Dementia Its Assessment and Management

Afza.Malik GDA

Dementia and Old Age Nursing Care

Dementia Its Assessment and Management

Dementia its types,assessment and diagnosis.Dementia treatment pharmacological, Non Pharmacological and Nursing Interventions.

What is Dementia

    Dementia is most commonly defined as a clinical syndrome of cognitive deficits that involves both memory impairments and a disturbance in at least one other area of cognition (American Psychiatric Association, 2000). 

    In addition to disruptions in cognition, dementia is associated with a gradual decline in function and changes in mood and behavior.

Causes of Dementia

    There are many causes of dementia and dementia like presentations. Differentiating these changes early in the course of illness is important because condition-specific assessment, monitoring, and management strategies can be employed. 

    Differential diagnoses among conditions that cause cognitive impairment are confounded by the fact that these conditions may coexist and disparate dementia disorders may be similarly clinically expressed.

Dementia and Clinical Goals

    Major goals in the clinical approach to a person presenting with cognitive impairments are identification and resolution of potentially reversible conditions (e.g. delirium, depression), recognition and control of comorbid conditions, early diagnosis and management of a dementia illness, and the provision of caregiver support. 

    The focus of this chapter is on assessment and management of the progressive dementia syndromes.

Dementia and Statement of Problem

    Global estimates reflect that 24.3 million people have dementia today, with 4-6 million new cases every year ( Ferri et al., 2005). The rapid growth of the older adult population in the United States is associated with a significant increase in the prevalence of dementia. 

    Dementia affects about 5% of individuals aged 65 and older (Richie &Lovestone , 2002), and the prevalence increases exponentially with age rising to nearly 50% in individuals aged 85 and older (Evans et al., 1989). 

    More than 4.5 million Americans have the most common form of dementia, Alzheimer's disease (AD), a number that is expected to triple by the middle of the 21st century (Hebert, Scherr, Bienias , Bennett, & Evans, 2003 ) .

 Alzheimer's Disease a Type of Dementia

    AD, the most common form of dementia, accounts for more than 60% of all cases. A chronic neurodegenerative disease, first described by Alois Alzheimer in 1907, AD is characterized by neurofibrillary plaques and "tangles" in the brain. 

    The extracellular accumulation of amyloid beta-proteins in the neuritic plaques is one of the hallmarks of AD ( Ariga , Miyatake , & Yu, 2010). The variation in the clinical presentation of the disease depends on the area of the brain that is affected. 

    Classic features of AD include progressive loss of memory, deterioration of language and other cognitive functions, decline in the ability to perform activities of daily living (ADLs), and changes in personality and behavior and judgment dysfunction (Castellani, Rolston, & Smith, 2010 ). 

    Mild cognitive impairment (MCI), a syndrome defined as cognitive decline greater than expected for an individual's age that minimally interferes with ADLs (Gauthier et al., 2006), may be a precursor of dementia. 

    Incidence rates of MCI are 51-76.8 per 1,000 person-years, with a higher incidence in advanced age, lower education, and hypertension (Luck, Luppa , Briel , & Riedel-Heller, 2010). 

    Individuals with MCI are nearly twice as likely to die and more than three times as likely to develop AD in a 5-year period as a cohort of individuals without MCI (Bennett et al., 2002).

Dementia, Multi Infarct

    VaD , sometimes referred to as vascular cognitive impairment and previously known as multi-infarct dementia (MID), refers to dementia resulting from cerebrovascular disease. 

    It is the second most common cause of dementia among older adults and represents approximately 20% of all cases of dementia in the United States (Román, 2003). There are many types of VaD , and lumping them under a single rubric causing some diagnostic confusion (Kirshner, 2009). 

    The diagnosis of VaD is based on the association between a cerebrovascular event and the onset of clinical features of dementia, including evidence of focal deficits, gait disturbances, and impairments in executive function. 

    As compared with AD, memory may not be impaired or is more mildly affected. It is not uncommon that AD and VaD pathology coexist and this, often referred to as a mixed dementia, is likely to increase as the population ages ( Langa , Foster, & Larson, 2004),

Dementia with Lewy bodies

    DLB is a neurodegenerative dementia that results when Lewy bodies form in the brain. Lewy bodies are pathological aggregations of alpha-synuclein found in the cytoplasm of neurons ( McKeith et al., 2003). 

