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DEMENTIA
AND BEHAVIOR
Alzheimer’s Disease (AD)
or Dementia of the Alzheimer’s Type (DAT) is, by far, the most
prevalent form of dementia, accounting for approximately 60% of
dementias. The onset of Alzheimer’s Disease is insidious and the
course is one of progressive deterioration.
Personality changes
associated with Alzheimer’s Dementia.
Personality changes are as
much a part of AD as cognitive difficulties and can be among the
first symptoms of the illness. Two-thirds of patients exhibit
passive behaviors early in the course of illness, including becoming
less cheerful, less responsive, and less active, with passive
behaviors maintained throughout the course of illness. During early
stages of the disorder, depression is often present and can result
in exacerbation of cognitive deficits. In middle stages, dependency
and anger are common. AD is associated with four behavioral changes
included in the definition of major depression – decreased
interest, poor concentration, fatigue, and changes in psychomotor
activities. Some symptoms shared by AD and depressive disorder which
are thought to be secondary to the cognitive (not mood) disturbance
in AD include: flattened affect, paucity of speech, slowed gait, and
generalized psychomotor slowing.
In the late stages of AD,
the sleep-wake cycle becomes disrupted, patients frequently pace and
wander and lose the ability to perform ADLs (dressing, feeding,
personal hygiene). In very advanced stages, motor deficits include
rigidity and bradykinesia. Terminal stages of AD are characterized
by mutism, inability to ambulate, and loss of sphincter control.
Stages of Cognitive
Impairment and Associated Behavior Problems in Dementia
Stage 1) Normal. No
subjective complaints of or objective manifestations of cognitive or
functional decline.
Stage 2) Normal aged
forgetfulness. Subjective complaints of cognitive decrement.
Longitudinal studies indicate that most elderly people with these
complaints do not decline when followed over intervals of a few to
many years.
Stage 3) Mild neurocognitive
disorder. Deficits become manifest, but are only subtly manifest in
the context of a detailed clinical interview. People at this stage
can generally carry out simple and complex activities of daily life.
However, people at this stage who engage in complex occupational and
social activities may begin to manifest performance deficits that
become evident to others who know them well. Concentration and
calculation deficits, memory deficits, decreased performance on
queries related to orientation may be evident as well as deficits in
a variety of cognitive tasks (i.e. copying designs, calculations).
Deficits are subtle and only evident to the clinician. Symptoms in
this stage may persist for as long as 7 years.
Stage 4) Mild Alzheimer’s
disease. Deficits become readily manifest in the course of a
detailed clinical interview, but people at this stage can still
potentially maintain themselves independently in community settings.
Deficits in complex ADLs such as managing personal finances and
cognitive deficits become overtly manifest. Concentration and
calculation deficits, overt deficits in recent memory, remote
memory, and orientation are observed. Persons at this stage are
often quieter, more withdrawn, and walk more slowly. One third of
patients have affective disturbances, with depression predominant.
Anxieties may develop about personal finances or income taxes.
Duration: 2 years.
Stage 5) Moderate Alzheimer’s
disease. Deficits preclude independent community survival. Patients
lose the ability to choose proper clothing to wear for the season
and activities. Concentration impairment and calculation deficits
with errors evident during subtracting serials 2’s from 20 are
apparent. Major current aspects of personal and public life are
frequently not recalled. Persons at this stage invariably know their
own names and generally know their spouse’s and children’s
names. Remote memory deficits are not overt unless the clinician
queries in detail. Orientation is impaired such that the patient
might not know the current year. Mood disturbances increase.
Tearfulness and agitation are increasingly evident, although
magnitude is greater at the next stage. Fear of being left alone
often develops at the same time as the patient loses the ability to
manage independently, with 40% of patients in stages 5 and 6 having
this problem. Fear of bathing commonly develops. Slowing of gait and
withdrawal are more evident. Paranoid and delusional ideation is
frequently present: 40% of patients have suspicions that spouses or
caregivers are hiding or stealing objects from them; 25% have
suspicions related to the nature of domicile (i.e. "take me
home" when at home). Sleep disturbances are characterized by
fragmented sleep (frequent awakenings in the course of the night
apart from purposes of urination). Duration: 1.5 years.
