Toolbox for Dementia | Comprehensive Case Management Certification

Welcome to Case Management Toolbox podcast, sponsored in part by All CEU's Continuing Education. I'm your host, Dr. Donnelly Snipes. Case Management CEUs are available for these podcasts@allce.com slide that's allceus.com casemanagement I'd like to welcome everybody to today's presentation of Case Management Toolbox. Today we're going to be talking about dementia Case management I am Dr. Donnellice Snipes. Today we're going to review the symptoms of dementia and differentiate between dementia and normal aging. Will review the types of dementia, possible causes and preventative factors for dementia and finish by looking at the biopsychosocial needs of people with dementia and their caregivers. Some great resources that you can go to online are the Dementia Society of Ottawa and Renfrew counties and dementia. So let's talk first about what is dementia? We hear about it, but what exactly does it look like? It's characterized by changes in cognition, sensory functioning, behavior and emotion. So let's look first at cognitive and sensory changes. Memory loss Memory loss is very common in dementia and it's not just, you know, getting a little bit forgetful. It is pronounced memory loss that impairs psychosocial functioning. Difficulty in communication, especially in finding the right words to communicate or keeping track of a conversation. So somebody with dementia may be talking and they'll be mid sentence and totally forget what they were talking about. Now, again, some of us have that occasionally. I'll be lecturing sometimes and I'll go off on a tangent and kind of forget what. My point was that's not what we're talking about here. We're talking about they just kind of stop dead in their tracks and they can't remember what you were talking about at all. Reduced ability to organize, plan, reason or solve problems. Difficulty handling complex tasks. And this can be depending on the level of dementia. It can be anything from something like cooking dinner and following a recipe to doing work, whatever work entails for them. If it's a complex task, confusion and disorientation, including getting lost in familiar places, maybe they've gone to the same Walmart every day for every week for the past, you know, 10 years. And they go into Walmart and they can't figure out where things are or where they are, or they may get lost in their neighborhood. Difficulty with coordination and motor functions. As this progresses, the brain changes will cause problems with balance as well as some coordination. Now, this is different than Parkinson's disease. There is some dementia that may go along with Parkinson's disease. But this is not necessarily tremors. A lot of it's just coordination, walking, going up and down stairs, those sorts of things. Loss of or reduced visual perception. And this can be changes in ability to perceive colors, distance or see at night, etc. A metallic taste in their mouth and a decreased sense of smell. So if you're working with a client who starts complaining about these things, then you might want to kind of pay attention to what's going on. If you're working with a client and they start showing any of these symptoms to a greater degree than you would expect based on their current situation, be concerned. I know some people are specifically hypersensitive to painkiller medications, for example. So after surgery they may be a lot more foggy headed and have a lot of these symptoms. But as soon as they're not taking that medication, those symptoms go away. We want to make sure this is something that's pervasive, it's not due to medicine. And we're going to look at some other causes of what we'll term reversible dementia as we go through this presentation. The final cognitive symptom of dementia that I want to mention is agnostia. This is the loss of ability to recognize objects, people, sound, shapes or smells. The sense is not necessarily inferior, so they're hearing may not be inferior, but they may not recognize people's voices. Their sight might not be, you know, too bad. It may be appropriate for their age, but they may not recognize people when they see them. In progressed cases, they may see something like a dog and not be able to identify what it is. They won't be able to label it as a dog. Psychological changes that occur in dementia, there are changes in personality and behavior. A lot of times there's greater regression and people may become more irritable and have more difficulty with higher order complex thought reasoning, things that we attribute to adults, if you will. There is often depression, anxiety. Some people may have hallucinations. It's important to be aware of that so we recognize and we can help somebody with dementia. If they're having hallucinations, it can be quite frightening to them, Helping them understand, you know, that they're safe. Their hallucinations are very real to them. We don't want to get into a power struggle arguing about what is and isn't there, but ensuring that they feel safe. There may be mood swings, there can be agitation, especially with changes in routine. One of the things, if you're working with somebody with dementia, you want to try to Maintain the same routines most of the time. If there's going to be a change, give them a heads up that there is going to be a change in the routine. And ideally have a safety kit that if you want to call it whatever you want to call it, something that you can carry with you. So if the person starts getting agitated, you can help distract them. For some people, that will be their emotional support animal. For other people, that may be a blanket that they can put on their lap or something that they can fidget with when they start getting nervous because things are not the way they're supposed to be. Depends on the person. You need to figure out what types of things are going to help them de escalate when they start to get agitated. And remember when you're dealing with dementia that what works today may not work tomorrow. Partly because of the progression of the disease. What worked a month ago may not work now. But you can have changes day to day or even hour to hour in what may work. So you want to have multiple tools in your toolkit to present in order to try to figure out how to best help this person. And they're not trying to be difficult. They are responding to their sensory input. And, you know, think about what it must be like if you start having difficulty remembering things, you lose your train of thought, you get confused really easily, can't figure out where you are. That can be really scary. Put some hallucinations in on top of that and you know, the world can be very intimidating for people. So one of the things that we do typically when we are under a lot of stress is we try to control things as much as possible, which is why changes in routine can really freak somebody out. The other thing that you want to pay attention to is if they are showing signs of apathy, they just, they don't want to do anything, they don't care about anything. And they may start isolating and withdrawing. And you're going to find out a little bit later that isolation and withdrawal typically speeds up the progression of the disease. As I've talked about already a little bit. There's often some confusion about the difference between normal aging and dementia. Part of what we're talking about, if you just want to make it really simple, is degree. A lot of the symptoms that people have in dementia, people have in normal aging, but it's. They're much smaller, much less intense than in dementia. In normal aging, they can be kind of annoyances. Sometimes in dementia, they actually interfere with daily functioning and the ability to live independently. In normal Aging people have occasional forgetfulness. I remember my grandfather, God bless him, there was one day that he ran around the house for what seemed like forever to me, because I was younger, and he was looking for his glasses, and he couldn't find his glasses, and we kept looking everywhere. For some reason, he had set his glasses down in the refrigerator. My guess is he had his glasses on. He took them off, and he reached in to get something from the refrigerator. But then he needed a hand to shut the door. So he put his glasses down in the fridge, transferred what he was carrying to his left hand, and shut the door with his right hand. But, you know, who would have thunk to look in the refrigerator for his glasses? Now, later on in life, he did develop, you know, some problems with cognitive functioning. But this was 20 years before that. This was, you know, kind of what was probably normal aging at that point. You can use notes as reminders for people who have occasional forgetfulness. You know, that's often helpful to remind them, you know, what they need to do. In normal aging, people have slower processing. It takes them a minute to gather things. So whether you're playing chess with somebody or you're having a conversation, or they're trying to learn something, it takes a little bit longer. It's not impossible. You just have to give them a little bit more time, which is especially true if it's a complex task that they're trying to accomplish. People who are experiencing normal aging, it takes them longer to learn new information. If they're reading a book or learning about gardening or picking up a new hobby or whatever it is they're trying to learn, it's probably