evaluation of suicidality, dangerousness to self and others, and the potential for aggression, as well as the evaluation of living conditions, safety of the environment, adequacy of supervision, and evidence of neglect or abuse. So, you know, the first ones are kind of obvious. We do those a lot anyway. But when we're working with somebody who is an older adult who may be starting to have difficulty living independently, then we need to start looking at, is it safe for them at home? What are their living conditions like? How safe are they? Who helps them take their medicines, et cetera. And work with the family with a release of information, obviously, to develop a comprehensive care plan. So we know that somebody is checking in on mom or grandma or whatever. Screening, the 88 or mini cog are among many possible tools you can use. Patients should be screened for cognitive impairment. If the person's family members or others express concerns about changes in his or her memory or thinking, you observe problems or changes in the patient's memory or thinking. The patient is 80 or older. The person has low educational attainment. So, you know, what does educational attainment have to do with it? Well, we want to look at why did they have low educational attainment? You know, they may have a low IQ. They may have FASD or, you know, which prevented them from achieving what they needed to do, which would rule out or lessen the concern about cognitive impairment now. Maybe they never were as perceptive as people with a higher IQ, for example. If there's a history of type 2 diabetes, now that one was new to me. Stroke, history of stroke in the person, even suspected stroke, a history of depression. We want to take a look at that. Trouble managing money or medications. And if the person is having episodes of delirium where they're either confused or disoriented about what's going on. Episodes of delirium may get more frequent in people as they get older, but it doesn't necessarily mean that that's normal. And I'm talking, you know, in their 80s or older, where people wake up and there takes a minute to get oriented to person in place. Delirium usually lasts longer than just a minute. So if the person is agitated for, you know, several minutes, it's something to be concerned enough to have an evaluation done. Demographic and social factors may impact the course of treatment and include age. You know, the person who is 40 is going to have a different treatment plan than the person who is 70 when they're diagnosed with Alzheimer's or Parkinson's disease. Their gender, because medications respond differently to the different genders. Social support. Some people may be able to live independently longer if they've got good social support. Whereas, you know, if they don't, then they may have to go into inpatient care sooner. Their resource availability, not just social support, but transportation, can they get to and from the doctor? Can they get out to get their medications? Can they, you know, is somebody able to drive them to get their food or whatever is needed? And their ethnic background, not every person wants to be treated in the same way. Not every person sees treatment or sees interventions that we may use as acceptable. So we want to talk with them about what their preferences are for treatment. Some people prefer to use more spiritual and faith healing and culturally identified healing practices. Whereas other people may go straight for the hardcore Western medicine interventions. So we want to talk with them about what works for them and what is culturally sensitive. Counselor goals. You've been waiting for this. Establish and maintain an alignment with the patient and family. You know, if we don't have an alliance, we're not going to be able to really help them very much. So let's just put it all out there and go, all right, let's figure out how we can work together to the best of everybody's. Ability. Perform a diagnostic evaluation and refer the patient for any needed general medical care. And any other services that you may need to refer out for. Assess and monitor psychiatric status for the presence of noncognitive psychiatric symptoms, i.e. mood disorders, and the progression of cognitive symptoms. So this is something that we can do. The local area agency on aging may be able to link you up with an agency that can provide case management services because I know a lot of us can't bill for case management. We can only bill for counseling services or certain things. So, you know, look at what resources are available in your community. Assess and educate the patient and family about future symptoms and the care likely to be required. So is this likely to progress? If so, how fast, what kind of care are you looking at? You know, is there going to be a time that this person has to go into inpatient treatment? Help patients and their families think about financial and legal issues due to the patient's incapacity. Now, you're going to help them think about it and, you know, realize that they probably need to start taking steps, but it's going to be up to them to figure out what kind of financial and legal steps they want to take. Help patients and their families think up, educate the patient and family about the illness, its treatment, and available sources of care and support. When people first get this diagnosis, whatever the diagnosis is. Dementia, Parkinson's, Alzheimer's, it's