VOLUME 21

ISSUE 1

spring- summer 2011

Published by the National Association of Professional Geriatric Care of Managers 3275 West Ina Road Suite 130 Tucson, Arizona Geriatric Care Management 85741 520.881.8008 / phone 520.325.7925 / fax www.caremanager.org

Co-Morbidities and Dementia

Guest Editor’s Message ...... 2 By Karen Knutson, MSN, MBA

Dementia, Diabetes, Hypertension, and Alcohol Abuse: A Case Study of Medical Co-morbidities ...... 3 By Karen Knutson, MSN, MBA

Alzheimer’s Disease Co-morbidities...... 7 By M. Reza Bolouri, M.D.

Frontal Lobe Disorders and Dementia...... 9 By Patricia Gross, Ph.D., ABPP-CN

A Different Dementia: Different Challenges...... 13 By Sharon Mayfield, BSN of Geriatric Care Management Spring/Summer 2011

Guest Editor’s Message Coordinating the Complex Care of Clients with Dementia and Co-Morbidities By Karen Knutson, MSN, MBA, RN

Care managers play a pivotal role in in psychiatric classification, co- options available for our clients? coordinating the care of their clients. morbidity does not necessarily imply Selected articles have been chosen As people live longer, the complexity the presence of multiple diseases, to provide more understanding of of life will continue and the increasing but rather an inability of a single the co-morbidities associated with prevalence of chronic disease will diagnosis to account for all of the dementia. Hopefully you will find pose many challenges for coordinating individual’s symptoms. new insights and approaches to such complex care. While the experts hash out integrate into your practice. In health care, co-morbidity is definitions of co-morbidity there The first article which I authored, defined in two different ways. The is a great need for public policy “Dementia, Diabetes, Hypertension, first defines a medical condition to acknowledge and address the and Alcohol Abuse: A Case Study of existing simultaneously but increasing complexity of individuals Medical Co-morbidities” uses a case independently with another condition. living longer in our society and the study that describes the relationship The second defines a medical challenges these co-morbidities of the client’s dementia and diabetes, condition that causes, is caused by, represent. hypertension, and alcohol abuse. or is related to another condition. This issue of the Geriatric Care Integrating the client’s history, In reviewing the literature the first Management Journal highlights observation, and functional assessment definition is the standard and the dementia and co-morbidities. What instruments help to develop a plan second definition is newer than the is it that we do as care managers that of care. The article demonstrates standard and less well accepted. In is especially important? How do how care managers can incorporate psychiatry, psychology, and mental we sort out the co-morbidities when their knowledge of dementia and co- health counseling, co-morbidity refers more than one chronic illness is morbidities to improve both client and to the presence of more than one present? What are the most effective family outcomes. diagnosis at the same time. However, assessment, treatment, and care continued on page 3

Editorial Board Rona Bartelstone, LCSW Fort Lauderdale, FL Cathy Cress, MSW Santa Cruz, CA Lenard W. Kaye, PhD Orono, ME Carmen Morano PhD of New York, NY Leonie Nowitz, MSW, LICSW New York, NY Journal Emily Saltz, MSW, LICSW Newton, MA Geriatric Care Management Monika White, PhD Santa Monica, CA Published by the: National Association of Professional Geriatric Care Managers 3275 West Ina Road, Suite 130, Tucson, Arizona 85741 • www.caremanager.org Editor-In-Chief Published two times a year for members of NAPGCM Karen Knutson Non-member subscriptions: $95.00 per year MSN, MBA, RN Charlotte, NC © Copyright 2011 The Journal of Geriatric Care Management is published as a membership benefit to Graphic members of the National Association of Professional Geratric Care Managers. Non-members may subscribe Design to Journal of Geriatric Care Management for $95.00 per year. Send a check for your one-year subscription to: HagerDesigns Subscription Department, NAPGCM, 3275 West Ina Road, Suite 130, Tucson, Arizona 85741. Dallas, Texas