going to take them longer than it did when they were twins. They may have difficulty finding the right word. They have this word that's, like, right on the tip of their tongue, and they're trying to find it again. That's something that I experience kind of frequently. That doesn't necessarily mean that somebody is on their way to dementia. We want to give the person time to find that right word. And if they're having difficulty, give them some time. And then at a certain point, you may offer, you know, try to figure out what their. What word they're looking for and offer it up to them. In normal aging, people have slowed, slowed reaction times. Driving becomes a little bit more hazardous. But other reactions, such as when they slip and fall. When we're younger, we have faster reaction times. We can brace ourselves better. When people are older, those slowed reaction times may contribute to more problematic falls. They are able to complete their activities of daily living. In normal aging, people can bathe by themselves, they can brush their teeth, etc. As people get older, you know, once they start getting into their upper 80s, their 90s, so on and so forth, There may be a point where there are some things that aren't quite as safe. When my grandmother got into her 90s, she would forget to turn off the stove. And, you know, that was. I don't think she was at the point where you would call it dementia. She sure wasn't as spry as she used to be. But there were some concerns that we had about her safety, being alone. But she was 92 years old. I mean, for goodness sakes, we want to make sure that people are safe in normal aging. And in normal aging, people, as I said earlier, have problems with balance as our muscles change, as our body changes as we get older, we may have a little bit more difficulty with balance as our vision changes as we get older, may have difficulty with balance as our reaction times slow. So when we trip when we're younger, we can generally catch ourselves when we're older. When people are older, they may fall more easily. And a lot of times, people who are older are also on medications that can affect their balance, Everything from blood pressure medication to psychotropic meds. That's not dementia. That's a side effect of the medication. We do need to be aware of it. To sum it up again, in normal aging, you're going to see a lot of the same issues that you're going to see in dementia, but to a much smaller degree. The forgetfulness is definitely manageable in normal aging, etc. Let's talk briefly about some different types of dementia, because it's not just Alzheimer's. In Alzheimer's disease, we're all familiar that that's a progressive type of dementia. In stage one, the Alzheimer's has started to develop, but there are no symptoms of memory loss yet. And this stage can last up to 20. Lot of times people don't start getting their diagnosis of Alzheimer's until, you know, in their mid-50s at least. So, you know, from there to 20 years, that's 75, 76. Then it may start progressing when they get into their 80s and 90s. The point is that if somebody gets a diagnosis of Alzheimer's and they're, you know, still in what you would consider midlife, you know, under 65, helping them recognize, or whatever age they get, helping them recognize that they may stay in this stage for up to 20 years, you know, let's not just throw in the towel yet. There's plenty of time before stage two sets in. Stage two is mild cognitive impairment and involves mild changes in memory and thinking skills. This is where you're getting a little past normal aging, but still definitely generally manageable. The person may need more prompts, may need you to check in on them on a daily basis, but a lot of times in stage two people are still able to live relatively independently. Generally in stage two, it's better if they have at least a roommate, but they're not needing 24 hour care. In stage three, this is late stage dementia or what we call typically refer to as Alzheimer's dementia. In this stage, memory and thinking skills are so impaired that the person needs help to complete daily activities of living. Bathing, brushing their teeth, cooking, remembering to eat. They may get confused very easily. Another type of dementia is Korsakoff syndrome or Wernicke Korslokoff syndrome depending on the presentation. We not all Korsakoff syndrome goes on to become Weirnicky Korsakoffs, but Korsakoffs is what we're going to be concerned with. Korsakoff syndrome is most readily seen in people who are alcoholic. Alcohol has a direct toxic effect on the brain cells and it can also be caused by the fact that alcohol not only is it toxic to the brain cells, but it's causes deficiencies in the B vitamin thiamine. And when that happens, you start seeing cognitive impairment and what's referred to as Korsakoff syndrome. If you have a client, regardless of whether they are labeled an alcoholic, quote unquote, if they are a moderate to heavy drinker and they decide to detox themselves or stop drinking cold turkey and they start showing signs of dementia, it is a medical emergency. They need to get to the emergency room so they can get an IV of thiamine. The longer they are in this toxic state, the longer they're experiencing Korsakoff syndrome, the lower their prognosis for recovery. If it's nipped in the bud, so to speak, a lot of times people make a almost complete recovery. Another place that you may see Korsakoff syndrome is in people with anorexia and those who've had bariatric bypass surgery. Both of these conditions also lend themselves to thiamine deficiency. Why am I bringing that up? If you're working with a client who is not eating well, or you know, maybe they had bypass surgery when they were 30 and now you're working with them and they have some early signs of dementia and they're not eating well or they're not following their dietary guidelines, you may start seeing signs of Korsakoff syndrome. It's important at that point to make sure again, it's a medical emergency. Get them to the doctor to be evaluated and potentially get an IV of vitamin B.1. Older people, especially older people with dementia, are also prone to forgetting to eat or to not eating enough, which when we talk about anorexia, it doesn't have to be necessarily the eating disorder. Anorexia in general, the term means not eating enough. And a lot of people who are elderly, especially those with dementia, will forget to eat. And if they do that for long enough, they may start having a vitamin B deficiency. The earlier you can catch this, the better their prognosis. So even if they've got some other kind of dementia, let's not add Korsakoff syndrome on top of it. Another type of dementia is AIDS dementia complex. It's present in about 7% of people that are not taking anti HIV drugs. So as the, as AIDS progresses, it starts impacting the brain and it can develop into AIDS dementia complex. If you've got a client again that you're working with, and maybe you are working with them as a case manager for HIV and you know, everything's going along swimmingly, whatever, and all of a sudden they start showing signs of dementia. We can't rule out the AIDS dementia complex. And finally vascular dementia, and this is probably next to Alzheimer's, the most common type of dementia. It includes a wide range of symptoms caused by a reduction in blood supply to the brain, usually due to strokes or heart attacks. Now it can happen if the person, you know, regularly loses oxygen supply because of, you know, they're strangling themselves or something. But I mean, they have to lose blood supply to their brain. Symptoms can develop a month or more after a major stroke. If somebody has a major stroke and they get out, they go through rehab, three, four weeks later, they're discharged from the long term care facility and they're still having some case management. People coming in to work with them, maybe a cna, come in once a day to check on them and do stuff. You could at that point still see dementia start as a result of the vascular injury. The main symptom of vascular dementia is slowness and thinking, speed, problems concentrating and difficulty planning and organizing. So what you're going to look at is compared to prior to the stroke, after the stroke is the person showing a markedly different rate of thinking and ability to concentrate. It's also common for persons with vascular dementia to experience mood Changes. If somebody starts having mood swings or becomes particularly irritable, aggressive, depressed, it needs to be checked out. You don't want to wait. If it's one day, you know, you might kind of wait and see how they're doing tomorrow, depending on the degree. But if it goes on for a couple of days, it's definitely worth getting checked out. Dementia with Lewy bodies is often misdiagnosed as Alzheimer's disease, Parkinson's disease and dementia with Lewy bodies and produces similar brain changes. So that's kind of almost indistinguishable when you're looking at the mri. The main symptom in dementia with Lewy bodies are memory loss, disorientation, visual hallucinations and sleep issues. People with Parkinson's disease, at some point, up to 50%, I believe, is the stat, at some point during the course of their disease, may start experiencing dementia and hallucinations. As I said earlier, it is so important for us to make sure that they know that they're safe when they start having these hallucinations. Dementia with Lewy bodies