probably a kick in the gut. They're probably going to be in a crisis denial sort of place. So the information we give needs to be written down. It needs to be short and to the point. You know, this is not the time to overwhelm them with stuff unless they want to be overwhelmed, but we'll get there in a minute. And be prepared to repeat it. You know, if you can have the resources available on your website or links to resources on your website so they can go back and reread the same documents when they're in a better place mentally, that can be really, really helpful. Some people on the other hand want to be completely immersed in it, which is another reason if you have a page on your website dedicated to Alzheimer's resources or something, or you know of a resource, then you can refer people to that resource so they can digest it at their own pace. We want to monitor safety and intervene when required. So if the person, you know, my grandmother was a perfect example, she did not want to go into long term care, but it got to the point where she was not safe being at home for 24 hours by herself. And so at a certain point, the doctor had to stand up and say, you know, y'all, she needs, she needs to go to an assisted living facility. This is not safe for her anymore. So it's going to be up to the professionals sometimes to advocate because the, in this case, the kids, my mother and her brother felt guilty because we knew Grandma didn't want to do that. And Grandma didn't want to do that. So everybody was trying to avoid and figure out how they could work around it. And finally the psychiatrist just said, there's no way around it. It's the only safe option is inpatient at this point. And, you know, eventually, you know, we were able to all work together and move through that. But it's important to let the patient know what's going on and intervene. Don't be afraid to say something. Improve their quality of life. You know, if somebody's in inpatient care and they want to do a particular activity or if they're living at home and they want something, you know, help them figure out how they can have their highest best quality of life as they define it. You know, that's great problem solving and it helps them and it keeps them engaged. Maximize function in the context of existing deficits. So, you know, maybe they're not able to do to cook as much anymore, but we want to maximize function in the other areas of their life. And then if they can't cook anymore, you know, make sure they have resources so they can make something besides cereal, which is really boring after a while. And it's not super nutritious. So, you know, help them figure out how to maximize their quality of life, given the deficits that they've got. And we want to help them improve cognitive skills, mood and behavior whenever possible. As I said, a lot of times if you get people engaged in something and get their brain working again, it can help slow at least slow down the progression. The mood can improve if they have more social interaction, if they feel like they're making progress or at least not getting worse. You know, so there are a lot of things that we can do that may seem like case management. But if we're helping the person to move towards a happy, fully actualized life as good as they can have it, then, you know, that's where we need to go. Goals for treatment. It was asked, is it possible that as treatment goes along that the client may want to change it later as their dementia gets worse? Yes. And that's where the multidisciplinary team comes in. You know, as a person's dementia gets worse, they may start having ideas that are contrary to their own wellness. And that's generally where the physician is really good about putting down their foot or whatever. But yeah, I mean, people want to change their course and that's okay. And if something's going to make them happier, if something's going to make them more comfortable, then sure, let's do it. And we don't know how their disease is going to progress. So we may have anticipated them going into long-term care in, you know, five years and then seven years down the road, they're still living independently. You know, we're not going to necessarily strictly adhere. We're going to adjust the treatment plan to fit the course of that person's illness as it plays out. But we do want to plan ahead, you know, sort of worst possible scenarios so we don't get caught with our proverbial pants down. Side effects of psychotherapy. Now, a lot of times we talk about side effects of medications. Side effects of psychotherapy can include frustration because they're not getting it. They're having problems processing. They don't see the point. There are a lot of reasons somebody can get frustrated in psychotherapy. They may be trying to treat their depression and it's not getting any better. So we want to figure out what's causing the frustration and how can we ameliorate it. We may need to focus on solutions. We may need to focus on helping them see some of the progress that they've made. We may need to switch gears all together. You know, CBT for somebody with cognitive impairment is probably not going to be the best intervention. If they're having trouble making connections to begin with and identifying automatic beliefs, you know, that's too much. So we want to fit the treatment for the person and their stage of the disease. They may have catastrophic