    Clinical features include cognitive and behavioral changes in combination with features of parkinsonism. Disorders of executive function occur early. Hallucinations and visuospatial disturbances are prominent. 

    Although rigidity and unsteady gait are common, tremors are not ( Geldmacher , 2004). Many, but not all, patients with Parkinson's disease develop a dementia years after the motor symptoms appear. 

    Distinctions have been made clinically between the DLB and the PDD based on the sequence of the appearance of symptoms ( McKeith et al., 2005). DLB and PDD may represent the same pathological process along a disease spectrum (Hanson &Lippa , 2009).

Assessment and Its Goals

    Early identification of cognitive impairment is the most important goal in assessment. Cognitive impairment resulting from conditions such as dementia, delirium, or depression represents critically serious pathology and requires urgent assessment and tailored interventions. 

    Yet, diminished or altered cognitive functioning is often perceived by health care professionals as a normal consequence of aging, and opportunities for timely intervention are too often missed ( Milisen , Braes, Fick, & Foreman, 2006). 

    Although distinctions have been made comparing the clinical features of the common cognitive impairments associated with delirium, dementia, and depression, this is difficult to do clinically because these conditions often coexist and older adults can demonstrate a typical features in any of these conditions.

    The second most important assessment goal is to identify a potentially reversible primary or contributing cause of a cognitive impairment. The common causes of reversible cognitive impairment ( ie ., delirium) in the older adult are covered in the delirium chapter in this text.

Dementia History Taking

    Complaints from the patient or observations made by others of memory loss, problems with decision making and/or judgment, or a decline in an ADL function should alert the health care professional that a progressive form of dementia might exist. 

    Collecting an accurate history is the cornerstone to the assessment process, yet this obviously is a challenge in the individual presenting with cognitive impairment. The assessment domains covered in history taking include functional, cognitive, and behavioral queries and observations. 

    The history-taking process involves first interviewing the patient followed, perhaps, by clarifying, elaborating, and validating information with the family or others familiar with the capabilities and expressions of the patient.

    Even when a diagnosis of dementia has been made, it is often not communicated well across care settings. The easiest way to increase recognition of dementia in older hospital patients is to add the items “severe memory problems,” “AD,” and “dementia” to the list of diseases and conditions patients and families are routinely asked about on intake forms and in intake interviews.

 Dementia Functional Assessment

    AD is characterized by impairment in the ability to perform ADLs. Because cognitive assessment can be embarrassing and/or threatening, it may be more respectful to initiate the conversation around the patient's functional domain. 

    Asking the patient to elaborate on his or her functional abilities in ADLs as well as instrumental activities of daily living (ADLs) and eliciting any identified decline with specified chronology can provide some insight.Several functional tools have been tested specifically in individuals with dementia.

    The Functional Activities Questionnaire (FAQ) is an informant-based measure of functional ability and has been recognized for its ability to discriminate early dementia (Pfeffer, Kurosaki, Harrah, Chance, & Filos, 1982 ) . 

    An informant, typically the primary caregiver, is asked to rate the performance of the patient in 10 different activities. 

    The Modified Alzheimer's Disease Cooperative Study-Activities of Daily Living Inventory (ADCS-ADL) is a specific functional tool used primarily in clinical drug trials to assess and monitor patients with moderate-to-severe AD ( Galasko et al., 1997). 

    Clinical studies using this scale have indicated that cholinesterase inhibitors offer an effective approach to treating functional decline ( Potkin , 2002). 

    The patient's daily caregiver is asked to rate the older adult's usual performance on the more basic measures of function over the previous month to identify progression of functional decline.

Cognitive assessment

    The cognitive domain is assessed as part of a broader mental status evaluation, the components. Because some of the parameters of a mental status evaluation (such as memory or cognition) might be measured with a standardized tool such as the Mini-Mental State Examination (MMSE), others require specific inquiry or direct or indirect observation by the health care professional and/or care giver. 

    The measure of mood is totally subjective and is based on self-report status. The evaluation always provides the opportunity to identify sensory impairments (ie, vision and hearing loss), which can further impact cognition, function, and behavior. There are a variety of tools for assessing cognitive impairment, some more sensitive to mild dementia and others to moderate-to-severe dementia.