often lasts an average of five to eight years from the time of diagnosis to death, but the time span can range anywhere from 2 to 20 years. Helping people figure out what they need to do to extend their lifespan after they get this diagnosis and reduce the progression or slow the progression is going to be really important. And frontotemporal dementia is not really common. The main functions affected by frontotemporal dementia, as you would expect, frontotemporal area of the brain, are language skills, the ability to focus, and the ability to control impulses. This type of dementia is more commonly seen in people under the age of 65. There are other, and I put reversible with a question mark here, because the degree that they're reversible kind of depends on when you catch them and the person. But there are things that can cause dementia that can be, address and reduce or at least halt the progression of the disease. Clinical hyperthyroid and hypothyroid so any thyroid issues that have too much or too little thyroid hormone have long been linked with reversible cognitive impairment in patients. Once the thyroid issue is addressed, generally the cognitive impairment goes away. Cognitive impairment, dementia and psychosis have also been described in patients with chronic, chronic hypocalcemia. That means too much calcium hypoparathyroidism. And the parathyroid gland is a gland in your neck. And when it is dysfunctional, it can cause cognitive impairment and hypercortisolism, which we've talked about before when we've talked about the HPA axis, the fight or flight response. Hypercortisolism. Remember, cortisol is your stress hormone. Hyper means too much. When people are under excessive stress, they're going to have a fair amount of cortisol. People with PTSD may exhibit hypercortisol responses to stress triggers, which means that people with PTSD early in life, we want to prevent this situation where their brain and their body is constantly bathed in too much cortisol because that's toxic to the, to the brain cells. We want to help them address that PTSD. Hypercortisolemia is also evident in approximately 50% of depressed patients, especially those with the melancholic subtype. Think about a lot of the people that we work with who may have dementia or may be experiencing cognitive issues and they're depressed people as they age, especially going through age related changes, experiencing the grief and all that stuff that goes along with those developmental stages. Some people experience a fair amount of depression. When they experience this depression, their cortisol levels may go up. And if their cortisol levels remain up during that depression, it can be toxic to the brain and start causing cognitive problems. Additionally, nearly 33% of people with type 2 diabetes have elevated cortisol levels. Oh my gosh. Why is that? Well, during the fight or flight response, when cortisol is released, one of the things it does is tell your body to dump blood sugar. It says, there's not enough blood sugar. We need some more fuel for the fight or flight response. People with type 2, type 2 diabetes, when they have recurrent severe hypoglycemic episodes, low blood sugar cortisol is just dumped into their system in order to get their blood sugar up. Their brain is trying to help them survive. But again, that much cortisol repeatedly can be toxic to brain cells. We want to help people who are well, regardless of how old they are. If we start working on helping people prevent and control diabetes, manage their blood sugar, address their depression and address ptsd, we're going to reduce the risk of the development of dementia in a lot of people, in people who already have dementia. When we start controlling these things, we're going to be able to hopefully and in most cases be able to slow the progression of the disease somewhat because these are all exacerbating factors. We also want to make sure that people are regularly getting their thyroid tested when they go in for their annual exams. Thyroid problems can happen at any point in life. It's not just something that you get when you're a little kid or when you're 50. They can happen at any point in time. Making sure to check those thyroid hormones is really important. Some of the reasons that thyroid hormones may get out of whack are due to changes in hormone levels. And as we age, we know that certain hormones go down drastically which can have an impact on people's thyroid. Another cause of dementia related symptoms is carbon monoxide poisoning. Think about people that you know who may experience, you know, typically when we think about dementia, we think about people who are older. If they are experiencing, if they are older, a lot of times they have difficulty staying warm. So a lot of people who are older may have space heaters. Their sense of smell may not be as good as it used to be. So they may not notice the smell of natural gas if their pilot light goes out in their gas stove. There's a lot of things that can prompt the development of CO2 poisoning. Carbon monoxide poisoning can lead to a delayed onset cognitive decline, beginning days to weeks after apparent recovery from the initial insult. So if somebody was exposed to carbon monoxide and experience carbon monoxide poisoning, you know, again, they get better and then, you know, six weeks, maybe even two months later, they start showing signs of dementia. We want to make sure that this is addressed as quickly as possible. Cognitive decline, personality changes, incontinence, parkinsonism and even mutism may occur, but the majority of victims recover within one year, year. If the dementia was caused by carbon monoxide poisoning, prognosis tends to be relatively good. If they're not exposed to it again, however, there is a recovery period that, so we want to let people know that, alright, you know, this is a side effect of what happened when you were exposed to the carbon monoxide. It will get better, it's just going to take some time. Carbon monoxide is a colorless, odorless gas found wherever fuel is burned, including small engines like your lawnmower or your generator, gas ranges, furnaces, fireplaces and grills. It's very important for people of any age to make sure that they have their gas appliances serviced regularly and they have carbon monoxide detectors in their house to prevent carbon monoxide poisoning. Other sources of carbon monoxide poisoning. If you are going in and you're doing a home study looking for safety issues, you can assess these. You can also generally call the fire marshal and a lot of times they'll come out and do a safety inspection of a house. But furnaces, as I said earlier, chimneys that are closed, if the flue is closed or if the chimney is blocked by a bird's nest or something. Water heaters that are not electric, a gas or propane stove or oven, gas powered space heaters, gas powered clothes dryers, grills, please don't grill inside. Power tools and lawn equipment that use gas, and even an attached garage that regularly houses vehicles. I know in the winter, sometimes we get into our car and we turn it on and we let it run and warm up. Well, even if you've got the door open, some of that carbon monoxide that's building up in the garage is not going to go out the door. Some of it may filter into the house. Symptoms of carbon monoxide poisoning, including carbon dioxide poisoning, include dizziness, blurred vision, weakness and fatigue, confusion, shortness of breath during mild activity, nausea and headaches. So what are we looking at? If somebody suddenly starts being more dizzy than usual and having blurred vision, weakness and fatigue, a lot of things could cause that. We want to be kind of aware of that. They're not going to start showing the cognitive signs, if they ever do, until, you know, a period after the carbon monoxide incident. So these are the things that we're looking for. If you go to do a home visit on somebody and they are acting, you know, strangely, they're dizzy, have blurred vision, they're confused, may have nausea or a headache. You want to be aware. If they have carbon monoxide indicators in their house, check those out, check any sort of fuel based appliances that may be in the house and just try getting them out of the house. If getting them out of the house makes the symptoms go away, that's what we call a clue. Dementia is a progressive disease. The speed of progression varies depending on the type of dementia and the person. If the person is gung ho and takes right to early interventions and does everything they can do to delay the onset, then they're going to probably do better than somebody who just throws in the towel as soon as they get the diagnosis. Also, the age at which the person gets their diagnosis is potentially going to affect it. People who get their diagnosis when they're 85 may have more difficulty slowing down the process as opposed to somebody who gets the diagnosis when they're 55. Medical complications can speed the progression of the disease like we talked about earlier. And we're going to talk about some other medical complications. High blood pressure, diabetes, thyroid issues, all can speed up the progression of dementia. But if we control them, then at the very least they won't speed it up. If we get them under control, then it actually may slow the Progression if they were previously not well controlled, and genetics, some people are just going to progress more quickly than others. Authors