reactions. If you start talking about something, they may get completely disinhibited or dysregulated and start feeling like the world is ending. So, you know, being aware that that might happen, they may become agitated or depressed when they start thinking about stuff. They may start talking about stuff that's bothering them and get stuck there and feel depressed, feel hopeless. So we want to pay attention to that and try to, as we do with most clients, try to end the session on a positive note. Try to make sure that they're not walking out more agitated and more depressed. And sometimes it means not necessarily going to those difficult places if the person's not able to handle it at that point in time. You're kind of going to need to use a clinical judgment. Important aspects of psychiatric management include educating the patients and families about the illness and treatment, sources of care and support, and the need for financial and legal planning due to the patient's eventual incapacity. Now, some of the things that they're going to need to think about are power of attorney for medical and financial decisions and up-to-date will and the cost of long-term care. And that's not something that most of us as clinicians are equipped to talk about at all. So we want to refer them to, you know, United Way information and referral if they don't already have an attorney to see if there are legal resources. Go to the local area agency on aging. They generally work with attorneys who specialize in working with older adults and older adult issues. So you can identify places to refer people to so they can access the resources they need. Patients with dementia require a treatment plan that's individualized, multimodal and evolving. The frequency of their visits is going to be determined by the patient's clinical status, the likely rate of change, the current treatment plan, of course, the need for any specific monitoring of treatment effects, like if they start taking a new medication, they may need to come in more frequently, and the reliability and skill of the patient's caregivers. If you think the patient is safe only coming in once a month because the disease is not progressing too much, that's grand. But if you have concerns that you need to have a little bit more frequent follow-up, then they may have to end up coming in once a week. Behavior-oriented treatments identify the antecedents and consequences of problem behaviors and reduce the frequency of behaviors by changing the environment to alter those antecedents and consequences. Yada, yada, yada. We look around, we figure out what's agitating this person and how can we change that or what prompted this outburst and how can we address that? You know, maybe it's loud music or somebody changes the channel or it could be somebody sat in their chair. You know, whatever it is for that person, we need to figure out ways we might be able to intervene. We want to look at the stimulus that caused the behavior. And then we also want to look at the reinforcers. You know, if the person keeps doing that behavior, why do they keep doing it? Why is it beneficial? What do they get out of it and take that benefit away and redirect them to an alternate behavior that will also help meet their needs but is not considered a problem. Stimulation-oriented treatments, recreational activity, art therapy, music therapy, pet therapy, Tai Chi. There are a lot of different stimulation-oriented treatments that are designed just to get the body moving and the brain moving. Emotion-oriented treatments include supportive psychotherapy and can be employed to address issues of loss in the early stages of dementia. The person realizes what's going on and they're having to deal with a bunch. And reminiscence therapy, which has some modest research support for improvement of mood and behavior. Because a lot of times people can remember stuff from 15, 20 years ago, even if they can't remember stuff from last week. So if they think about the good times, it can help improve their mood and behavior. The keywords you want to remember in managing people with cognitive impairment is tolerate, anticipate, don't agitate. You know, tolerate within reason. Obviously we don't want to let them do something that's harmful to themselves or others. But we need to kind of give them a wide berth. If they're doing something instead of getting irritable with them right away, we want to look at what was the function of this. If somebody got up and went into their room and took all the clothes out of the closet. Okay. So you put them back and 30 minutes later, they go and do the same thing. And you could get irritated with that pretty easily. Or you can stop and go, what is the function of this behavior? You know, let's tolerate this behavior. It's they're doing something. There's a method to what they're doing. Let me figure out what that is. Maybe they're looking for something else to wear because they're too hot. Or maybe they're bored and they're just trying to figure out something to do so they're rearranging their closet. You want to talk with them about what are you hoping to accomplish. If they can't articulate that, then you may have to do some investigation. Particular concerns and long-term care is the use of physical restraints and antipsychotics. Restraint use in this population can be decreased by environmental changes that reduce the risk of falls and