Gold Standards of Cognitive Assessment

    The gold standard of tools that measure cognition is the MMSE developed more than 30 years ago ( Folstein , Folstein , & McHugh, 1975). Used extensively in clinical trials as well as in a variety of clinical settings, it is relatively easy to administer and score and can be used to assess cognitive changes over time. 

    The annual rate of decline on the MMSE in AD is 3.3 points annually (Han, Cole, Bellavance , McCusker, &Primeau , 2000). The MMSE has established validity and reliability, although concerns continue to be expressed by clinicians that it is time consuming and, in some circumstances, the relevance of selected questions has been raised. 

    The MMSE score is strongly related to education, with high false-positive rates for those with little education, and predictive power is also significantly influenced by language (Parker & Philp, 2004). 

    It is insensitive to executive dysfunction and has been criticized for a lack of sensitivity in detecting early or mild dementia (Leifer, 2003). As has been suggested with other measures of cognitive testing, the MMSE may have a cultural bias (Manly & Espino. 2004). 

    Clinicians must remain aware that a high score on the MMSE does not rule out cognitive decline or the possibility of dementia, particularly in high-functioning individuals with cognitive complaints (Manning, 2004). 

    The tool is no longer in the public domain and copyright permission must be secured. A tool with comparable sensitivity and specificity for detecting dementia is the St. Louis University Medical Status (SLUMS) examination, and it is available free (Tariq. Tumosa , Chibnall, Perry, & Morley, 2006).

Language Based Tools 

    Unlike the more language based tools described earlier, the Clock Drawing Test (CDT) assesses cognition focused on executive function. 

    A systematic review of the literature identified the CDT's usefulness in predicting future cognitive impairment (Peters & Pinto, 2008). Scoring is based on the ability to free-hand draw the face of a clock, insert the hour numbers in the appropriate location, and then set the hands of the clock to the time designated by the examiner. 

    The CDT is strongly correlated with executive function ( ie ., the ability to execute complex behaviors and to solve problems) and is useful in the detection of mild dementia (Royall, Mulroy , Chiodo, & Polk, 1999). 

    It also correlates moderately with driving performance as the CDT score drops, the number of driving errors increases (Freund, Gravenstein , & Ferris, 2002; Freund, Gravenstein , Ferris, Burke, & Shaheen, 2005).

    A clinically useful tool that combines the CDT with measures of cognition ( ie , three-word recall) is the Mini-Cognitive (Mini-Cog: Borson , Scanlan, Brush, Vitaliano, &Dokmak , 2000). 

    The Mini-Cog detected cognitive impairment in a community sample of predominately ethnic minority better than primary care physician assessment (84% vs. 41%), particularly in milder stages of the disease ( Borson , Scanlan, Watanabe, Tu, & Lessig , 2005 ).

Mini Cognition Screening 

    A systematic review of the Mini-Cog for screening for dementia in primary care demonstrated that it was brief, easy to administer, clinically acceptable and effective, and minimally affected by education, gender, and ethnicity (Milne, Culverwell, Guss , Tuppen , &Whelton , 2008) with psychometric properties similar to the MMSE ( Brodaty , Low, Gibson, & Burns, 2006).

Behavioral Assessment

    Behavioral changes occur both early and throughout dementia ( Kilik , Hopkins, Day, Prince, Prince, & Rows, 2008) and are also seen in MCI: commonly, these include depression, anxiety, and irritability ( Monastero , Mangialasche , Camarda , Ercolani , &Camarda , 2009). 

    Regular assessment and monitoring can help identify the triggers of disruptive behavior and early manifestations of the behavior. Timely interventions that result in de-escalation of the behavior can help decrease the level of distress experienced by both the patient and the caregiver. 

    Behavioral management can help maintain functionality and safety. Commonly demonstrated behaviors are those associated with agitation and psychosis. 

    Asking the patient about levels of restlessness, anxiety, and irritability is important because, at times, these emotional or behavioral states occur even earlier than cognitive changes. 

    Aggression, wandering, delusions and hallucinations, and resistance to care are manageable with pharmacological and non pharmacological treatment options.

Psychosis and Aggression

    The literature on the link between psychosis and aggression in people with dementia is mixed ( Shub , Ball, Abbas, Gottumukkala , &Kunik , 2010). The Neuropsychiatric Inventory (NPI) measures frequency and severity of psychiatric symptoms and behavior oral manifestations in individuals with dementia. 