estimate researchers that as much as 35% of dementia cases could be prevented by targeting nine modifiable factors. The first one is early life education. And they're not exactly sure how these necessarily work, but I'm going to propose some theories for you. They find that people who have more higher education tend to have a lower risk of dementia. My argument there would be it's not so much the education as the opportunity. People who have higher education tend to have higher jobs or higher paying jobs, so they are under less stress, so they have less cortisol. They're also able to access medical care with regularity. So any of these other medical things that may predispose somebody to dementia can be controlled and they typically have better access to nutrition and they're able to eat a healthy diet that helps their immune system function as it should, and yada, yada. So education is important. It is a factor. But my suspicion is it's a factor because it's basically reduces stress and increases the favorability of the environment. Midlife hypertension is a big risk factor for vascular dementia. We want to help people control that. Obesity also increases the risk of dementia. They found that in general, obesity increases dementia by 42%, it increases Alzheimer's risk by 80%, and it increases the risk of vascular dementia by 73%. So that is a big reason to help people, regardless of their age, to get their weight under control. It's never too late. Diabetes, as we talked earlier, can also contribute to the development of dementia. They suspect that a lot of that is because of the frequent hypoglycemic episodes. So if diabetes is controlled, obviously you can't make it go away. But if it's controlled, then it's not going to have the same impact as if it's. The blood sugar is all over the place. Hearing loss has been associated with dementia as well. And the interesting thing is people who are deaf, you know, don't have any higher rates of dementia than the rest of the population. But what they speculate is that as people age and they start to lose hearing, they start to lose functioning. People who are deaf are in the deaf community and they are embraced by the deaf community and they embrace the deaf community so they don't feel socially isolated. As people get older, if they are losing a function that they once had and they feel like they're becoming more and more isolated, then that can contribute to depression, which can contribute to the development of dementia, old age. Smoking is a risk factor. As we get older, our veins and arteries and stuff naturally stiffen up a little bit. But smoking has a significant impact on our vascular system. So on top of regular aging, if people are smoking in older age, it causes more vascular problems, which contributes to the development of vascular dementia. Depression is associated with dementia, as we talked about earlier, and this could be due to hypercortisolism, like we talked about, or just unstimulating environments. As people become when they're depressed, they become physically inactive and withdrawn, and they're not as doing much to move their bodies. They're not getting as much oxygen into their system, which may contribute to cognitive decline. Physical inactivity has been shown to contribute to the development of cognitive problems. Partly they suspect because when we are physically active, we are taking in a lot of oxygen, and that oxygen is fueling the body. Remember, vascular dementia is caused by a depletion of oxygen to the brain cells. Well, you know, if you're not active, you're not cutting off the circulation to your brain, and you're not cutting off the oxygen to the brain cells, but you may be not fueling them or feeding them with as much oxygen as they would really like. And social isolation is also significantly associated with the development of dementia. This is one of those that they're not sure if it's chicken or egg. Social isolation and depression both may be early warning signs of dementia, or they could develop as a result, or they could exist and dementia could develop as a result of those things. So we want to make sure that people don't feel socially isolated. Primary prevention. This is the fun part, regular physical activity. When people engaged in at least 30 minutes of physical activity a day, and that was things like walking two miles, it wasn't anything super intense necessarily. When people engaged in 30 minutes of physical activity per day, they greatly reduced their risk of dementia. This protective factor, interestingly, was increased as the number of activities increased up to about 4. So throughout the week, if one person was going out and walking every single day, that's one activity done seven times. But if they walked some days and swam some days and biked some days and, you know, push mowed the lawn some days, those are four different activities, and the protective factor was actually increased. They speculate that not only does the activity increase oxygen, but it also, when you're doing more activities, you're stimulating more neural pathways, so you're keeping that brain more alive and having to function as opposed to doing the same thing repeatedly where you can kind of do it on autopilot. Higher levels of intellectual activity and an intellectually stimulating environment may also reduce the risk of cognitive decline later in life. Doing puzzles, and it could be number puzzles, it could be playing Scrabble, it could be playing chess, it could be putting together puzzles. Anything that is stimulating going to help. A lot of people show a significant cognitive decline. Not dementia necessarily, but show a significant cognitive decline when they retire because they're no longer going to work and engaging with people. And, you know, there's also an element of depression and social isolation that sets in for some people after they retire. Work with your clients to identify what types of things do they like to do and make those available to them easily. And have an intellectually stimulating environment. You don't want to have them sitting in a room where the walls are white. They've got no pictures on the. On the walls at all. It's just very bland. They don't have any windows, you know, pretty much like a prison cell. That's not okay. We want to have a intellectually stimulating environment. One of the great things about assisted living facilities is they've always got activities going on. The one that my grandmother eventually moved into was wonderful because they required residents unless they were physically unable to come down to eat their meals in the dining room, which sort of forced them to interact with other people. And she thought she'd hate it. At first she was not happy about having to go, but once she got there, she started making friends and she would tell us about the people that she would be eating dinner with and that sort of thing. And the younger Anita, so to speak, started coming back out again. So a stimulating environment just can't be underemphasized. A lower level of education increases the risk of having Alzheimer's disease by approximately 30%. We already talked about the reasons those may be. Again, with higher education. People tend to engage in more intellectual activities and. And maintain a more intellectually stimulating environment. Social engagement, the degree of loneliness, decreased social networking and activities seem to be associated with the higher risk of cognitive decline. Encouraging people to get out and interact. When people start to become homebound for some reason because of mobility issues, it is even more important to make sure that they are getting out and engaging or people are coming in and engaging with them. In order to prevent the onset of cognitive decline, dietary modulation obviously needs to be recommended or prescribed, so to speak, by their doctor, not us. But diets that are high in omega 3s, antioxidants and B vitamins serve to bolster normal Health mechanisms that are a natural deterrent of chronic health conditions such as Alzheimer's disease, but it doesn't really have any specific disease efficacy. It's not like you can say, well, if you eat this one food or take this one vitamin, it'll prevent Alzheimer's disease. No, but we do know that if we keep the body healthier and more oxygenated and physical activity and social engagement and all that kind of stuff, then people tend to have a much lower risk of developing dementia and, or Alzheimer's. And reduction or cessation of symptom progression once the symptoms have appeared can also be accomplished through the use of cholinesterase inhibitors and NMDA agonists like ketamine. These medications may improve acute symptoms, but they don't slow the progression. So if somebody's having a hard time with concentration and they're acutely depressed and, you know, having a lot of acute symptoms, then taking one of these medications may help address the issues of right now. It's not going to slow the progression, but it'll make their quality of life in the moment better. And physical activity, again has been shown to help reduce some of the symptoms of dementia by, you know, increasing oxygenation, keeping those muscles and ligaments and everything loose and active so they have less problem with balance. And generally physical activity is with other people, so there's less social isolation. Physical activity also has been shown to reduce depression in multiple studies. We also