Options For Elder Care

Is mom a little forgetful or does she have Altzheimer's Disease?

She is a little forgetful but….

“My mom repeats the same story over and over again, but she never forgets to go to Sunday services.”
“Dad misplaces things all the time but is still walking a mile every day.”
This is frequently how adult children will express their concerns that their parent could have some type of memory issue when contacting my Geriatric Case Management firm for assistance. Families seem to readily acknowledge and respond appropriately to physical illnesses but frequently fail to respond to the signs of dementia. Busy primary care practitioners (PCP) fail to recognize the early signs of cognitive decline in their 15 minute office visit, particularly as many patients conceal symptoms or deny their existence.
More than a third of people over age 70 have some form of memory loss, according to a national study by a team of researchers at Duke University Medical Center, the University of Michigan, the University of Iowa, the University of Southern California and the RAND Corporation. The group performed the first population-based study to determine the number of people who have some form of cognitive impairment, with and without dementia. These findings illustrate that nearly every family will be faced with caring for a family member that has some type of memory impairment. As a case manager we need to assist families in improving the quality of life for this growing population.
Many people mistakenly use Dementia as a synonym for Alzheimer’s disease. Dementia is an umbrella-like term that can be described as any brain syndrome that causes multiple cognitive deficits, similar as saying when someone fever and you do not know the cause. We will concentrate on the dementia's most common in the elderly.
• Alzheimer’s Disease which accounts for 50-70% of all dementia cases
• Vascular Disease, which accounts for 15-20% of dementia cases and includes anything diagnosis that disrupts blood high to the brain
• Lewy Body Disease, which accounts for up to 20% of dementia cases

                                                   Family Warning Signs of Dementia
Families need to differentiate Normal Aging from Dementia. Changes in ordinary capability and attitude among the elderly are among the best warning signals that further cognitive screening should be performed. Below is a list of signs of dementia.
• increased difficulty carrying out ordinary daily activities – initiation of getting dressed or preparing a meal from scratch
• poor or declining cognitive function
• deterioration in hygiene - no longer showering or changing clothes on a routine basis
• inability to fulfill normal responsibilities – leaving unopened mail, paying bills
• health changes - weight loss, incontinence, appetite changes, bruises suggesting a fall
• increased isolation
• loss of ordinary interest in social contacts, activities or hobbies,
• attitude changes including abuse of alcohol or drugs, reporting depression, unusual argumentativeness or suspiciousness
                                                             Diagnosing Dementia
According to the DSM-IV diagnostic criteria assessment for dementia a patient must have:
Memory Loss – inability to learn new information or to recall previously learned information
And two or more of the following:
1. Aphasia: language disturbances
2. Apraxia: motor activity impairment although intact function
3. Agnosia: failure to recognize/identify items despite intact sensory functioning
4. Disturbances in Executive Functioning: planning, organizing, sequencing, initiation of tasks
5. Inability to function in a social or occupational setting

There are many psychological tests to measure cognitive function. I use a combination of three tests as a concrete justification of the presumed diagnosis based upon observation and family history.
1. MMSE: The Mini-Mental State Exam is the most commonly used test for complaints of memory problems or when a diagnosis of dementia is being considered. It also serves as a base line for further testing. The MMSE test includes simple questions and problems in a number of areas: the time and place of the test, repeating lists of words, calculations such as spelling WORLD backwards, language use and comprehension, and basic motor skills. It is the standard test used to measure cognition. The MMSE is primarily used to determine if an older person has dementia of varying nature. I have found this test is not as accurate in assessment of the initial stages of dementia for people with a high intellectual ability.
2. CLOCK TEST: The clock test is given to pick up on memory issues that are frequently missed with the MMSE. I personally find it a more reliable instrument as it can pick up executive function abnormalities. Executive cognitive dysfunction can precede the memory disturbances of dementia. People with executive cognitive dysfunction can have a normal Mini-Mental State Examination (MMSE) score but still have severe functional limitations. The clock test is a moderately sensitive and specific adjunct for detecting executive cognitive dysfunction. Such disturbances result in difficulties with instrumental activities of daily living (e.g., bathing, dressing, cooking, shopping, driving and taking medications). They produce dissociation between volition and action; for example, patients do not lose their ability to dress but, rather, are unable to initiate these tasks or choose weather-appropriate clothes.
Executive function involves the ability to think abstractly, and to plan, initiate, sequence, monitor and stop complex behavior. People with executive dysfunction have difficulty with managing the household finances, taking their medications with reminders, cooking a meal, and performing their ADL’s independently. Detection is critical to the client’s safety and ability to remain living independently.
3. THE TRAIL MAKING TEST: The trail making test (TMT) is a short and convenient estimate of cognitive functions, principally attention and working memory. There are a part A to the test and a part B. I usually just administer the Part B in either oral or written form. The patient is asked to complete draw a line alternation between serial sequences of letters and numbers. The TMT is thought to require executive control, specifically, flexibility of thinking and greater demand for working memory.