    The NPI takes about 10 minutes to administer, during which the caregiver is asked screening and probing questions related to the presence and degree of behaviors such as agitation, anxiety, irritability, apathy, and disinhibition. 

    The NPI also includes a measure of caregiver stress. A briefer questionnaire version, the NPI-Q, also has established validity ( Kaufer et al., 2000).

    Because as many as 50% of individuals with dementia have coexisting depressive symptoms (Lee &Lyketsos , 2003), it is important to conduct an adjunctive assessment of depression. 

    Recognizing depressive symptoms in older adults is challenging, and using an interviewer-rated instrument is recommended in addition to using clinical judgment (Onega, 2006). 

    The Geriatric Depression Scale (GDS) is a screening instrument that takes only a few minutes to administer and is discussed along with appropriate depression management strategies in detail in Chapter 9. Depression in Older Adults.

    Referral of the patient to a neuropsychologist for more extensive neuro psychological testing might be indicated to provide more specific diagnostic information associated with neurodegenerative disease states and areas of brain dysfunction. 

    This kind of assessment can identify subtle cognitive impairments in higher functioning individuals, can distinguish MCI from dementia, and can provide direction and support for care providers and the family (Adelman & Daly, 2005).

Diagnostics and Physical Examination

    Once the functional, cognitive, and behavioral domains in progressive dementia have been established through history taking of the patient and caregiver, a thorough review of systems is undertaken, followed by the physical examination. 

    The history-taking process narrows the differential diagnosis of reversible and irreversible causes for dementia. A thorough neurological and cardiovascular examination will help to specify the etiology of a single type or combined dementia that will direct the need for laboratory and imaging tests. 

    Cardiovascular findings such as hypertension, arrhythmias, and extra heart sounds or murmurs along with focal neurological findings such as weakness and sensory deficit may favor a diagnosis of VaD.

    Pathological reflexes, gait disorders, and abnormal cerebellar findings may be indicative of AD; and parkinsonian signs might indicate dementia associated with either Lewy bodies or Parkinson's disease (Kane, Ouslander , Abrass , & Resnick, 2009).

    There are no specific laboratory tests for the diagnosis of progressive dementia other than those that can primarily indicate a potentially reversible or contributing cause. 

    The American Academy of Neurology (AAN) recommends two specific laboratory tests ( ie , thyroid function and B,,) in the initial evaluation of suspected dementia ( Knopman et al., 2001). 

    The AAN similarly recommends that all patients with suspected dementia have a magnetic resonance imaging (MRI) study or non-contrast computed tomography (CT) as part of the initial workup. 

    Once dementia has become clinically relevant and a cause becomes apparent, there is no further diagnostic yield afforded by imaging.

Caregiver Assessment

    It is important to remember that the caregiver is a patient, too, in that they suffer, as does the patient with dementia. Caregiver need and burden refers to the psychological, physical, and financial burden associated with caregiving Caregivers are at risk for depression, physical illness, and anxiety (Cooper, Balamurali, & Livingston, 2007; Schoenmakers , Buntinx , &Delepeleire , 2010 ) . 

    The Zarit Burden Interview (ZBI) can be used to identify the degree of burden experienced by the caregiver. The ZBI is a four-item screening followed by an additional 12 items with good reliability and validity (Higginson, Gao, Jackson, Murray, & Harding, 2010). 

    Administration of this tool to a community-dwelling caregiver can ind icate the extent of impact caregiving has on the caregiver's health, social, and emotional well-being and finances. The Modified Caregiver Strain Index (CSI) is another tool that has been used to identify families with caregiving concerns (Onega, 2008). 

    There is a growing body of literature that describes the relationship between people with dementia and the family members who care for them (Ablitt, Jones, &Muers , 2009).

Nursing Interventions and Care Strategies

    There is no cure for progressive dementia. The management of individuals with dementia requires pharmacological and non pharmacological interventions.

Pharmacological Interventions

    The goals of pharmacological therapy in dementia include preserving what the disease destroys in cognitive and ability, minimizing what the disease imposes in the way of functional behavior disturbances, and slowing the progression of the disease effects brought on by the destruction of neurons ( Geldmacher , 2003 ). 

    Nurses, regardless of whether they are the prescribers of drug therapy, need to be informed about the variety of drugs used in managing dementia and the evidence supporting the pharmacological approaches. 