want to prevent the development of complications from the disorder, including major depressive disorder. If you have somebody with cognitive decline, early stage dementia, whatever it is right here, we want to help them mitigate their mood. So cognitive behavioral interventions may be useful if someone is still cognitively able to, to participate in those other things, like reminiscence therapy can be useful for helping people address or prevent depression. We want to prevent falls. If people fall, especially older people, they tend to get injured and then be bedridden for a while, which can contribute to pain. It can contribute to social withdrawal and obviously inactivity. All three of those are no good. We want to help them prevent injury. And with dementia, balance and coordination is impacted. So we want to make sure that the dementia symptoms don't prompt a fall and cause other complications, like having to get a hip replaced. Nutritional deficiencies can also happen during dementia, as we spoke about earlier, because people with dementia are often not thinking about, did I eat from each food group? You know, that's not something that they're able to even conceptualize. Short term memory goes first. Generally, people with dementia can remember Things in the distant past, but things in the recent past are way foggier. And diabetes can also be a complication of the disorder if the person is not eating a healthy diet. As a multidisciplinary team, you want to try to work with physical therapists that can help with movement problems through exercises, gait training, and general physical fitness programs. Speech therapists might be helpful with voice volume and projection. And as dementia progresses, people often start having problems swallowing, so speech therapists can help with swallowing issues. Occupational therapists help find ways to more easily carry out everyday activities such as eating and bathing. Music or expressive arts therapists may provide meaningful activities that can reduce anxiety and agitation and improve well being. Counselors can help people and their families learn how to manage difficult emotions and behaviors and plan for the future. And palliative care specialists can help improve a person's quality of life by relieving disease symptoms at any stage of the illness. There are a lot of people besides just the case manager and the doctor who could potentially be involved and help this person slow the progression of the disease and achieve their highest quality of life. The goals that we have for people with dementia include independence, safety, developing a sense of meaning and happiness, and contentment. And there are some general methods that we need to use. Whether you're a case manager or a clinician or doctor, we want to make sure that the person is safe from falls. Look around their house. Do they have stairs that they've got to climb? Do they have rugs that they might trip over? What could contribute to falls? Thinking about a person who's becoming progressively unsteady on their feet. Want to make sure they're safety from, safe from wandering. They can't get out and wander away. Make sure that they're not able to do something where they could get burned, such as if they're working with a gas stove or, you know, or even an electric stove. Make sure that all guns are locked up so the person with dementia can't get access to them because they may forget, if you will, that they're working with them. And make sure that carbon monoxide is controlled for adequate quality sleep is important for clearing up foggy headedness as well as for helping the body rest and repair and rejuvenate. Adequate nutrition. Make sure you're getting those B vitamins and omega 3s. Medication compliance can help delay the progression of the disease. Physical activity. As we already talked about, increased social interactions and ensuring people engage in some sort of meaningful daily activity. We don't want people with cognitive decline or dementia to be sitting on the couch watching TV all day long or sitting in a window just staring out into space. We want them to be able to engage in some sort of meaningful activity every single day. Special Issues for People with Dementia the needs of a person with early onset dementia can be very different from traditional onset dementia because they may be actively working and raising a family and be otherwise healthy and strong. This is especially true as we have started getting older before we've started having children. So it's not uncommon to have someone who is 50 have a child in high school and you know, early onset dementia can hit in mid-40s and after. In the early stage of dementia, a person can still function rather independently and requires little care or assistance. So for these people you may need to have appointment reminders, a daily to do list. If they have medications, they may need to have schedule or put it in one of those little boxes or subscribe to one of the services that prepackages all their medications. Whatever you need to do to help them remember to take their meds, you can also install a medication app on their mobile device that prompts them to remind them to take their medications at specific times. For some, you may need to help them choose their outfits. They may get confused about what's appropriate to wear for what season and this tends to be later in the process. But you can hang complete outfits in the closet and they can pull out a complete outfit. So the complete outfit would have a shirt, pants, underpants, any sort of undergarments the person needs. Go shopping together. If the person is starting to have difficulty remembering and making judgments, or even driving, you may need to go shopping with the person to help them remember what they need to get in order to make sure they have enough food in the house for the week, especially if they can't drive themselves. There are a lot of grocery stores that are starting to deliver groceries, even fresh produce and stuff, so you can check with grocery stores in your area to see if they do deliver. A lot of times there's a real minimal delivery fee and the person doesn't have to ever leave their house. Regular check ins while the person is still living independently is important. With my grandmother we had somebody calling her every morning and somebody calling her every evening to make sure that she was doing okay. Family counseling might be needed to deal with grief issues related to the diagnosis. Regardless of how old the person is, when they get their diagnosis, the family is going to have a lot of adjustment to do. Financial planning and legal planning both need to start happening at this Time while the person with the dementia diagnosis is still cognitively able to make the decisions that he or she needs to. Other things you may need to do include putting notes on the microwave to remind the person not to put any metal things in there, no silverware, or the duration to put put into the microwave to cook common food so they don't get things scalding hot. And coffee makers and other appliances if you can find them, that automatically shut off so the person doesn't have to remember to shut those things off, can be helpful for increasing the period of time that the person can live independently. In middle stage dementia, the person can't function independently anymore. They have greater difficulty communicating, and we're going to talk about some communication tips in a minute. They need assistance with activities of daily living such as bathing, grooming and dressing. Initially, an individual may only need prompts or cues to perform these tasks, but as the disease progresses, they will get to the point that they need actual assistance doing these activities. At this point, transportation is required, they can't drive themselves, and supervision is necessary. In late stage dementia, the person needs a significant amount of care 24 hours a day. There are often mobility issues at this point. Even things like getting in and out of the bed can be a challenge. Swallowing becomes an issue in late stage dementia and caregivers have to make sure food is cut into small pieces and is soft, such as yogurt or applesauce, or is pureed. At this point, people often start looking at options for care because it's difficult for one person to be the full time caregiver. Looking at hiring part time caregivers or moving a loved one to a nursing home can be really difficult decisions for a lot of families and they may need not only emotional counseling but also financial counseling to help them figure out how they're going to make this work. Monitoring tools the functional assessment Staging test and if you're watching this in the video, I'm going to show you an example of it. It is a really awesome tool that can be used to determine basically what stage of dementia a person is at, and it goes from stage one to stage seven. But stages six and seven have sub stages. Stage one, for example, the person either has no difficulty either subjectively or objectively accomplishing daily activities, so for some reason they got the diagnosis, but they're not having any problems right now. In stage two, the person complains of forgetting the location of objects and they start having subjective difficulties at work and doing things that they used to do and it may start to get really frustrating for them. In level three, there's decreased job functioning and difficulty traveling