Dementia and Alzheimer's

Will Holmes à Court
Will Holmes à Court
Last updated 

Background

Dementia and Alzheimer's are often used interchangeably, but they have very different meanings. Dementia describes a wide range of symptoms. These symptoms impact a person’s ability to perform everyday activities independently. 

Alzheimer’s is a neurodegenerative disease that is the most common cause of dementia. In Alzheimer’s, the brain might already show signs of the disease while the person might not experience any symptoms.

Common issues for people with dementia 
  • Not wanting to receive personal care 
  • Not willing to go to the doctor
  • Not following the doctor's treatment plan
  • Losing important things
  • Getting lost 
  • Unsafe task performance
  • Repeated calls to contacts
  • Refusing help
  • Being rude 
  • Badmouthing you to others
  • Making up stories
  • Using drugs and alcohol to cope
  • Excessive or minimal eating or drinking (dehydration)
  • Perseverating - sorting papers or purses over and over again
  • Mixing up day and night
  • No solid sleep time
  • No empathy when hearing a sad story
  • Fatigue and apathy
  • Emotional meltdowns
  • Swearing, sex talk, racial slurs, ugly words
  • Not doing personal care routines
  • Paranoid and delusional behaviour
  • Threatening caregivers
  • Shadowing, eloping, wandering
  • Seeing things and people
  • Undressing in public
  • Striking out at others
  • Feeling sick and complaining of pain
  • Falls and injuries
  • Urinary tract infections - behaviour is aggressive and yelling
  • Contractures and immobility
  • Infections and Pneumonia
  • Making emergency calls 000
Understanding the types and causes of dementia;
There are 10 early warning signs of dementia. (Teepa Snow)
  1. Memory loss for recent or new information and repeats self frequently
  2. difficulty doing familiar, but complex tasks such as managing money, managing medications and driving
  3. Problems with word-finding
There are many diseases where dementia is a symptom. 

Alzheimer's disease

Alzheimer's is a progressive disease that destroys memory and important mental functions. Brain cell connections and the cells degenerate and die, eventually destroying memory and other critical mental functions. Memory loss and confusion are the main symptoms.

Cognitive changes include mental decline, difficulty thinking and understanding, confusion in the evening (sundowning), delusion (false beliefs not based on reality), and disorientation. Memory loss is one of the earliest symptoms, along with a gradual decline of other intellectual and thinking abilities (called cognitive functions), and changes in personality or behaviour.

Alzheimer’s is the most common form of dementia.
Watch this video link https://www.alzinfo.org/understand-alzheimers/

The 7 stages of Alzheimer's disease;
  1. Normal - just forgetful, or is it dementia?
  2. Normal age forgetfulness - half or more of the population over 65 experience subjective complaints of cognitive and/or functional difficulties, such as finding the correct word when speaking and misplacing objects.
  3. Mild cognitive impairment - repeats questions to others, concentration deficits, capacity to master new skills declines, and if still working, job performance declines.
  4. Mild Alzheimer's - difficulty managing activities of daily living ADLs, writing skills, and numeracy skills decline. In the absence of emotional responsiveness, the person withdraws socially and denies to others their decline in capacity. This stage generally lasts about two years.
  5. Moderate Alzheimer's - the person requires assistance to avoid daily living catastrophes, disorientation when not at home, choosing inappropriate clothing for the weather, failing to change clothing, unable to recall significant life events and forgetting home address, schools attended, a decline in handling finances and cash, unable to count backwards from 20 by 2s. This stage generally lasts 1.5 years.
  6. Moderately severe Alzheimer's - unable to carry out any ADLs independently, require assistance to dress correctly, remove one layer of clothing before another is applied, assist with showering (water temp) and oral care, incorrectly managing toileting routine, incontinence. Cognitive deficits are severe little or no memory recall or confusing the identity of one person with another. Unable to recall schools attended, occupations, children, and parents. Purposeless activities like moving objects where they don't belong. The person experiences shame, depression and verbal outbursts when in public and aggression to carers on their return when left alone. This stage generally lasts 2.5 years. 
  7. Severe Alzheimer's - continuous assistance with ADLs to survive. Speech has declined to half a dozen intelligible words, difficulty walking, unable to sit independently, physical rigidity is evident, especially in the neck and joints, and contractures can appear. Infantile reflexes appear, such as the sucking and grasp reflexes. The most common cause of death is pneumonia, heart disease and cancer.  This stage generally lasts 1 to 5 years, depending on the quality of care and support. 
Listen to this audio link https://www.alzinfo.org/understand-alzheimers/clinical-stages-of-alzheimers/.

Vascular dementia
This is a progressive disease with symptoms that become closer to those of middle and later-stage Alzheimer's disease. Life expectancy is around 5 years after symptoms begin.