    Although there is substantial evidence that adults with mild-to-moderate AD (and perhaps VaD and DLB) would benefit from drug therapy, there are no solid data in support for drug therapy into the advanced stage of the disease (Olsen, Poulsen, & Lublin, 2005).

    Acetylcholinesterase inhibitors are the mainstay of treatment. Four are currently available in the United States: donepezil hydrochloride (Aricept), rivastigmine tartrate (Exelon), galantamine hydrobromide ( Reminyl ), and tacrine hydrochloride (Tacrine)- the oldest and less favored drug because of its adverse effect on the liver and multiple daily dosing. 

    Cognitive improvements in patients with mild-to-moderate AD have been shown for each of the other three drugs (Birks, Grimley Evans, Lakovidou , &Tsolaki , 2000; Birks & Harvey, 2006; Loy & Schneider 2006). 

    These drugs also provide cognitive and behavioral improvement in other forms of progressive dementia including VaD ( Kavirajan & Schneider 2007) and DLB ( Erkinjuntti et al., 2002; Wild, Pettit, & Burns, 2003). 

    With the exception of tacrine, the acetylcholinesterase inhibitors are safe and well tolerated: however, they may have gastrointestinal side effects ( ie , nausea, anorexia, and diarrhea). 

    Dementia pharmacological therapy can improve the quality of life for the patient and the caregiver and delays nursing home placement ( Geldmacher , Provenzano, McRae, Mastey , &Leni , 2003; Lopez et al., 2002). 

    Rivastigmine is also available as a transdermal patch. Memantine (Namenda), approved for moderate-to-severe dementia, has a different mechanism of action than the acetylcholinesterase inhibitors. 

    This N-methyl-D-aspartate receptor antagonist has neuroprotective effects that prevent excitatory neurotoxicity. Individuals with AD and VaD have improved cognition and behavior on this drug (McShane, ArcosaSastre , &Minakaran , 2006). 

    Side effects of memantine, although uncommon, include diarrhea, insomnia, and agitation. Combined administration of cholinesterase inhibitors with memantine demonstrated increased efficacy in advanced AD as compared to cholinesterase inhibitors alone ( Riepe et al., 2007).

Pharmacological Therapy for Problematic Behaviors

    Behavior changes are common in the mid to later stages of progressive dementia and, although non pharmacological interventions are preferred, supplementation with a tailored drug regimen is sometimes necessary. 

    Psychotropic medications, primarily anti psychotics, can be administered to help the individual regain control and be less disruptive positive outcomes for the caregiver as well as the patient. 

    Drugs must be prescribed in the lowest effective dose for the shortest amount of time (Gray, 2004). The patient needs to be closely monitored for effectiveness and adverse side effects. Psychotropic medications have a high risk of adverse drug events and this is covered in Chapter 17.

Minimize Adverse Drug Events

    Psychotropic therapy for different behaviors is always short term ( ic , 3-6 months). Once the target symptoms are relieved or abbreviated, then consideration must be given to terminate therapy. 

    Long-term psychotropic drug therapy should be considered only if the symptoms reoccur. Psychotic symptoms (such as delusions and hallucinations) frequently occur in the later stages of progressive dementia ( Ropacki &Jeste , 2005) and are often associated with agitation and aggression (Holroyd, 2004). 

    The conventional antipsychotic haloperidol (Haldol) has been used for decades and remains the most commonly used drug for control of psychotic symptoms in individuals with dementia. 

    A Cochrane Review (Lonergan, Luxenberg, &Colford , 2002) validated the useful role of Haldol in managing aggression but did not find evidence for its role in managing agitation for patients with dementia. 

    The side effects of conventional antipsychotics are considerable and include extrapyramidal symptoms, tardive dyskinesia, sedation, orthostatic hypotension, and falls.

    Although not approved by the US Food and Drug Administration (FDA), the atypical antipsychotics are often prescribed for use in patients with dementia. 

    Evidence reflects that they may benefit people with dementia, but the risks of adverse events (eg, cardiovascular, extra pyramidal symptoms) may outweigh the benefit, especially with long-term treatment (Ballard & Waite, 2006). 

    Agents available on the market include risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, and paliperidone. 

    There is little to no published data on the efficacy and safety of the last three drugs listed earlier. Additional research is needed to determine when and how to use psychotropic medications to address behaviors in individuals with dementia. 