to new locations and decreased capacity for organization. And it goes on like this through all of the stages. But the interesting thing with this is it's a quick and dirty guide, if you will, for assessing where a person is at. But when you do it, it gives you the stage the person is at. It gives you an expected untreated duration. So the person is at stage three, and if they go untreated, then they. It's expected they will stay in this stage for 24 months. Okay. Then it also gives you a mental age, so you can look at how old this person is cognitively in order to help better tailor your communications with them. And then an mmse, the Mini Mental Status Exam for Alzheimer's score, also gives you an idea of the person's status. If you're doing this functional assessment, staging test and say the person was at stage three and it was supposed to last 24 months, but they've been at stage three for six years, well, then they've extended or slowed the progression of the disease by at least four years. That can be something that's really hopeful for a lot of family members to see. You also want to monitor their weight. This is the best way if you're not there around the clock and to make sure that they're eating enough. You want to monitor for infections, pain, and illness. It's estimated that up to 60% of people with dementia have untreated issues because they can't articulate what's going on. They can't tell somebody effectively that their stomach hurts or that they think they've got a fever. We want to look for falls and injuries. Make sure that the person doesn't have any untreated bruises or wounds. Look for behavior changes. This can also indicate that the person has an untreated physical health issue. If they start getting cranky, think about younger children. When they start having an ear infection, their behavior changes. Medication compliance. You want to evaluate not only for the effects. Is it doing what it's supposed to be doing and continuing to do so. Are there any side effects that are of concern that need to be noted? And have there been any medication changes? You want to look at their mood and activities of daily living. Are they able to get up out of bed by themselves? Are they able to get from the couch to the refrigerator, you know, ambulate throughout the house effectively? Are they bathing appropriately? Are they feeding themselves well enough? And are they toileting on their own? Or are they having Accidents. These are all things that need to be assessed at least on a weekly basis. Social engagement what are they doing to engage with other people? If the person is homebound for some reason, like I said, it becomes even more important to make sure to bring people in, relatives, family, whatever it is. If for some reason they can't get there in person, setting them up with some sort of FaceTime arrangement can be really helpful because at least if they can be there via video, then they're getting some benefit of the social engagement. Do remember that people's abilities are going to fluctuate from hour to hour and day to day. Review any medications that the person's taking on a regular basis and consider whether any might be contributing to cognitive deficits, especially anticholinergenics, antihistamines, narcotics, sedatives, and benzodiazepines. Older people, their liver does not clear medications nearly as effectively and as quickly as a younger person, so toxic levels of a lot of these medications can build up in the person's system really quickly. It's important that the prescribing physicians be especially trained in geriatric medicine in order to prevent any side effects. But a lot of people who are older go to your general family practice doctors who don't have specialization in geriatric medicine, and they may end up getting a prescription for something like Valium. And the normal dose of Valium for a younger person is going to quickly be toxic to an older person. For example, add social activities in whatever the person wants to do. What do they like to do? Do they want to go to the park? Do they want to have people in? Do they want to go play chess? What is it that would make them happy? Add intellectual stimulation and meaningful daily activities based on what the person likes to do. What is meaningful for me may not be meaningful to them, so you need to add. Ask the client what would you like to do if the dementia is advanced? That may be too vague of a question, so you may need to give them options. Would you like to paint? Would you like to go to the movies? Would you like to go out to the park? Give them, you know, three or four options and let them choose. As the disease progresses even further, they may have difficulty with receiving auditory language. So you may have to give them pictures and allow them to point to what they want to do. Activities with tangible results that can be really helpful for this area include painting, having them create a life storybook, and they can use cutouts, they can use old pictures that they've got, they can draw Whatever they want to do. Gardening has been shown to be really therapeutic for a lot of older people. The key with gardening for most older people is to make sure that you're using raised garden boxes so they're not having to bend and stoop and kneel and twist in weird positions. But they do sell raised garden box kits that can be very easily assembled and they're very therapeutic. Playing or listening to music can be therapeutic. And looking at picture books, and when I say picture books, I mean those tabletop books that have a picture and maybe a sentence on every page. There are books about cats and ships and pretty much anything that you want. Nothing with too many words. If the person is experiencing difficulty with reading, you want to assess mobility issues of the person. Go around their house and if they're still working, go around their work. But for a lot of clients with dementia, by the time a case manager gets called in, they're pretty much not working. You want to look, can they get in and out of bed? The bed at my mother in law's house is, I swear that thing is four and a half feet high. And it takes everything I can do to get in that bed. Out is not as hard, but getting in, especially when I was pregnant, was really challenging. Want to make sure that the person can easily get in and out of bed, which may mean lowering the bed frame, adjusting the mattresses somehow. Can they get in and out of the shower or tub? This may mean installing grab bars in the shower or replacing a regular tub that you have to step in with a straight walk in shower. There are a lot of different options. If there are stairs in the house, they may need to get one of those stair lifts or. Well, that's usually the best thing. It's really difficult to get a elevator installed and really expensive. But they may need some sort of assistance with stairs. If you have solid floors, whether it's vinyl, wood, tile, those can get really slick, especially when they're wet. So what types of things does the person need to have so they don't fall? If they're coming in, you know, it was raining outside when they checked the mail and they came in and their feet got wet. And look around for tripping hazards. Some simple tripping hazards are often throw rugs and you know, rugs that people put in the hallway that are just. They're not attached to the floor. Make sure rugs are securely attached to the floor at all four corners. Assess mobility issues with their preferred activities. As people get this diagnosis, we want them to see that their life Is not going to end. But we also want to know what's meaningful to them at this point in time. If they like walking the dog. What mobility issues might you have here? You know, my grandmother would never be able to walk my boxer because he's horrible on a leash. That would be an issue. Some people may need a specially trained dog that's going to walk next to them. They may need to be in a wheelchair when they walk the dog, or they may need to have a backyard fenced in and they go out with the dog, but the dog is allowed to play freely. Try to use creativity. If they do woodworking, you know, what's their mobility like? My grandfather had Parkinson's disease and it broke his heart when he got to the point where he couldn't make his miniatures anymore. Are they safe when they're using whatever equipment that they're using? And how can we enable them to keep doing it as long as possible? What sorts of things? Like if somebody has visual issues, maybe getting a magnifying glass that they can look through when they're trying to do fine work can help them keep doing this a lot longer than they would have. If they do crochet, you know, for example, do they have any mobility issues in their hands? There are special crochet hooks you can do that are ergonomic and they have a much bigger handle so you're not pinching those fingers. That can help somebody continue to crochet longer. You know, just look at what may be interfering with the person's ability to do the activity and try to find a way to mitigate that problem. Assess their mobility issues as far as getting supplies. Can they drive? Can they go shopping by themselves? Some people can drive, but then when they get to the store, they can't remember what they were supposed to get. Or when they get to the store, it's just too exhausting to push that heavy cart all around the store. Figure out ways to mitigate that problem. Assess long