wandering. Careful assessment and treatment of possible causes of agitation, especially loud noises, sudden changes. Bed and chair monitors that alert nursing staff when a patient may be climbing out of bed or leaving a chair. And prompted voiding schedules throughout the day and night to decrease the urge for unsupervised trips to the bathroom. Now remember, this is obviously in inpatient treatment. Antipsychotics, benzos and anticonvulsants, trasadone, boost barone, beta blockers, most notably propanol, are used to treat agitation and psychosis. Now, if you're looking at some of these, you're like, oh my gosh, that would knock me on my butt. And, you know, if you're treating agitation, you know, treating may be sedating, whether that's the right thing or not is going to be a clinical decision. But any of these medications have been known to be used. Benzos are most useful for treating patients who are agitated because of prominent anxiety. And they perform better than placebo, but interestingly, not as well as your atypical antipsychotics. Hmm, who knew? So like, Sarah Quill, you know, thinking of those. Usually not recommended for other than brief use because of the risk of daytime sedation, tolerance, rebound insomnia, worsening cognition. So benzos can make cognition worse, disinhibition, delirium, risk of falls and worsening of sleep disorders. So people on benzos, they're going to get their circadian rhythms out of whack. They might cause hypotension, which makes them dizzy when they stand up, and worsening cognition. So you might have a whole cluster of problems because of benzos that you're thinking is cognitive impairment or cognitive decline of some sort. Not necessarily. Could be a side effect of medication. Antipsychotic medications, when overused, can lead to worsening of the dementia, over sedation, falls, and tardive dyskinesia. Older adults are more susceptible to the side effects of medications. Elderly and patients with dementia are more sensitive to certain medication side effects, including anticholinergenic effects and orthostasis. So again, that getting dizzy when you stand up. Psychostimulants, methylphenidate, basically your ADH DMEDs, if you want to kind of sum it up in something that we're using younger people, are associated with tachycardia, fast heart rate, restlessness, agitation, sleep disturbances, and appetite suppression. Now remember from the last two presentations, as sleep disturbances go up, depression symptoms often go up. So regardless of any of these medications, antipsychotics, benzos, or psychostimulants, all three of them have a potential side effect of sleep disturbances. So we want to pay attention to the client's depressive mood. SSRIs have a favorable result in treating depression, but can produce nausea and vomiting, agitation, Parkinsonian side effects, sexual dysfunction, and weight loss. Well, that's true for anybody, but we want to look at which is the lesser of two evils. Special considerations for elderly and demented populations include, 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. And elderly and demented patients are more likely to be non-compliant with treatment. So they may choose not to take medications sometimes, or they may double up here and there. So we want to be aware. So the prescribing physician is the one that's going to be doing this. But as somebody who interacts with the client more frequently, we want to be asking them, tell me about your medication. Are you having any side effects? How many did you take? You may do pill counting. That may or may not be part of your job. But you do want to pay attention to any side effects, especially once somebody either starts or recently stops a medication or has a dosage change. You want to look for any cognitive or physical new symptoms that may be coming up. Safety measures include evaluation of suicidality and the potential for violence, recommendations regarding adequate supervision, vigilance regarding neglect or abuse. Abuse is usually more obvious than neglect, but you can have financial abuse and emotional abuse that obviously don't leave any external marks. And restrictions on driving use and use of other dangerous equipment need to be considered for patients who are starting to experience cognitive decline, whether or not they're on medications. Specific psychosocial treatments for dementia can be divided into four broad groups. Behavior-oriented, emotion-oriented, cognition or thought-oriented, and stimulation-oriented. And we went over those. Basic principles of care that we need to remember and help the family remember. Keep requests and demands relatively simple and avoid overly complex tasks that might lead to frustration. Avoid confronting and deferring requests if the patient becomes angered. So, you know, you may need to just kind of back off and pick your battles. Remain calm, firm, and supportive if the patient becomes upset. Be consistent and avoid unnecessary change. Provide frequent reminders, explanations, and orientation clues. So, you know, don't forget we're going to be leaving for dinner to go to the restaurant in 30 minutes. You know, have you finished getting ready? Have you picked out the shoes that you're going to wear? Whatever you need to prompt the person with. Recognize declines in capacity and adjust your expectations appropriately. You know, as the disease progresses, the person is not going to necessarily be able to do the same things. So, we need to not hold them to that standard if they're just not capable of meeting it anymore. Bring sudden declines in function and the emergence of new symptoms to the awareness of the psychiatrist or the physician. Behavioral symptoms can be precipitated by both over and under stimulation. If they get bored, you know, just like anybody who gets bored, you can kind of tend to get into trouble. And over-stimulation can cause them to get stressed out and have other behavioral symptoms of agitation. Colonesterase inhibitors are often used to treat Alzheimer's. Just be aware of that. Vitamin E is one of those things that you might see prescribed to your clients who have cognitive impairments. So, just be aware of the medications you may see in the chart. 