    Other drug categories are sometimes used to control behavioral symptoms.

    Benzodiazepines (e.g. lorazepam, oxazepam, alprazolam) are sometimes used to manage agitation and aggression; however, the risk-benefit ratio is often unsatisfactory. Although benzodiazepines may be useful in rapidly sedating the agitated patient with dementia, the potential for falls and worsening of cognition limit long-term use.

    Although antidepressants and anticonvulsants are sometimes used to treat agitation in dementia, there is insufficient evidence to support their use. Behavioral disturbances should not necessarily be interpreted as depression.

Supplemental Therapy

    Anti-inflammatory drugs and estrogen; herbs such as gingko; and vitamins such as B,,, folate, and vitamin E-although sometimes touted and commonly used-have no proven efficacy for dementia, although some isolated studies have demonstrated a benefit. 

    Dementia associated with VaD requires appropriate control of hypertension, hyperlipidemia, and aspirin therapy. Parkinsonism (rigidity), seen with DLB, may benefit from dopaminergic therapy.

Non pharmacological Strategies

    Nonpharmacological strategies including those from the cognitive, behavioral, and environmental domains in combination with staff support and education are effective ( Burgener & Twigg, 2002). 

    Physical/functional, environmental, psychosocial, behavioral, and end-of-life (EOL) care interventions are discussed in the succeeding section.

Physical/Functional Interventions

    Maintaining physical and functional well-being of the individual with progressive dementia facilitates independence, maintains health status, and can ease the caregiving burden. 

    Interventions include adequate nutrition and hydration, regular exercise, maintenance of ADLs, proper rest and sleep, appropriate bowel and bladder routines, proper dental hygiene and care, and current vaccinations. 

    Because comorbidities are common ( Lyketsos et al., 2005), regular assessment, vigilant monitoring, and aggressive management of acute and chronic conditions are necessary. 

    Vehicular driving safety might need to be examined because recent evidence indicates that individuals with dementia pose a risk in driving safety (Man-Son-Hing, Marshall, Molnar, & Wilson, 2007). 

    There is insufficient evidence to support or refute the benefit of neuropsychiatric testing or intervention strategies for drivers with dementia (Iverson et al., 2010).

Environmental Interventions

    A specialized ecological model of care, which facilitates interaction between the person and environment in a more home-like environment, has proven to be beneficial for individuals with dementia. 

    This model affords greater privacy, encourages meaningful activities, and permits more choice than the traditional model of care. 

    It also demonstrates that individuals with dementia experience less decline in ADLs and are more engaged with the environment with no measurable differences found in cognitive measures, depression, or social withdrawal (Reimer, Slaughter, Donaldson, Currie, & Eliasziw , 2004 ) .

    A systematic review reported inclusive results and suggested that more research is needed with regard to the use of bright light in fostering better sleep and reducing behavior problems in dementia (Forbes et al., 2009). 

    The use of aromatherapy to reduce disturbed behavior, promote sleep, and stimulate motivation also shows promise but needs more study ( Thorgrimsen , Spector, Wiles, &Orrell , 2003). 

    Manipulation of the environment (eg, alarms, circular hallways, visual or structural barriers) to minimize wandering has not conclusively demonstrated to be effective ( Peatfield , Futrell, & Cox, 2002). 

    There is a lack of robust evidence supporting nonpharmacological interventions for wandering (Robinson et al., 2007).

Psycho Social Interventions

    Mental and social engagement is important to the well-being of all older adults. Meaningful activity and involvement is no less important in individuals with dementia. 

    Although the effectiveness of counseling or procedural memory stimulation is not supported in mild-stage dementia, reality orientation does appear to be effective (Bates, Boote , & Beverley, 2004). 

    The evidence suggests that cognitive therapy is more beneficial than no therapy at all, but it may be patient-specific (Forbes, 2004). Validation therapy, based on caregiver acceptance of the reality of the person with dementia's experience, may be of value but the evidence is lacking (Neal & Briggs, 2003).

    Recreational therapies including music have shown to reduce psychological symptoms in dementia with limited efficacy and questionable duration of action (O'Connor, Ames, Gardner, & King, 2009), and more research is needed to explore the effects of music therapy on the behavior and well-being of individuals with dementia (Wall & Duffy, 2010).