page 2 of Spring/Summer 2011 Geriatric Care Management

Dementia, Diabetes, Hypertension and

The second article “Alzheimer’s Alcohol Abuse: disease co-morbidities” by Reza Bolouri describes the psychiatric co- morbidities of depression, anxiety, A Case Study of psychosis, agitation, and aggression as well as the often-overlooked Medical Co-morbidities personality disorder. Symptom management, environmental By Karen Knutson, MSN, MBA modifications, and medication therapies are explored as the author describes a comprehensive approach Michael B, a 63-year-old single house. He had a lovely home full to managing co-morbidities. retired business executive with demen- of artwork and sculpture that he had In her article, “Frontal tia, diabetes, hypertension, and a his- collected over the years. The care Lobe Disorders and Dementia,” tory of alcohol abuse, living in Char- manager found him overwhelmed dur- Patricia Gross describes the lotte, North Carolina, was referred for ing the course of two visits to complete lesser understood medial frontal care management services by a friend. the evaluation because, as he said, “my syndrome, frontal convexity Michael’s older brother Eric, a retired house is out of control, and I can’t attorney, lives in Hawaii and had not syndrome, and orbital frontal seem to maintain it.” seen Michael in two years. Michael’s syndrome and provides case younger sister Linda, a teacher and Newspapers, mail, catalogs, dirty examples and treatment Michael’s health care POA, lives in dishes, glasses, and garbage were on options. She demonstrates how California and had not seen him in the the floor of every room on the lower neuropsychological evaluation can past year. Both brother and sister were level. The food in the refrigerator was be an important tool to help the scared and worried. They usually spoiled, and the freezer was a block care manager determine the client’s called him after work in the evening of ice. The sink was stopped up, and cognitive strengths and weaknesses which was often when Michael was the kitchen was bug infested. Spe- and how to best intervene. drinking. They didn’t know what else cific prescriptions ordered were never Sharon Mayfield has written a they could do. His sister said that filled and others including his insulin first-hand account of her work with Michael had become suspicious of had not been reordered in the past clients experiencing frontotemporal people who were trying to help him. four months. He was not taking his lobe disorders and the lessons He told her that he thought she wanted medications, and he was not testing she has learned while assisting to come and see him to declare him his blood sugar. The care manager families in their caregiving roles. incompetent. Michael’s friends and checked his blood sugar and it was She describes different symptoms, family reported to the care manager as 543, which was a seriously high level. she interviewed them that they were caregiving approaches, and explores He had lost his credit cards, calendar, experiencing difficulty in their rela- successful strategies that family and wallet and was unaware of his tionships with Michael and relation- caregivers can use. Case examples financial spending. He had accrued ships with one another as they tried to $25,000 in debt on one credit card illustrate how the care manager help him. can help. that he thought he had paid off. He Early in 2009 Michael participat- also looked at a bill for the purchase ed in a residential treatment program References of art and couldn’t remember what he for two months, but was drinking purchased or why. His cable was cut Valderas JM, et al. Defining again within 48 hours of returning off because of an unpaid balance. co-morbidity: implications for home. He went to a second residential understanding health and health services. Annals of Family Medicine. treatment program for 3 months, came The Challenges of 2009, 7(4): 357-63. back home, began drinking again, and Sorting It Out after an incident at work was forced First MB. Mutually exclusive versus to resign in January of 2010. Michael Sorting out the relationships co-occurring diagnostic categories? The between dementia and other chronic challenge of diagnostic co-morbidity. finally allowed the care manager into Psychopathology. 2005, 38(4): 206-10. his house on her fourth visit to the continued on page 4