Stage 6) Moderately Severe
Alzheimer’s disease. Individuals require assistance with basic
ADLs, losing the ability to bathe and dress without assistance and
experiencing increasing difficulties with toileting. Some patients
become anxious about toileting, going to the toilet repeatedly. Fear
of being left alone continues to be prevalent. Patients have
difficulty counting backward by 1’s. patients almost always recall
their own names and frequently continue to be able to distinguish
familiar from unfamiliar persons, although my occasionally forget
the name of their spouses. In the latter part of this stage, the
patient’s spouse is frequently confused with a dead parent. Speech
ability declines, with repetition of words or phrases (verbigeration),
interspersing genuine words with neologisms, or paucity of speech
common. Hallucinatory disturbances (visual most common) generally do
not by themselves require treatment apart from reorientation and
reassurance. Activity disturbances peak in the sixth stage, with
verbal repetitive behavior, pacing, wandering, and moving or hiding
objects. Aggressivity, which can be considered a response to both
circumstances and neurochemical changes, peaks in frequency and
intensity, with 25% of patients exhibiting threatening or violent
behavior. Affective disturbances are common in this stage. Diurnal
rhythm is frequently disturbed. Duration: 2.5 years.
Stage 7) Severe Alzheimer’s
disease. Patients require continuous assistance with basic ADLs. One
third of the US nursing home population is at this stage of
dementia. Speech abilities are severely limited – repeated queries
directed at the patient collectively produce responses of no more
than 6 intelligible words. Early in this stage, ambulatory abilities
remain intact. After speech ability is lost, ambulatory ability is
invariably lost. Early in the final stage, behavioral problems
decrease, with the exception of screaming which is a dramatic
symptom of early stage 7. Generally die approximately 2 years after
onset of this stage.
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ACT Clinical Staff
Assist Facilities in the Management of Behavioral Problems
Associated with Dementia
The first step to developing
a plan to manage behavioral problems associated with dementia is
careful evaluation of the resident. Depression in the elderly can
often present with severe enough cognitive disturbance to mimic the
dementia syndrome ("depressive pseudodementia") and is
distinguishable from AD or other dementias by careful history and
clinical examination. Identification of these patients is
particularly important since cognitive symptoms often disappear
following successful treatment of the underlying depression. Through
careful diagnostic evaluation, ACT clinicians can identify and
provide treatment for depression which might otherwise be presumed
to be primary dementia.
ACT psychologists can assist
in the management of residents with dementia through careful
assessment of cognitive and behavioral functioning. Facility staff
can then use this information in the development of care plans and
behavior intervention programs for these residents.
Finally, ACT psychiatrists
have extensive experience in pharmacological interventions which can
help alleviate some of the behavioral symptoms associated with
dementia. ACT psychiatrists provide ongoing monitoring of patients
receiving psychotropic medications to insure that medications are
effective and that the lowest possible therapeutic dosage is used.
COPING
WITH WANDERING
- If wandering
begins suddenly, have a thorough medical evaluation.
- Consider physical
causes – i.e. pain, hunger, cold, need to use restroom
- Arrange for
safe/secure location for the individual to wander
- Use distractions
– break up the area
- Camouflage
off-limits areas (i.e. exit doors)
- Help direct
confused individuals with clearly labeled rooms
- Remove items that
may trigger the response to leave (i.e. purse, coat, etc.)
- Provide meaningful
activities
- Provide
opportunities for exercise
- Reduce noise and
confusion in the environment
- Redirect, don’t
confront, wandering individuals. Use a calm, soothing tone of
voice.
Special
Events
 Happy
Birthday to Dr. David Cook, Mrs. Doris Moore, Dr. Linda Allen, Mrs.
Jean Patel, Dr. Pete Boyle, and Dr. Bob Zozus
Ms.
Karen Carlough, Executive Assistant celebrates her 2-year
anniversary with ACT, Inc. on November 4th.
ACT,
Inc is saddened by our loss of team member Dr. Kevin Richards
. We congratulate him on his new position with an
Atlanta-based hospital, where he may be near his children.
ACT,
Inc. welcomes new team members-
Dr.
Evans Mandes, clinical psychologist
Dr.
Linda Evans, Public Relations Specialist
Mrs.
Elizabeth "Scottie" Harrell, Billing Clerk
HAPPY
HOLIDAYS
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