term care planning. When they have their early diagnosis, they're still cognitively able to create advance directives to designate who will get power of attorney and identify their preferences for living transitions. When they can no longer live independently, safely, where do they want to go? And this is a time that they can start shopping around and looking for places that they may want to go in the eventuality that they have to go to an assisted living facility. Evaluate behavioral issues and safety again. Driving, wandering, cooking, bathing, shopping. We need to take a look at all of these things to make sure the person is Safe. Another thing that happens in people with dementia is called sundowning, in which confusion and agitation increase throughout the day. Basically, you can think of it as the person getting overstimulated as they go through the day. In order to help prevent sundowning, you want to mitigate vulnerabilities and triggers. If they didn't sleep well the night before, then they're probably going to have a more difficult day to day and they're probably going to start getting overwhelmed earlier. How can you handle that? You may need to cut out some activities or do something so it's not quite as stimulating that day. You want to make sure that they're getting good sleep at night so that they are awake during the day. Recognize the function of the agitation. What is this behavior telling you? If they're feeling. Starting to get agitated typically means they're starting to get nervous, they're feeling a threat for some reason. What is the threat? Do they feel threatened or agitated because they can't communicate what they want because something changed and that makes them feel out of control? What is the function of the agitation? Use visual cues for orientation and comfort. Make sure that they can look around and see things and get reoriented. Remember things in the near past. In the short term, they're not going to remember as much. So if they, if their child just had their grand. A new grandchild, they may not recognize their new grandchild if that picture is on the mantel. But they may recognize pictures of their adult child back from when that adult child was younger. So finding pictures that the person still remembers and can still connect to will help them feel safer and more grounded. Avoid arguing. You know, this is not the time to argue with the person when they're agitated, when they're feeling threatened, when they're confused. No, consider bright light therapy to adjust circadian rhythms. Full spectrum light, you know, so you want to look for the lights that say full spectrum. And you don't want the soft white. I know soft white is so much nicer, but you really need those harsh fluorescent bulbs that are at least the equivalent of 100 watts or more and put it within three feet of a person. There are a lot of lamps that you can get that are overhead lamps for like reading chairs. Those are the best ones to have. Or if you have a chandelier at the breakfast table, for example, that's generally about three feet from the person. If they're sitting at the table and have them exposed to that light for about an hour. The other easier option is if you've got a really sunny window that is facing the east. They can sit in front of that sunny window as the sun rises, watch the sunrise and get that, you know, natural light that will help set their circadian rhythms, increase daytime activity and limit daytime naps. We want to keep those circadian rhythms as steady as possible. That doesn't mean have them going from here, there and everywhere all day long. That's going to wear them out and be agitating. But you also don't want to sit at home and just stare at the wall or watch the birds all day long. Have them get up and do things and move their body. Daytime activity can also be stuff they do at home like practicing Tai Chi. And there are videos, Tai chi videos out there where the person can do Tai Chi in their seat so there's no risk of them falling. Avoid stimulants. Afternoon they may still like chocolate and caffeinated beverages and they still may use nicotine products. You know, ideally they're not because that contributes to the risk of vascular dementia. But you know, people are going to make their choices. If they can avoid those afternoon, then they're at a much greater. They're much better off in terms of being able to settle down by bedtime because those chemicals will be out of their system. Minimize stress throughout the day. TV or reading might be too difficult for some people to follow. I know some television shows are difficult to follow what's going on. So they may need to watch a simple television show that doesn't take a whole lot of concentration or do something different. Painting. Great. You know, not every. You don't have to be Bob Ross to go out and do a painting. Encourage people to paint if that helps them relieve stress. Pets. Petting an animal has been shown to reduce blood pressure. Reduce stress. Those can always be helpful for some people. If they've got assistance, they can do baking. You know, they can do more independent baking if you get something like the pre made cookie dough. So all they have to do is chop it into cookies and put it on a cookie sheet. If they want to bake it from scratch, then that might be something that you can do together. And that's really good for reminiscence therapy too because that might remind them of a time in their past when they used to bake things from scratch and then they'll start telling you about that. And a lot of times that brings up positive memories. And gardening, like I said before, can be very therapeutic. We also need to address caregiver stress. Just like with kids, when caregiver stress goes up. Kids stress goes up. Same thing with people with dementia. When caregiver stress goes up, their stress goes up. We need to address caregiver stress so the caregivers can, you know, have the highest, their highest quality of life, but it also will reduce agitation in the person with dementia. When it comes to behavioral issues, there can be problems. We want to first start with a functional assessment and identify what might be causing these issues. We want to do functional assessments, as I said earlier, with preferred activities. Look at the things that the person likes to do, identify their function. Does it give them a sense of meaning? Does it give them a creative outlet? Does it help them relax? What is it that this activity does for them and what abilities do they have to have in order to make it happen? And then you want to do a functional assessment of problem behaviors. If we can keep their preferred activities at a high level, you're probably going to have fewer problem behaviors. The problem behaviors have a meaning. We want to understand what the meaning is. One of the perfect examples is if you're working with somebody with dementia and they keep going into their closet and pulling everything out of the closet and putting it on the bed, and you don't understand why they're doing that, and they can't tell you why they're doing that. Well, we need to start looking for reasons what might be going on. Maybe they're too hot or too cold. Maybe they don't like the way it's organized. You know, you want to try to understand the best you can what is the function of this behavior? They're pulling all these clothes out of the closet. Maybe they're bored and they just want something to do and that's the only thing they can find to do. It'll take a little bit of sleuthing, especially if the person you're working with has lost a significant amount of their ability to communicate. But it can be done. Aromatherapy, especially lemon balm, rose, lavender and bergamot, have been shown to be really effective at reducing agitation. Music therapy and animal assisted therapy, as well as relaxation training, again, have been shown as being very helpful in reducing agitation in and unhelpful behaviors in people with dementia. If you can help them stay relaxed and help them do things that they enjoy doing, then the chances of them having inappropriate behaviors are less because they're not needing to communicate something is wrong. Reminiscence therapy helps people recall past happy times. Despite current issues with short term memory. Now there's a difference between remembering and reminiscing. If I say, do you remember last week? Da da da da. It puts you on the spot. It requires you to remember something specific. People with memory problems that may increase their agitation. If they can't remember a specific thing, even if it was from 15 years ago, it may feel make them feel anxious with reminiscence. These memories just kind of float to the surface. While people are doing things that they enjoy, have them listen to their favorite music. And as they're listening to it, they may have this memory that rises and they start sharing with you that that was the song that they first heard when they met their future spouse or whatever it is. They can handle and look at keepsakes, ornaments and jewelry, have them tell you about them, or just have them hold them. And sometimes they will bring back memories for that person that they'll share with you. You can bring out old magazines, some people have kept old magazines from that remind them of times in the past. Sometimes you can go find old magazines and books and share them with the person. If you can't find the paper version, you may be able to