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. If you can help them get out and get moving and change their focus so they're not sitting there dwelling and stewing, it can help. And if you can add to that social support, then, you know, bonus. Patients with severe or persistent depressed mood with or without a full complement of neurovegetative signs should be considered to be treated for antidepressant medications. Obviously, the psychiatrist is going to make that call. For mildly impaired patients, we're going to be looking at the following for treatment planning. Patients and their families are often dealing with recognition of the illness and associated limitations. They may appreciate suggestions for how to cope with these, such as making lists for the person of things that need to be done, using a calendar, having a schedule that's posted on the door. Identify specific impairments, but highlight remaining abilities. So we can deal with these impairments this way, but let's not forget about all this stuff that this person still has going for him. Caregivers should be made aware of the availability of support groups and social agencies. Patients with moderate to severe major depression who don't respond or cannot tolerate antidepressants should be considered for ECT. Electroconvulsive therapy has been shown to be very effective with this population, and it's not the old fashioned ECT that we remember from the movies. For the moderately impaired patient, you're going to increase supervision. Families need to be advised regarding the possibility of accidents due to forgetfulness, like leaving the stove on and starting a fire or, you know, that's probably one of the most common ones. Or difficulty coping with household emergencies and wandering. So if a pipe breaks in the house and there's suddenly a flood, the person may not know what to do and the house may flood. Patients should be strongly urged not to drive. As patients dependency increases, respite care such as home health, daycare, or brief nursing home stays may be helpful. At this stage, families should begin to consider and plan for additional support at home or possible transfer to long term care facilities. Delusions and hallucinations often but not always develop in moderately impaired patients. So as the disease progresses, we can see that there are more problems with independent living. Combativeness and physical violence are often associated with frustration, misinterpretations, delusions or hallucinations. So frustration is probably one of the biggest causes of combativeness and physical violence. It's like, don't tell me that. Don't touch me or whatever. A lot of times it's not combativeness like they're trying to like beat the tar out of somebody. It's they're trying to get you away. They're angry. So, but being aware of that and educating the family about how to handle that kind of behavior. They pose a particular problem for patients cared for at home because a lot of home caregivers are not skilled at dealing with de-escalation. And hospitalization and or nursing home placement may 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. So what's prompting this? You know, is the patient really uncomfortable? You know, if they've got a bladder infection, they may start, you know, having a lot of pain, which makes them more irritable. What's going on? And if the person's not able to articulate that, then it becomes a little bit more detective work on our parts. If the symptoms do not cause undue distress to the patient or others, they're best treated with reassurance and distraction. So, you know, if the person is a little bit agitated, not sitting still, pacing around, if it's not harming anybody, you know, it may not be one of those battles that is worth the fight. Try to accommodate the behavior, not control it. If the person insists on sleeping on the floor, place a mattress on the floor to make him more comfortable. Instead of insisting, you have to sleep up in this bed. Remember that we can change our behavior or the physical environment. Changing our behavior is going to result in a change in our loved one's behavior. Because if we're frustrated, they're going to pick up on it and they're going to get frustrated. They're like, you don't understand. So if we can take a breath and go, okay, let's look at this a different way or let's react a little bit differently. We can probably change the reaction. Check with the doctor. Behavioral problems may have an underlying medical reason, such as pain or adverse side effects. So make sure to rule out the easy stuff, so to speak. Behavior has a purpose. People with