Course excerpt from Alzheimer’s Disease: A Practical Guide
There are many treatable medical conditions that cause dementia or what appears to be dementia. Do not assume a person has dementia until other causes have been ruled out. These include:
• Medication drug interactions, side effects, or drug overdose (generally unintentional)
• Alcohol or substance abuse/withdrawal
• Vitamin and mineral deficiencies due to poor diet, such as vitamins A, C, B-12 and folate
• Traumatic brain injury due to falls, car accidents, or other trauma
• Hormonal dysfunction, primarily thyroid problems
• Metabolic disorders such as dehydration, kidney failure, or Chronic Obstructive Pulmonary Disease
• Infections, such as urinary tract infections or pneumonia
• Heart disease
• Brain disease, especially tumors
• Environmental toxins (AZC, 2017)
It is vital to assess whether a person has an underlying treatable condition that may relate to cognitive difficulties. Early detection of symptoms is important, as some causes can be treated. Medical and physical symptoms should be considered when memory concerns arise. These signs and symptoms include:
• Any new change or decline in vision or hearing
• Any dental concerns, especially those that could be contributing to pain or change in eating habits
• Seizure activity, either new suspected seizure activity or an increase in seizure frequency in an individual with a known seizure disorder
• New or worsened incontinence of bowel or bladder
• Weight fluctuations, either a noticeable gain or loss
• Change in appetite
• Any observed swallowing difficulties
• Sleep difficulties or other abnormal sleep patterns or habits
• New difficulty walking or changes in walking abilities
• Falls or increased risk of falls (for example, being unsteady or unaware of obstacles)
• Pain, either directly reported or suspected through observation of facial expression or other non-verbal clues.
A thorough review of the medication list is an important initial step in the evaluation of any new onset change or decline from baseline. Aging individuals may see multiple doctors and specialists, who can potentially prescribe medications or change treatment plans without collaborating with the others. Any time the medication list expands or new prescriptions are started, there is an increased risk of the medications interacting negatively, combining to make side effects more potent, or causing confusion and problems thinking.
Furthermore, as people age, their bodies change in ways that can influence how medications affect them. Older adults’ brains begin to change in structure and ability. Changes in digestive and circulatory systems, kidneys, and livers affect how fast medications are absorbed, metabolized, and removed from the body. Weight changes may affect the amount of medication older adults need, and how long the drugs stay in their bodies. Medication that was once well-tolerated may now make the elder forgetful and sleepy.
There are numerous types of medications that have potentially adverse effects on alertness and mental clarity and can contribute to symptoms of confusion, dizziness, and walking and balance disturbances. These include certain antihistamines, anti-anxiety and antidepressant medications, sleep aids, antipsychotics, muscle relaxants, antimuscarinics for urinary incontinence, and antispasmodics for the relief of cramps or spasms of the stomach, intestines, and bladder. Some of the drugs that can cause cognitive problems in older adults are sold over the counter. All medications, including prescribed, over-the-counter, and herbal medications should be periodically reviewed with a health care provider to make sure that all medications are necessary and that their benefits outweigh any unwanted risks (NDS, 2017).
Examples of medicines that can cause adverse effects include:
• Benzodiazepines, which treat anxiety, sleeplessness, and agitation, may increase older adults’ risk for memory loss, delirium, cognitive impairment, falls, fractures, and motor vehicle accidents. Health care professionals need to carefully consider these side effects when treating older adults and limit the use of benzodiazepines to treating conditions such as seizures or other neurological conditions, alcohol withdrawal, severe generalized anxiety disorder, and anesthesia, as well as end-of-life care. Benzodiazepines include Xanax®, Valium®, Ativan®, Librium®, and Versed®, among others (NAM, 2015).
• Medications that have anticholinergic effects – These drugs block one of the chemicals (acetylcholine) that brain cells use to communicate with each other. A drug’s anticholinergic effects can cause older adults to experience confusion, memory loss, and worsening of other mental functions, among other things. Several research reviews show links between drugs with anticholinergic effects and cognitive problems in older adults, such as delirium, cognitive impairment, and dementia. Some drugs with anticholinergic effects include Benadryl®, Cogentin®, Zyprexa®, and Seroquel®.
Delirium is a common and often preventable contributor to the cognitive decline in older adults. Health care providers can play an important role in identifying patients at moderate to high risk for delirium, especially in pre-surgery, intensive care, and post-acute care settings, where it occurs most often. Common risk factors for delirium include age greater than 65 years, hospitalization, chronic cognitive impairment or dementia, current hip fracture, severe illness, multi-morbidity, depression, cerebrovascular disease, and alcohol or substance withdrawal.