find a digitized version online. Let them look at it like Good housekeeping magazines from 1950. You know they're very different than the Good Housekeeping magazines of today. And letting the person look at it might bring up feelings and memories. And familiar scents and foods can also do that. If you're cooking a meal together, the person may reminisce about how they used to cook this meal for their children every Sunday, or whatever it is. Do things with the person and the memories will rise to the top. The reasons that underlie problem behaviors can be one or more of the following basic human needs. So remember when I said in the functional assessment, you want to understand what the need is? Let's look at those needs. Resolution of unfinished business in order to die in peace, they may need to say something or do something in order to feel peaceful. They want to live in peace and you're annoying the crap out of them. You're moving them here, there and everywhere and they just want you to stop. It's overstimulating. Adjusting to a new normal. When sight, hearing, mobility and memory fail, they may keep trying to do things and try to do it anyway. They may be doing it to make sense out of an unbearable reality. They may do it for recognition, status, identity or self worth. They may do it to be useful and productive. Maybe they're trying to cook a meal for you and as a surprise, they're trying to be productive and helpful. But you know, it's Dangerous. They may be doing it to try to get listened to and respected, express feelings and be heard. They may want to need a sense of being loved and belonging. They may be trying to get somebody to go, oh, that's awesome, thank you so much. They may be doing it because they have a need to be nurtured or feel safe and secure. They may be doing things for sensory stimulation or sexual expression. People with dementia still have sexual urges and feelings. We need to remember this. And they may be doing it to try to reduce pain and discomfort. They may be too hot or something may be hurting and they're trying to figure out how to make that pain go away. And they don't know how to tell you what's wrong. Caregiver needs and you know, we didn't cover a lot of this, but caregivers need resources. That's what it really boils down to. They need to understand the signs and symptoms of dementia, the course and prognosis of the condition, the treatments that are available, knowledge of how to help their loved one with communication, behavior issues and safety. A lot of caregivers report they just, they feel totally ill equipped to deal with their parent or loved one who has dementia because they just, they don't have the tools. What seems common sense to those of us who work in the field all the time, it's not, you know, necessarily that much common sense. So people need education and they need a little assistance to figure out how to mitigate these issues that come up. They need resources for local care and support for themselves as well as for their loved one. They may need financial and legal advice and advocacy. They may need help with medico legal issues such as driving. At a certain point, the person is not going to be able to drive anymore and they're going to have their license taken away. They may need local information sources, including libraries and voluntary organizations that can help them out. When, you know, this new behavior arises and they're not sure what to do about it. Local resources are really helpful. And finally, they may also need respite care for themselves. It's really exhausting to be a 247 caregiver, especially for people with dementia in stage 2 or stage 3. There can be in home or clubhouse care. So in home care is when, you know, a CNA or somebody comes in to the home to provide care. Clubhouse care is also known as daycare, in which the person with dementia leaves and spends eight hours or something at a facility in order to give the caregiver a break. Now, if they're going to daycare during the week so the caregiver can go to work. That's not a break. The caregiver also needs to know that they need to take some time to be them. So they're not just going to work and coming home and being a caregiver. They need to be themselves too. When communicating with people with dementia, get their attention. Remove distractions. Ensure they have glasses or hearing aids if they need them so they can see and hear you. Imagine that. Be patient and allow enough time for them to respond. And be careful not to interrupt. It is tempting sometimes to jump in, complete their sentences, yada yada. It's important to allow them the dignity to complete their own statements. Use visual reminders such as memory books and charts if the person needs them to help them get through the day. What they need to do throughout the day. Chore lists, any sorts of things like that. There was one client that I worked with that had schizophrenia, but same sort of thing. We created a list of things he needed to do every day, and it included bathing, eating breakfast, and swiffering the floor. And, you know, we had a list of things he had to do. And he put a check mark next to each one of them as he did them. This was a whiteboard. And at the end of the day, the caregiver that came in and checked on him would clear off the check marks and they'd start again the next day. Keep questions and requests to one at a time. Don't say, I need you to take out the garbage and then come back in here and take a bath. They're not probably going to be able to process all that. Let them take out the garbage. When they come back in, then tell them, okay, now it's time to go take a bath. Break larger tasks into smaller chunks. If it's too complicated, they may not get through it. If you're cooking together, for example, don't say you need to do these three things, or here's a recipe. One thing at a time. Okay, let's get out the flower. Now we need to measure the flower. Now let's put the flower in. You know, you see where we're going. Break them into very small chunks. Depending on the person's cognitive capacity, those chunks are going to vary in size. Empathize with their frustration. Most people with dementia, especially early stage dementia, understand that they're losing their capabilities and they remember when they used to be able to do things a lot faster or a lot more efficiently. And it can get, it can be agonizing for them. Empathize with their frustration. Anticipate misunderstandings, especially in people with dementia who have limited ability to communicate. You're doing a lot of guesswork and they may also not be able to interpret what you're saying as effectively anymore. Make sure to remember to enjoy the good times. There are going to be some good days and some bad days, and as the person progresses in their disease, it may be good moments, but savor the good moments. Reduce input late in the day. You know you can have activities during the day, but if the person is subject to sundowning, then you want to reduce some of the stimulation as the day progresses so they don't start hitting the wall, so to speak, and become agitated. Don't talk to the person with dementia like a baby or speak about them if they weren't there. They understand the tone of voice, and a lot of times they understand more than they can actually communicate. Treat them with the dignity that they deserve. If they struggle to find a word or communicate a thought, give them a minute, but at a certain point, maybe gently try to provide the words that they're looking for. Frame questions and instructions in a positive way. Instead of, Instead of, don't do that anymore. Tell them when you start feeling like you need to go to the bathroom, I need you to tell me so I can take you. Instead of don't soil your pants anymore. Be open to the person's concerns, even if he or she is hard to understand. As the disease progresses, the person may have difficulty finding the right words and substitute words that make no sense. But they also may just like they're having difficulty swallowing, they may have difficulty actually forming the words. So it may become more difficult to understand their speech. But try to listen. Try your best to understand. Look for clues in their emotions, their body language, and take their surrounding environment into consideration when you're trying to communicate with someone with dementia. Dementia can be permanent or temporary and caused by a variety of factors, including diabetes, hiv, stroke, heart attack, depression, thiamine deficiency, carbon monoxide poisoning, Lewy bodies, or genetics. A variety of interventions can be used to assist the person with dementia and their caregivers, and these include ensuring sufficient sleep, assisting them with communication, and conducting a functional assessment of preferred and problem behaviors in order to identify the function again of the preferred behaviors because that person is going to want to still do those things if they did something to get status and recognition. Then as their disease progresses, they're still going to want to do things to get the status and recognition. So we need to find alternate ways to meet those needs. I hope this was informative and I will see you next time. Thank you for listening to Case Management Toolbox podcast. Go to allce.com casemanagement to access the CEU course for this episode. You can also subscribe to Case Management Toolbox Podcast to be notified when new episodes are released.