Lewy body dementia (LBD)
LBD is a disease associated with abnormal protein deposits called alpha-synuclein in the brain. These deposits called Lewy Bodies affect chemicals in the brain whose changes, in turn, can lead to problems with thinking, movement, behaviour and mood. Newly diagnosed people live between 5 and 7 years, and advanced stage diagnoses live up to 2 years. Lewy Bodies are often present in the brain of a person with Parkinson's disease; sometimes, they are considered the same. The difference is that in a Parkinson's person, the physical changes are first to appear, and in LBD, the cognitive changes are the first to appear. Signs of LBD are;
  • changes in thinking and reasoning
  • confusion and alertness that varies significantly from one time to another and one day to the next
  • slowness, gait imbalance and other Parkinsonian movement features
  • well-formed visual hallucinations (a sensory experience without any real-world stimulus, maybe visual, auditory, tactile, gustatory or olfactory)
  • delusions (false beliefs not based in reality)
Progression of Lewy Body Dementia;
Early stages - delusions, restlessness, REM (rapid eye movement) sleep disorder, movement disorder, urinary issues.
Middle stages - motor impairment, speech difficulty, decreased attention, paranoia, significant confusion.
Later stages - extreme muscle rigidity and speech difficulties, sensitive to touch, susceptible to infections

Frontal lobe dementia (FLD)
FLD is also known as frontotemporal dementia, which occurs when the frontal lobes of the brain begin to shrink (atrophy). An estimated 10% - 15% of dementia cases are FLD caused by clumps of an abnormal protein (amyloid plaques) and bundles of fibres (neurofibrillary tangles or tau) forming inside the brain. These are thought to damage the cells and stop them from working correctly. The proteins mainly build up in the frontal and temporal lobes of the brain at the front and sides, affecting short-term memory recall, olfactory senses (taste and smell) and lower mood that mimics depression. People can live with FLD for 2 to 17 years.

Transient Ischaemic Attack (TIA) mini-strokes
TIA symptoms include weakness on one side of the body, vision problems and slurred speech. These are transient and often resolved in 24 hours. People may experience difficulty walking, muscle weakness, problems with coordination or weakness on one side of the body, feeling faint, dizzy, light-headedness or vertigo, slurred speech or impaired voice, blurred vision, facial muscle numbness, difficulty swallowing, mental confusion or reduced sensation of touch.

Delivering care to clients living with Dementia

Preparing to provide support to those affected by a person with dementia 
  • client - confirm symptoms when observed by the client, 
    • "yes, that is part of the disease, it is not your fault or controlled by you", 
    • "how can we keep you feeling safe and secure when you experience these symptoms?"
  • family - redirect the family and carers to understand that the symptoms observed in their relative are part of the disease and not deliberate or manipulative behaviours. Empathise by saying 
    • "It must be very difficult to see your relative present these behaviours when you have never known them to be like this. These behaviours and symptoms are attached to the disease, it is not their fault if the disease is presenting these symptoms which are beyond their or your control." 
    • "Your relative needs empathy and tolerance as they experience these uncontrollable symptoms. Reassure them that they are safe with you".
  • visitors - same as family. Visitors may be shocked by changes in their friend's condition since they last visited. Support workers should be encouraged to ask the visitor to use their empathy skills, explaining to the visitor that it is the disease-causing these changes and encouraging them to talk about old memories they had together. 
Providing care and support to people with dementia by using;
  • person-centred approaches
  • individualised plan
  • identify the need for a stable and familiar environment
  • recognise signs of abuse and neglect 
Communication and dementia
Use appropriate communication strategies, 
  • verbal and 
  • non-verbal communication to maximise engagement
Considerations related to communication with a person with dementia;
Culture  and spirituality
Language - Translator
Sensory impairments
Para language strategies to support comprehension for people with dementia and ABI

Managing behaviours of distress
Recognise that behaviours of distress are;
  • a form of communication for unmet needs these include hydration, nutrition or a medical condition such as a urinary tract infection - UTI
  • inappropriate type or level of care services for the client's needs
  • cognitive or physical issue
  • mental health issue
There are many types of behaviours of distress;
  • Social withdrawal
  • Wandering
  • Socially inappropriate behaviour
  • Eating - too much food or refusal of meals
  • Refusal of services
  • Sexually inappropriate behaviour
  • Resistance to personal care
  • Verbal disruption and repetition (echolalia)
  • Aggression
Identifying changes in the client’s condition is vital, and notifying the supervisor of the incremental behavioural episodes.

Strategy - Observe and record behaviours of concern/distress on a behavioural chart that includes columns for date, time, possible reasons for the behaviour (antecedent), and the strategy used to manage the behaviour. Completing a behavioural chart could be used by the GP to evaluate medication or to guide the supervisor, family and carer on the best response to behaviours exhibited.

Respond to behaviours of distress with;
  • reality orientation
  • validation strategies to relieve distress and agitation; 
  • reality orientation, validation, reassurance, redirection.
  • Safe CW positional practices for people with signs of distress
Providing activities for maintenance of dignity, skills and health, 
ensure safety and comfort balanced with autonomy and risk-taking
  • Music therapy
  • Art therapy
  • Pet therapy
Implementing self-care strategies for the CW