Event ID: 1038360
The Lewin Group
Understanding and Responding to Behavioral Symptoms
Among Individuals with Alzheimer's Disease and Related Dementias
Operator: Ladies and gentlemen, thank you for standing by and welcome to Understanding and Responding to Behavioral Symptoms Among Individuals with Alzheimer's Disease and Related Dementias conference call. At this time, all participants are in a listen-only mode. Later, we will conduct a question and answer session. If you should require assistance on today's call or if you'd like to ask a question, please press star and then zero. I'd now like to turn the conference over to our host, Rachel Johnston.
Rachel Johnston: Thank you and welcome everyone. My name is Rachel Johnston, and I work at the Lewin Group. Thank you for joining us today for the Geriatric-Competent Care series on Caring for individuals with Alzheimer's Disease. Today's webinar is on Understanding and Responding to Behavioral Symptoms Among Individuals with Alzheimer's Disease and Related Dementia.
This webinar is the fourth in the series presented in conjunction with Community Catalyst and the Lewin Group and supported through the Medicare/Medicaid Coordination Office at the Centers for Medicare and Medicaid services.
I would also like to note that continuing medical education and continuing education credit is available for today's webinar from the American Geriatric Society and the National Association of Social Workers. In order to receive credit, individuals must read the learning objectives and faculty disclosures, complete the pre-test by 12:20 p.m., participate in the webinar, complete the post test with a score of at least 80% by 2:00 p.m., and complete the program evaluation by 5:00 p.m.
CME CE certificates will be emailed in approximately four to eight weeks after the post test is completed. MMCO is developing technical assistance in actionable item tools based on successful innovations and care models such as this webinar series. To learn more about our current efforts and resources, please visit resourcesforintegratedcare.com for more details. All other questions and answers will be posted to the resources for integrated care website within a few days.
Additionally, on the website you can find the presentation and post recording. Please contact if you have any questions or additional comments during or after today's presentation. Before we get started, I'd like to remind you that all microphones will be muted throughout the presentation. However, there will be a brief question and answer opportunity at the end of the presentation. If do you have a question, please use the question field to submit a question to our team. We will select a handful of questions to answer.
At this time, I'd like to introduce our moderator, Carol Reagen. Carol is a Senior Advisor with Community Catalyst with over 30 years of experience. Carol's work has included policy research, analysis, legislative advocacy primarily on health insurance coverage, programs, and services for low income children and families, long-term care, and workforce development. Now, Carol, I'll turn it over to you.
Carol Reagen: Thanks, Rachel, and welcome everyone. I'm really pleased to introduce our expert panel for today. I think you'll find the presentations will be incredibly useful for your work. Let me introduce them in the order in which they're going to speak, and then I'll turn it over to them, and then we'll do our polls.
Dr. Gregg Warshaw is an academic family physician and a geriatrician. He's an advocate for improving the training of physicians and other professionals to care for older adults. Dr. Warshaw is a clinical professor of family medicine and geriatric medicine at the University of North Carolina in Chapel Hill. He was previously the director of geriatric medicine program at the University of Cincinnati, College of Medicine from 1987 to 2015. Dr. Warshaw was the director of the Christ Hospital University of Cincinnati Geriatric Medicine fellowship training program for physicians at the University of Cincinnati, and was the medical director at Maple Knoll Village, a continuing care retirement community in Springdale, Ohio.
He is the past president of the American Geriatric Society and the Association of Directors of the Geriatric Academy Programs. Dr. Warshaw has regularly served as an advisor to federal agencies and foundations and professional organizations and was a 2013, 2014 Atlantic Philanthropies Health and Aging Policy Fellow, where he consulted with the division of chronic and acute care at HCMS and assisted with Community Catalyst Voices for Better Health project in Ohio to bring the expertise of geriatrics into the dual-eligible demonstration projects. Welcome, Dr. Warshaw.
The second speaker is Dr. Geri Hall, who is an advanced practice registered nurse, a clinical nurse specialist, and a Fellow in the American Academy of Nursing. She's been working with people with dementia for 37 years. A formal clinical professor at the University Of Iowa College Of Nursing, Dr. Hall's currently an Advanced Practice Nurse at Banner Alzheimer's Institute. She developed the first theoretic framework for planning and evaluating dementia care--the progressively lowered stress threshold. A prolific speaker, author of 100 publications, Dr. Hall has served on public policy groups and testified before the President's panel on bioethics. Recently, Dr. Hall re-focused on caring for people with non-Alzheimer's dementias, particularly frontal temporal degeneration and the Lewy Body disease.
Then finally, we have Beth Spencer, who is a clinical social worker, specializing in dementia care since the early 1980s. She has worked with individuals with memory loss and their families in a variety of settings, including the University of Michigan's Cognitive Disorders Clinic, as the director of University of Michigan's dementia day programs, in private practice, and as a consultant to numerous residential care programs. Beth is a co-author of several publications, most recently “Coping with Behavioral Change in Dementia, a Family Caregiver's Guide”. She teaches gerontology classes at the School of Social work at the University of Michigan, where she is co-investigator of the Couple's Life Story project, a research intervention for couples. Until recently, she was the project manager of the Hartford Center of Excellence in Geriatric Social Work. As part of that work, she co-developed and is a faculty member of a new interdisciplinary 34-hour online certificate, Advanced Clinical Dementia Practice. She is currently a caregiver for her mother and continues to council caregivers at the University of Michigan Geriatric Center.