dementia typically cannot tell us what they want or need. They may do something like take all the clothes out of the closet on a daily basis. And we wonder why we talked about that earlier. Always consider what the need the person might be trying to meet with their behavior. And when possible, try to accommodate them. If they're bored, try to help them find something else to do. If they want to sit in front of the sun, you know, try to help them find a sunny window instead of continually walking outside. What works today may not work tomorrow because multiple factors influence troubling behaviors. It's not just cognitive decline. There's a whole bunch of physiological emotional and cognitive stuff. In addition to environmental and social, you know, who's around that is going to influence the person's behaviors and mood. And the disease is going to progress. So we need to take each day and go, all right, you know, what worked yesterday, we can try it. But if it doesn't work today, let's not get frustrated. Let's say, all right, we need to find a new solution instead of getting fired up about it. The key to managing difficult behaviors is to be creative and flexible. Behavior is triggered. It occurs for a reason. It might be something you did or said. It could be a change in the physical environment. It could be the perfume you're wearing. The route to changing behavior is disrupting the patterns that we create. So we want to try a different approach. If you walk in like gangbusters and it stresses the patient out, well, maybe you want to try to come in a little bit differently the next time. Or instead of yelling or doing whatever, you might want to positively redirect the patient if they're getting upset and continually changing the channels. You might try to redirect them to a different activity. Sundowning can be best described as a peak period of agitation or other behavioral disturbances during the evening hours. So alerting patients, families that, you know, evening may be a little bit worse. So prepare. Challenges in home care settings include family care providers have to work at jobs outside the home. There's adverse emotional impact on caregivers and children or grandchildren because there's some stress going on. And 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. And you can identify with that. I mean, there's caring for a disabled family member. There's, this is not what I expected to be doing. There's, I can't believe that I'm losing my parent and they're going through this because this is the person I always looked up to. And now I'm having to help them bathe. There's a lot of other issues and subtle issues and boundary changes that caregivers have to deal with. Many different conditions can cause cognitive impairment. The key to managing difficult behaviors is being creative and flexible. Patients with severe or persistent depressed mood with or without a full complement of neurovegetative signs should be evaluated for treatment with antidepressant medications. Our goals are to establish and maintain an alliance, perform the evaluations and make referrals as needed, assess and monitor their psychiatric status for the presence of noncognitive symptoms and the progression of cognitive symptoms and keep in touch, keep in sync with the multidisciplinary team. 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. Help patients educate the patient and family about the illness, its treatment and available sources of care and support. Monitor safety and intervene when required. Sometimes you're going to have to stand up and be the unpopular one and improve quality of life and maximize function in the context of existing deficits. You know, you have these deficits, but what else do you have? So let's focus on the good things that you've got going, your strengths and then we'll ameliorate or mitigate the deficits as much as possible. And work to improve cognitive skills, mood and behavior to try to help the person be happy, healthy and as fulfilled as possible. The University of Kentucky offers free CEUs for nurses, social workers and CNAs for working with people with cognitive deficits. And Alzheimer's care curriculum is also available to, if you happen to work with people with Alzheimer's, it's a much more in depth presentation than what we went through here today. One of you had asked, what's the impact of diet and the research out there that I read and it wasn't addressed in the APA guideline. So, you know, I'm just going to kind of spitball because I was doing some research on when I did research on nutritional interventions. The research indicates there are there are certain nutritive supplements and certain dietary eating practices that can help stave off cognitive decline to a certain extent and that can help keep everything working a little bit better. But the research seems to be really, really mixed and really conflicted. So I would want to learn more about their process for doing the research and explore more confounds before I started, you know, necessarily referring to a nutritionist. But the physician may make a referral to a dietitian in order to make sure the person is at least eating a well rounded diet because that will certainly help. Any other questions for me today? All righty everybody have a fabulous weekend and I will see you on Tuesday. We're going to start with brief interventions, which is one of my favorites next week. Thank you.