Cognitive testing seems to provide concrete evidence to families that the person does indeed have the cognitive issues they were identifying as concerning. If the family desires further cognitive testing, I recommend a neuropsychological evaluation.

                                                               Treatment
Once the dementia is identified I work with the family to determine the best plan of care for the client.
1. Assure that medical issues such as thyroid disorders, B12 deficiency, uncontrolled hypertension, depression, are not contributing to the dementia by assuring testing has been done by the PCP to rule out these underlying medical/psychological concerns.
2. Create a supportive environment:
• Conduct a home safety evaluation that looks at environmental factors that could put the person with cognitive impairment at risk, such as poor lighting, uneven surfaces, hand rails on steps, grab rails in bathrooms, removal of dangerous/poisonous substances, heating and electrical.
• Development of a medication distribution system that will assure proper adherence to prescribed medications.
• The kitchen can be a potentially dangerous place for someone who is not able to recognize the danger of a sharp knife or a gas stove left on. Remove sharp instruments and if needed, remove the knobs to a gas oven.
• Create an environment with routine and structure as this assists in orientation and the feeling that they are safe and secure.
• Ensure that helpful information is accessible to the client. A large white board with a calendar of daily/weekly events can help reassure the person. Posting of emergency numbers or setting the phone to pre-dialed numbers is also helpful.
• Physical activity is important as it helps prevent disruptive behavior or agitation.
• Avoid excessive stimulation but not to the point of isolation. Continued mental activity including hobbies and current events should be encouraged.
3. Help with managing finances:
This is the time for the Durable POA to assume responsibility for managing the person with dementias finances. Direct debits, direct deposits of income and on-line checking helps the job of the POA not be overwhelming. The POA may want to have the mail forwarded to their address to avoid the mail getting lost or misplaced in the home of the person with dementia. It is recommended to keep a detailed record of all financial transactions completed when acting as the POA and to share this information with another family member to avoid any potential problems with family members or the person with dementia may feel people are stealing from them.
4. Outside Help:
Most persons with dementia will resist in home help as they do not have the insight into their disability. I recommend starting with a slow introduction of a medically supervised caretaker into the home that a registered nurse has developed a plan of care for the caretaker to follow. Never hire someone directly without direct supervision for a client with dementia. If the caretaker was a good match, they will develop a relationship so that the person with dementia looks forward to the visits and assistance. The caretaker can assist with personal needs, light housework, meal preparation, laundry, providing meaningful activities, taking the person out, assuring the client takes their medication as scheduled; all dependent on the individual needs of the client. Health Insurance does not cover the cost for in-home care so if the client is low income, there are entitlement programs that may pay for their services.
5. Security:
The person with dementia could wonder outside and forget to close the door, may have problems finding their way home, or lock themselves out and become confused and afraid.
• Medical Alert Bracelets can be inscribed with the diagnosis of dementia and have a number to call for emergencies
• Good to have a space set of keys at the neighbors
• Advise the local police that the person has dementia and if there is a sutable window or door which can be opened from the outside
• There are alerts which can be purchased to alarm when a door or window is being opened
• Although persons with dementia frequently cannot utilize a cell phone, it is a good device to track the wear location of a person using the Google map tool or other method.
• The alarms that require pushing a button on a necklace or arm bracelet are of little help with a person with dementia as the person does not remember how to use it.
6. Medications:
Treatment with both a cholinesterase inhibitor such as Aricept and a NMDA receptor antagonist, Namanda, has shown promising results in slowing down the loss of performance of activities of daily living.
Antipsychotics such as haloperidol, and resperidone can be used to control severe agitation in the advanced stages of dementia.
Current research is being conducted on many other dietary supplements with promising results as a memory enhancer such as adding omega 3 fatty acids and Vit B supplements.