    Support groups, counseling, and education for individuals with early AD and their caregivers are essential. 

    Caregivers often experience physical, financial, social, and emotional losses, and providing information through a structured education program and engaging them in the care planning process are essential (Jayasekara, 2009).

Behavioral Interventions

     Behavioral and psychosocial symptoms of dementia are common with every form of progressive dementia, particularly in the moderate stage. The three most troublesome symptoms are agitation, aggression, and wandering. 

    Problematic behaviors that occur during meals or bathing can be particularly challenging. It is important to recognize and realize that any new behavior could be a sign of an acute illness or an environmental influence. 

    Unrecognized pain can cause disruptive behavior. Short-term use of physical restraints may be necessary, but those selected should always be the least restrictive type and used for the shortest duration of time. 

    The Progressively Lowered Stress Threshold (PLST) is a framework to optimize function, minimize disruption, and help the caregiver (Smith, Hall, Gerdner , & Buckwalter, 2006). 

    The PLST model increases the positive appraisal and decreases the negative appraisal of the caregiving situation ( Stolley , Reed, & Buckwalter, 2002) and helps the caregiver manage the aggressive behaviors demonstrated in AD (Lindsey & Buckwalter, 2009). 

    By adapting the environment and routines, interventions are designed to help the patient with dementia use his or her functional skills and minimize potentially triggering reactions. There are six essential principles of care in the PLST:

1. Maximize safe function: Use familiar routines, limit choices, provide rest periods, reduce stimuli when stress occurs, and routinely identify and anticipate physical stressors (ie, pain, urinary symptoms, hunger, or thirst).

2. Provide unconditional positive regard. Use respectful conversation, simple and understandable language, and non-verbal expressions of touch.

3. Use behaviors to gauge activity and stimulation: Monitor for early signs of anxiety (eg, pacing, facial grimacing) and intervene before behavior escalates.

4. Teach caregivers to “listen” to the behaviors: Monitor the language pattern (eg, repetition, jargon) and behaviors (eg, rummaging) that might be showing how the person reduces stress when needs are not being met.

5. Modify the environment: Assess the environment to ensure safe mobility and promote way finding and orientation through cues. 6. Provide ongoing assistance to the caregiver. Assess and address the need for education and support.

Advance Planning and End-of-Life Care Interventions

    Advanced planning and providing directives for care are important in guiding the types of interventions used at the end of life and can decrease the caregiver stress in proxy decision making. 

    Nursing homes are common sites for EOL care for people with progressive dementia; however, only 51% of all nursing home residents nationally have an advance directive (Mezey, Mitty, Bottrell, Ramsey, & Fisher, 2000). 

    As many as 90% of the 4 million Americans with dementia will be institutionalized before death (Smith, Kokmen , & O'Brien, 2000), making this environment in particular an important focus for EOL care.

     There is a lack of research published on EOL care in nursing homes and most of it is descriptive (Oliver, Porock , & Zweig, 2004). The end stage of AD may last as long as 2-3 years (Brookmeyer, Corrada , Curriero , & Kawas, 2002) and frequently distressing signs and symptoms occur at this time.

    Dementia itself or often-associated conditions can cause physical symptoms such as poor nutrition, urinary incontinence, skin breakdown, pain, infection, shortness of breath, fatigue, difficulty in swallowing, choking, and gurgling in addition to the behavioral symptoms mentioned earlier. 

    There is no acceptable standard treatment for the consequences of advanced dementia and, where guidelines do exist, there is minimal to no palliative care content. 

    Aggressive treatments such as antibiotics, tube feedings, psychotropic drugs, and physical restraints to address problematic behaviors appear to be prevalent, although there is no substantial evidence that these approaches are effective in end-stage dementia and that prognosis and life expectancy are improved by these strategies (Evers, Purohit, Perl, Khan, & Marin, 2002). 

    Measuring quality of care at the end of life for those with dementia poses significant challenges because of the limitations in subjective reporting and therefore relies on the caregiver's analysis of cues to monitor the patient's condition and experience ( Volicer , Hurley, & Blasi, 2001 ) . 

    Despite the clear recognition that significant improvements in EOL care for those with dementia is needed ( Scherder et al., 2005), there is a lack of systematic evidence on how to approach palliative care for this population (Sampson, Ritchie, Lai, Raven, & Blanchard, 2005).

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