When You Forget that You Forgot:

Recognizing and Managing

Alzheimer’s Type Dementia, Part I.

Revised by M. Smith (2003) from K.C. Buckwalter and M. Smith

(1994), “When You Forget That You Forgot: Recognizing and
Managing Alzheimer’s Type Dementia,” The Geriatric Mental
Health Training Series, for the John A. Hartford Center of Geriatric
Nursing Excellence, College of Nursing, University of Iowa
Goals for Today

™ Describe essential features of dementia

™ List common types of dementia
™ Identify “reversible” causes of dementia
™ Describe behaviors in each of 4 stages
™ Discuss the PLST model
More than “confusion”

™ Many things can interfere with memory

9 Being overloaded; having too much going
on at one time
9 Medications, even ones taken according to
directions
9 Illness and disease that are unrelated to
brain disease
9 Unfamiliar surrounding such as relocation
or hospitalization
Dementia
™ Permanent loss of mental abilities
caused by damage to brain cells
™ NOT a “normal” part of aging!
™ The common end result of many
entities
9 diseases
9 traumas
9 infections
9 drugs
Dementia: Essential Features

Progressive loss of intellectual abilities . . .

™ MEMORY impairment
9 Short-term early
9 Long-term later
™ Loss of LANGUAGE
9 Loss of ability to express oneself
9 Loss of ability to understand what is said
Dementia: Essential Features

™ Loss of PURPOSEFUL MOVEMENT

9 Has the physical ability
9 Can’t perform the task (e.g., getting
dressed)
™ Loss
of ability to accurately interpret
SENSORY INFORMATION
9 Cannot understand what is seen, heard,
felt
9 Not related to sensory impairment
Dementia: Essential Features

™ Impairments in . . .
9 Abstract thinking
9 Ability to reason
9 Judgement
9 Impulse control
™ Personality changes
9 Not “him/herself”
Dementia: Essential Features

™ Lost
abilities result in
CHANGES . . . Get away from
9 Personality me, you big fat
slob!! You
9 Behavior #@!!!#*!!!
9 Emotion

“My mother would never say such a thing!”

Who has dementia?

™ Dementia is a “generic term”

9 Many different types
9 Alzheimer’s disease Æ Most common type
™ Risk increases with advancing age
9 25% of 80 year olds
9 33% of 85 year olds
9 50% of 90 year olds
Who has dementia?

™ Common problem among nursing

home residents: 50% to 80% have
dementia
™ Increasing problem among those in
assisted living: 50% to 67%
™ Many at home, cared for by family
Dementia: Types
Types

™ Alzheimer’s Type
a.k.a. Alzheimer’s Disease
9 360,000 new cases annually
9 4 million Americans afflicted
9 4th leading cause of death
9 14 million (1 out of 45) by the year 2050
9 80% of population in nursing homes
9 Leading cause of behavioral symptoms
Dementia: Types
Types

™ Vascular, a.k.a., Multi Infarct

9 Step-wise, “patchy” loss of abilities
9 Sudden onset, slower course, more variable
™ Mixed dementia
9 AD and another type (e.g. vascular, Lewy
Body Dementia)
Dementia: Types
Types

™ Frontotemporal
Dementia (FTD)
9 a.k.a. frontal lobe; Pick’s disease one type
9 Affects younger age group
9 More common in women than men
9 Insidious onset, like AD
9 Personality changes, language problems
early, memory loss later
Dementia: Types
Types

™ Diffuse
Lewy Body
Dementia (LBD)
9 More fluctuation in impairment
9 Visual hallucinations common, often vivid
9 Parkinson-like features
9 Repeated falls common
9 Particular sensitivity to antipsychotics
Dementia: Types
Types

Dementia due to . . .
™ Medical disease like HIV Disease
™ Neurological disease
9 Parkinson’s Disease
9 Huntington’s Disease
™ General medical conditions
9 Anoxia
9 Vitamin deficiency
Dementia: Types
Types

™ Bottom Line:
All Alzheimer’s is DEMENTIA . . .
but not all DEMENTIA is
Alzheimer’s!!
Dementia: Types
Types
™ LOTs of variability
in presentation!
9Within specific types . . .
9BETWEEN types . . .
™ Overlapping syndromes are
common
9Dementia AND delirium
9Mixed dementia
“Reversible” Dementia

™ Multiple health problems may cause

“confusion”
™ Always explore alternative causes
™ Treatment of underlying physical
problem may arrest losses
™ Problems not fully “reversible” but
remaining capacity may be preserved
D-E-M-E-N-T-I-A
D rugs
Like working a puzzle . . .
E motion
M etabolic
E ndocine
N utrition
T rauma
I nfection
A lcoholism
Stages of Dementia

™ Early - Forgetful
™ Middle - Confused
™ Later - Ambulatory
™ Terminal - Endstage
Early: Forgetful

™ Short-term memory
impaired
9 Loses things
9 Forgets
™ Blames stress,
fatigue
™ Compensates with
lists, memory aids
™ Depression common
Later: Confused

™ Loss of memory
™ Increasing
disorientation
9 Time
9 Place
9 Person
9 Things
Confused: Example