                                                  Planning for the Future
Because dementia is usually progressive it is essential to plan for the future. Decisions determining when it is time to move out of the home to a more supportive environment needs to be made by a professional who has expertise in dementia care. This decision depends on many factors such as severity of the disease, behavioral issues, finances, home environment, family availability, and presence of other physical or psychological disorders impacting on the dementia. The final stages of dementia are one of the most difficult to manage in a home environment, especially with associated behavioral issues.
When the home is no longer a safe place for the patient with dementia or care cannot be managed effectively the next step would be to look for an assisted living that specializes in the care of those with a diagnosis of Alzheimer’s or dementia. The dementia specific units are equip to handle all the physical, environmental, behavioral and psychological issues associated with end stages of dementia using primarily behavioral measures vs. only medication management seen in other settings.
End of Life Issues need to be addressed early on when a diagnosis of Alzheimers disease or dementia is determined. Families need to determine a long range plan including how they will manage the final stages of the disease. Treatment needs to be geared towards maintaining comfort rather than prolonging life. Hospice should be consulted early on to assist in the management of this life limiting illness to provide support to the family and assure the final stages of this disease are managed with dignity for the client and family.

Barbara (Bobbi) Kolonay RN BSN MS CCM
Geriatric Care Manager
CEO Options For Elder Care
Pittsburgh PA
P: 412-443-1365
F: 724-443-6051
Web: www.optionsforeldercare.com
Professional Management of the Geriatric Client in Western PA

Health Care Reform Needed for Older Adults on Medicare in 2010

Both the House and Senate passed far-reaching health care reform bills last year, but the election of Massachusetts Republican senator Scott Brown this week makes it more difficult—but not impossible—to pass final legislation that reconciles the differences between the House and Senate bills. There are a number of procedural options for passing a health reform bill that has the support of a majority in both the House and the Senate and that President Obama would sign. What should not be an option is giving up on health care reform.
Older adults and people with disabilities in particular will lose if the Medicare improvements in health reform are not implemented.
People with Medicare now face a gap, or “doughnut hole,” in their drug coverage, when their benefits stop and they must pay the full price for their drugs in addition to the premiums for drug coverage. In 2010, people must spend nearly $4,000 out of pocket to get out of the gap; most never get out and many split pills or stop taking their medicine instead. If we give up on health reform, that coverage gap will grow to more than $7,000 by 2019. Senate leaders and President Obama have promised that the final bill will include a phase-out of the coverage gap by 2019, which is already part of the House health reform bill.
Medicare provides coverage for the treatment of illness and injury, but it falls short in providing affordable coverage of preventive care. Both the House and Senate bills eliminate deductibles and coinsurance for preventive benefits, and the Senate bill would provide 100 percent coverage for an annual health assessment.
One in five people with Medicare who are discharged from the hospital are readmitted within 30 days. Preventable readmissions cost Medicare $12 billion every year. Both the House and Senate bills provide incentives to hospitals to improve care after discharge and for specialists and primary care doctors to improve the coordination of care.
People with Medicare aren’t the biggest losers if Congress gives up on health reform. Over 20,000 people in the U.S. die each year because they lack health insurance, according to the Urban Institute. There are now 50 million people with no health insurance in our country. If we give up on health reform, that number will grow to 54 million in ten years, according to the Congressional Budget Office. Both the House and Senate bills would cover more than 90 percent of U.S. residents.
People who can’t get health benefits through their jobs, or who lose their insurance when they lose their jobs, can now be denied coverage if they have a pre-existing condition. Both the House and Senate bills would make this practice illegal. If we give up on health reform, insurance companies will be able to continue to deny coverage to the people who need it most—those with illnesses needing treatment.
These are the essential elements of health reform: covering the uninsured, prohibiting unfair insurance company practices and improving Medicare. We can’t give up now. We have too much to lose.