The American Delirium Society (2015) notes that each year, over 7 million Americans suffer from delirium while hospitalized. People who experience delirium in the hospital (compared to people without delirium) are more likely to:
• Have a longer hospital stay and greater hospital associated complications.
• Have higher mortality rates, both while in the hospital and up to a year later.
• Need long-term care after hospitalization due to loss of physical function while in the hospital.
• Develop dementia even if delirium is resolved during the hospital stay.
Hospitals are not likely to recognize delirium. The Society estimates that more than 60% of patients with delirium are undiagnosed during their hospital stay.
Older adults often react differently to common medical conditions. A urinary tract infection, pneumonia, pain, myocardial infarction and even constipation can cause delirium. When experiencing delirium, a patient may suddenly be unable to concentrate or pay attention. They may show erratic behavior, such as panicking and trying to leave the room because they think the room is on fire. Once the underlying medical problem is resolved, the person’s confusion and agitation will clear.
Confusion and delirium are not normal for older adults. Check for underlying medical issues first.
It can be difficult to know whether a person has dementia or is experiencing delirium. To the untrained observer, the symptoms look similar.
Delirium can often be prevented by avoiding the use of indwelling bladder catheters, ensuring the person drinks enough water, providing adequate pain control, getting the person up and walking early after surgery, and making sure the person has adaptive devices such as hearing aids and eyeglasses. Additional prevention includes allowing hospitalized older people to sleep undisturbed between 10 p.m. and 6 a.m. so that their normal sleep cycle is less disrupted (AZA, 2018c). Guidance from the American Geriatrics Society (McCormick, 2015) gives the following evidence-based recommendations for delirium prevention and management:
• Nonpharmacological interventions should be administered to at-risk older adults to prevent delirium. These include walking; orienting older adults to their surroundings; sleep hygiene; and assuring adequate oxygen, fluids, and nutrition.
• Healthcare professionals should have ongoing education about delirium.
• Each hospitalized person should be evaluated medically to identify underlying factors that could cause delirium and manage those factors proactively.
• Postoperative patients should have adequate pain control.
• Avoid medications that might cause delirium.
• Avoid the use of Cholinesterase inhibitors to prevent or treat delirium. These are drugs to treat Alzheimer’s disease and include Donepezil (Aricept®), Rivastigmine (Exelon®) and Galantamine (Razadyne®).
• Benzodiazepine drugs should not be the first choice for agitation treatment. Neither benzodiazepines nor antipsychotics should be used for people with hypoactive delirium.
• Restraints should be avoided if at all possible. They may increase the person’s agitation.
Alzheimer’s Disease: A Practical Guide is a 3-hour online continuing education (CE/CEU) course that offers healthcare professionals a basic foundation in Alzheimer’s disease prevention, diagnosis, and risk management.
This course will present practical information to aid healthcare professionals as they interact with clients who are diagnosed with any of the many types of dementia. We will review what is normal in the aging process, and what is not; diagnostic criteria for Alzheimer’s disease; testing cognition and gene testing; risk factors; and clinical research. We will then discuss the struggle caregivers face and provide strategies for how best to support them.
The next section will provide practical guidance for caring for a person with Alzheimer’s disease, including daily care activities, keeping the person safe, and unwanted behaviors. Next we will review prevention and compensation strategies to help people protect their cognitive health as they age, including modifiable risk factors that have the potential to reduce the prevalence of Alzheimer’s disease. A final section on protecting our elders from scams and how to find reputable resources for information is included.
Course #31-12 | 2018 | 56 pages | 20 posttest questions
CE Credit: 3 Hours
Learning Level: Introductory
Professional Development Resources is approved to sponsor continuing education by the American Psychological Association (APA); the National Board of Certified Counselors (NBCC ACEP #5590); the Association of Social Work Boards (ASWB Provider #1046, ACE Program); the American Occupational Therapy Association (AOTA Provider #3159); the Commission on Dietetic Registration (CDR Provider #PR001); the Alabama State Board of Occupational Therapy; the Florida Boards of Social Work, Mental Health Counseling and Marriage and Family Therapy (#BAP346), Psychology & School Psychology (#50-1635), Dietetics & Nutrition (#50-1635), and Occupational Therapy Practice (#34); the Ohio Counselor, Social Worker & MFT Board (#RCST100501); the South Carolina Board of Professional Counselors & MFTs (#193); the Texas Board of Examiners of Marriage & Family Therapists (#114) and State Board of Social Worker Examiners (#5678); and is CE Broker compliant (all courses are reported within a few days of completion).