Thank all three for joining us today. Before we turn it over to Dr. Warshaw, I'm going to ask you all a little bit of information about yourselves with this little poll. Which of the following best describes your professional area? You can see the choices up there. If you could click one and hit Submit your answer, it will give us a sense of those of you on the phone and on the web, so one more minute or a few more seconds. Submit your answer and let’s see who we've got on the phone. Do we have the results of the poll yet? There we go. Oh, great, so we can see it. Interesting. We've got the most social workers, but of course behind is someone in medicine, nursing, physician assistant, some other and a few advocacy and some healthcare administration. Thanks very much.
The next poll, we'd like to know a little bit about what setting you work in. You can see the options here, so please click one that best represents where you work, and then click to submit the answer. Maybe five more seconds--okay, and let's see what we've got for where people are working. Interesting, so we've got a split between community-based organizations and managed care organizations. Great. Some in ambulatory and homecare setting and quite a few others, so at the end of the webinar, some of you will get to say where you work in your other. We'd love to know a little bit more about where you work.
Thanks very much for that, and now I'm going to turn it over to Dr. Warshaw to open up our webinar today.
Gregg Warshaw: Thank you, Carol. Thanks to the participants for joining us today for the webinar. This outline shows you how we're going to go through the presentation. Next slide.
We can now go to the learning objectives and next slide. This is a good place to start.
I think those of you who have been on the previous webinars know or you know from your work that Alzheimer's disease has a variety of presentations and symptoms--short term memory loss, other changes that we see commonly with the dementia. Along with those memory and cognitive problems, we also see a number of behavioral and psychiatric symptoms. This occurs in many adults with Alzheimer's disease and similar dementias. These symptoms can be very distressing for families and challenging for clinicians, but the good news, as we'll talk about today, is that there are many strategies to prevent or manage these symptoms so that caregivers can be more successful in helping their relatives or the patients that they're taking care of. Next slide.
These are some of the behavioral symptoms that we see in dementia. Some of these are fairly straightforward. For example, disinhibition is a symptom where people may no longer be able to maintain certain social norms. This may include interpreting people or speaking out of turn. It may be using language that people are not familiar with. Sometimes older people with dementia will start using four letter words. I've heard daughters or sons tell me they didn't even know their mother or father knew these words, and they'll start using them in conversation. These types of behavioral symptoms can be confusing and distressing to families.
There are also symptoms that fall into the category of psychosis where people have delusions and may believe that, for example, somebody is trying to poison them. They may believe that something is coming into their room--some kind of strange gas that's going to get to them. They also may have hallucinations. Sometimes these are friendly figures that they see in their room. Other times there are figures of former family members, or sometimes they're frightening hallucinations. Next slide.
As a physician, the first thing I'm trying to do when I learn about a behavioral problem in a person with a dementia is to understand if there's any secondary cause that could be going on with the person that could explain the behavior in addition to the dementia. I'm looking for a new condition such as an infection. Even simple infections like urinary tract infections could lead to new behavioral problems.
I'm looking to see if we're managing preexisting medical problems properly. People who have chronic arthritis may not be treated adequately, and the chronic pain could lead to behavioral symptoms, or they've been started on a new medication. Particularly, I'm looking for anti cholinergic medications like over-the-counter antihistamines or medications that are used for bladder control. These new medications could interfere with people's ability to actually maintain their normal state.
Anytime there's something new going on or their behavioral symptom is acute in onset or evolving rapidly, I'm looking for a new medical condition or medication toxicity that could explain the symptom. Next slide, please.
My assessment will be taking a careful history from the patient, in particularly, the informant or people that are directly observing the behavior and are with the person on a regular basis. When did it start? What's been the course of the symptoms? Are there associated circumstances like a new caregiver or a change in environment, or has the person not had adequate sleep? Have there been other stressors, and how is the caregiver doing? Is the caregiver stressed out, exhausted? This could lead to the person with the dementia starting to recognize that things are not good in their environment. Next slide.
Not all dementias are Alzheimer's disease, and we'll emphasize this more as we go through the program, because when you have other causes for dementia, you may have different types of behavioral symptoms that need to be managed in a different way. It may occur in a different time sequence.
This example is a case of an 80-year-old woman who has a nine-month history of short-term memory loss. She is also losing some of her ability to manage her day-to-day activities, but her family is concerned about her having hallucinations of small children and animals. She is also having more trouble walking and has hand tremors. On exam, I actually noticed that there was increased muscle tone and resting tremors. These findings, particularly the early onset of hallucinations, more trouble walking, and neurologic findings on exam is very atypical in early Alzheimer's disease. These would be findings that we'd find much later in the illness--not just a nine-month history. This presentation is not typical of Alzheimer's. Next slide.
This presentation, actually, that you just heard was probably more similar to what I'd see in somebody with Lewy Body disease. I've listed some other types of atypical dementias or different causes of dementia that are different than Alzheimer's. Dr. Hall will speak more about this in her presentation. Next slide.
One of the areas of controversy in the management of behavioral symptoms in dementia is the use of medications to control symptoms. The class of medications that has received the most attention are the anti-psychotic medications, particularly the atypical anti-psychotics which are widely used now for the treatment of psychiatric illness in adults. These atypical anti-psychotics are particularly useful at times for aggression and psychosis, but there are many risks with their use. These include cerebral vascular disease increases, side effects that may cause motor disruption in the person's function. They may also cause metabolic disorders like diabetes.