™ “Helen” crochets using a single simple

stitch but doesn’t remember that she is
retired - and sometimes puts her bra on
over her blouse.
™ “Harold” greets everyone like his oldest
friend (“Nice to see you! So good of you
to drop by! I’m great! How are you?”)
but doesn’t know his own wife.
Confused: Example

™ “Mildred” avoids the question “How

old are you” with “Jack Benny and I are
both 29.” When asked what she had for
lunch, she replied, “I went to the
Riviera and had pink champagne and
caviar.”
™ “George” got lost walking in his
neighborhood of 30 years -- as soon as
he could no longer see his own house.
Later Still: Ambulatory
Dementia
™ Progressive loss of
ability interferes
with FUNCTION
™ Increasingly
withdrawn and self-
absorbed
™ Depression tends to
resolve
Ambulatory: Functional losses

™ Willingness and ability to bathe

™ Grooming
™ Choosing among clothing
™ Dressing
™ Gait and mobility
™ Toileting
™ Communication, reading, and writing
skills
Ambulatory: Behaviors

™ Behavioral
symptoms more
common
9 Irritability
9 Agitation
9 Anxiety
9 Pacing
™ Reduced tolerance
for stress
™ Resistiveness to care
Endstage Dementia

™ All abilities lost

9 Mute
9 No longer walks
9 Little purposeful
activity
9 Forgets to eat, chew,
swallow
™ Complications are
common
Symptoms: Not in distinct
stages!
™ Lossesand symptoms vary from person
to person, depending on
9 Extent of brain cell death and loss
9 Location of brain cell death and loss
9 Speed with which losses occur
Common Behavioral Symptoms

™ Concealed memory losses

™ Wandering
™ Sleep disturbance
™ Losing and hiding things
™ Inappropriate sexual behaviors
Common Behavioral Symptoms

™ Repeating questions
™ Repetitious actions
™ Territoriality
™ Hallucinations
™ Delusions
™ Illusions
Catastrophic Behaviors

™ Agitation ™ Noisy behavior

™ Combativeness ™ Purposeful
™ Confusion wandering
™ Fearfulness ™ Sudden withdrawal

™ Night wakening
from activities
™ “Sundown”
syndrome
Unexpected, intense, and “out of
proportion” reactions to a situation . . .
PLST: Progressively Lowered
Stress Threshold model

™ Developed by nurse researchers in Iowa

(Hall & Buckwalter)
™ Emerged from observations of persons
with dementia
™ Based on theories of “person-
environment fit”
PLST

Basic principles:
™ Some behaviors result from losses
associated with dementia
™ Other behaviors result from
environmental stress
™ Stress takes many forms in dementia
™ Stress threshold is lower in dementia
PLST

™ Goals
9 Redefine “stress” for person with dementia
9 Recognize lowered stress threshold
9 Interpret behavior as anxiety that increases
to cause dysfunctional behavior
9 Manage stress for person with dementia
» Modify routines, approaches
» Monitor personal, social, environmental stress
PLST: Normal Stress Threshold
Dysfunctional
Normal Stress Threshold Behavior

Anxious
Behavior

Stress

Normal
Behavior
Time
PLST: Lowered Threshold

Normal Stress Threshold

Dysfunctional
Behavior

Stress
Anxious
Behavior

Time
PLST Behaviors

™ Increased anxiety ™ Purposeful

™ Night awakening wandering
™ Catastrophic ™ Confusion, agitation
behaviors ™ Combative behavior
™ “Sundowning” ™ Diminished reserve
syndrome
More likely to occur as stress increases
PLST: Catastrophic Behaviors

Normal Stress Threshold

Dysfunctional
Lowered Stress Threshold Behavior

Anxious
Behavior

A.M. P.M.
PLST: Sources of Stress

™ Fatigue
™ Multiple competing stimuli
9 Noise, confusion
9 Television, radio, public address
9 Too many people
9 Too many things going on at once
» Eating dinner
» Taking medications
» Meal-time entertainment
PLST: Sources of Stress

™ Physical Stress
9 Illness, medication side-effects
9 Hunger, thirst, discomfort
™ Changes
9 Caregiver
9 Routine
9 Environment
PLST: Sources of Stress

™ Demands that exceed abilities

9 Decisions that are too complex
9 Tasks that are outside abilities
™ Negative and restrictive feedback
9 “Don’t do that!”
9 “Your parents are dead”
9 “But this IS your house”
9 “No, you’re not going to work”
PLST: Care Planning Goal

™ GOAL - To act like a “prosthetic

device” that supports the person do
what what he/she is able to do
9 Interventions serve like memory “crutch”
that fills in for lost abilities
9 Supports person to be autonomous in spite
of lost abilities
9 Keeps stress at manageable level
throughout the day
PLST: Care Planning Goal

Normal Stress Threshold

Dysfunctional
Lowered Stress Threshold Behavior

Anxious
Behavior

A.M. P.M.
PLST: Summary

™ Consider ...
9 Safety needs of client & other residents
9 Disruptive behaviors
9 Inability to participate in care
9 Disturbances to other residents
9 Family needs
9 Increased care time and need for staff
Dementia: Incurable – Not
Untreatable!
™ Preserve and enhance remaining
abilities
™ Avoid unnecessary stress and
overstimulation
™ Treat illness or other complications
™ Provide education and guidance for
families and other caregivers