Medications to Avoid in the Elderly

Forty-eight medications or classes of medications to avoid in adults age 65 or older have been identified by a national expert panel charged with updating widely used criteria for potentially harmful medications in older adults.

Estrogen in older women and the popular over-the-counter antihistamine, Benadryl, were among those on the list to avoid in the update of the 1997 Beers Criteria, published in the Dec. 8 issue of the Archives of Internal Medicine.
Nonsteroidal anti-inflammatory agents such as Motrin® and Advil®, or ibuprofen, made a second list of medications to avoid in older adults with certain medical conditions; nonsteroidals and aspirin, known to increase the risk of bleeding, were listed as potentially inappropriate for people with gastric or duodenal ulcers. Researchers also added to this list of conditions that increase patients' risk for adverse drug events; additions included cognitive impairment, depression, Parkinson's disease, anorexia, malnutrition and obesity.
Another reason for these increased adverse events is how drugs affect people may change as they age. "As we age, we have more subcutaneous fat, less lean body mass, less total body water; all those things conspire together to lead to increased drug toxicity and overdose," Dr. Fick said.

"The issue that you worry about in older people is changes in the pharmacokinetics of the drugs; how the body actually uses the drug, what the body does to the drug," said Dr. William E. Wade, University of Georgia pharmacist and associate department head for the Department of Clinical and Administrative Pharmacy in the College of Pharmacy. "Renal function changes, which can affect how drugs are cleared from the body. The metabolism can slow down. Often the half-life, or how long the drug stays in the body, changes because of that," said Dr. Wade, a study co-author. That means drugs that were well tolerated for years, may cause problems as people age.

"The single most common problem that I see in my practice comes from the benzodiazepine group of tranquilizers (such as the anti-anxiety medications, Valium and Xanax)," said Dr. Tom W. Jackson, MCG geriatrician and a member of the expert panel that updated the Beers Criteria. "These drugs tend to calm people down and relax them but they also dis-inhibit them. The effects are much like alcohol," said Dr. Jackson, who is on the American Geriatrics Society Board of Directors. "Folks who are on these medications are also much more likely to fall … they are actually four times more likely to fall and break their hip than people who are not on these medications." Dr. Jackson opted to participate in the panel because of the enormous problems he sees in seniors with drugs and drug interactions.

Part of the reason the Beers Criteria was needed was, despite the growing number of people reaching senior status, there are not enough practitioners, such as Dr. Jackson, who specialize in geriatrics and are knowledgeable about the problems, Dr. Fick said. Also, many drug studies do not include older adults and only recently did the body of published work exploring drug use and appropriateness in those adults begin to grow. "There was not enough evidence out there that we could pull and analyze," she said. So Dr. Fick used methodology similar to that used by Dr. Mark H. Beers, editor-in-chief of the "Merck Manual for Geriatrics" and a co-author on the update, to develop the first set of criteria.

She put together a geographically diverse panel of 12 experts, including pharmacists, geriatricians and geriatric psychiatrists, who were familiar with the latest medical literature on the topic and brought their own experience with patients and drugs to the review as well.

The criteria will require continual updating because health care is changing daily, with new medicines, new findings about old medicines and disease, old medicines being discontinued and more, she said.

Some of those discontinued medicines made the list of 15 medications or medication

Beers Criteria:

http://seniorjournal.com/NEWS/Eldercare/5-01-06BeersCriteria03-Tb1.htm