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Dementia, Diabetes, 140 over 90 or higher can also seem to information including the time of Hypertension and Alcohol spur Alzheimer’s disease-like process- onset of Michael’s cognitive deficits, Abuse: A Case Study of es. The clinical approach at present is the progression of his symptoms, and Medical Co-morbidities to maintain as low a blood pressure as family history of dementia from his continued from page 3 possible to prevent dementia as well as siblings, friends and medical provid- stroke. There are no other potentially ers. The care manager uncovered that illnesses can be difficult. A clearer effective therapies. Michael had a five-year history of understanding of the client’s dementia symptoms. Over the past medical co-morbidities can help Relationship of two years he began eating and drink- the care manager develop a more dementia and ing excessively, made art and sculp- comprehensive understanding and alcoholism ture purchases of over $100,000, and approach to care planning. Most studies have indicated was reported by friends to have poor Relationship of that excessive alcohol consumption judgment on a number of issues. At dementia and diabetes leads to cognitive impairment but one time he had a regular routine of the pathological mechanism remains eating, drinking, and shopping. Over Rates of dementia are higher in unknown. A common theme in the the past two years his eating, drinking, people with diabetes than in those literature was that most patients of and shopping spiraled out of control. without. The strongest effect Michael was not in has been noted in vascular de- denial of his drinking. mentia; however, there is an Figure 1: Executive Function He did not remember association with Alzheimer’s that he had already had disease as well. Impaired Poor organizing skills his normal routine of fasting glucose levels are ap- Poor planning, impaired attention, losses in train of thought 1-2 drinks an evening, proximately twice as common and began having 2 in people with Alzheimer’s Poor judgment: cannot determine good ideas additional drinks. He disease and diabetes than then transitioned from Poor problem solving: impaired short term memory with diabetes alone. One having wine with study found that a 1% rise Poor insight: doesn’t recognize deficits dinner to purchasing in A1c (i.e.: from 6.0% to vodka by the 1.7 liter Poor reasoning: cannot think through matters 7.0%) was associated with a bottle. When the care significant decline in scores manager did her as- on three different tests of mental alcohol abuse are in denial. One study sessment he was spending $40/day on functioning. The risk of dementia goes compared the cognitive impairment alcohol. He told the care manager that up significantly if clients maintain an of alcohol-dependent patients to the he couldn’t understand why he became A1c in the 8% range. The micro-vas- cognitive impairment of patients with an alcoholic after he turned 60 years cular changes in diabetes are greatly Alzheimer’s disease. In that study all of age. underrated as a brain disorder, and the domains of cognition were impacted author of one research article even to the same degree. After an extensive Integrating Observation suggested we consider Alzheimer’s Medline search of dementia and alco- and Functional disease “type 3 diabetes.” holism, the author was unable to find Assessment Instruments any studies indicating that cognitive The care manager used the Relationship of impairment leads to excessive alcohol Folstein Mini-Mental State Exam dementia and consumption. Because alcohol is a (MMSE) to evaluate Michael’s cogni- hypertension toxin that is especially harmful to the tive functioning on the first visit. He Studies have found that high liver, elevated liver enzymes are the received a score of 26 out of 30. He blood pressure in middle age is associ- bio-markers for excessive alcohol con- was experiencing difficulty with ated with increased risk of dementia sumption. An elevation of the liver orientation, short-term recall, and was later in life. One study found that enzymes, aspartate aminotransferase not fully oriented to his environment. successful hypertension control re- (AST) and/or alanine aminotransfer- However, he had good attention/ duced the risk of dementia. The same ase (ALT) occur when liver cells are calculation skills and good language triggers for heart disease – high blood damaged or destroyed. Liver disease skills. While his long-term memory pressure, obesity, and diabetes seem is the most likely diagnosis if the AST was good, he had significant difficulty to increase the risk of dementia too. level is more than twice that of ALT. with short-term memory and could not Historically, the association was with always remember what had just hap- “vascular dementia” where memory Integrating the Client’s pened. His difficulties with activities problems were linked to small strokes. History of daily living (forgetting to take his New studies recognize a mix of two Returning to the client in the medication, fill and reorderprescrip - dementias. Blood pressure readings of case study, the care manager gathered tions) were due in part to his inabil-

page 4 of Spring/Summer 2011 Geriatric Care Management ity to recall recent experiences and Returning to the client in the and a PET scan were ordered as well required prompting and assistance by case study, the care manager spoke to as an EEG. The neurologist told Mi- another person. Michael’s sister and brother about set- chael that whatever was going on with While the Folstein (MMSE) ting up caregiver services immediately his brain, his drinking was accelerat- serves as a good, first-line general for 12 hours per day, 7 days a week in ing it. He suggested an in-home detox screening tool and takes only 10 min- addition to ongoing medication man- program as Michael refused to go utes to administer, it does have its lim- agement by an RN care manager on through a hospital based program, and itations since it focuses on a selection a weekly basis. Michael also needed prescribed Ativan 5 mg three times of concrete thinking a day on a tapering schedule skills and does not test while he quit drinking alcohol. the executive function Figure 2: Frontal and Temporal Atrophy on Pet Scan He also recommended that he skills of organizing, stop driving. planning, judgment, Behavioral disinhibition On the second visit problem-solving, Addictive behavior the neurologist reviewed insight, and reasoning the lab results including Apathy and loss of sympathy and empathy (See Figure 1: Execu- thyroid function, folic acid, tive Function). These Perseverative or compulsive behavior and B12 levels, which were are crucial abilities, Excessive eating and drinking normal. After reviewing 12 as they help Michael have short- term memory make decisions in regards to personal care, health care, assistance with financial financial, and legal matters. Impair- management and possible Figure 3: Client Goals and Strategies ment of these skills increases the risk transportation. The next that he will make serious mistakes or step was to recommend a Goals: Avoiding alcohol and major shopping even be exploited by others. It was neurologist who special- purchases (art, sculpture, antiques) the impression of the care manager ized in dementia for a that Michael was experiencing diffi- dementia work up to rule Managing client’s average blood sugars and blood pressure to decrease risk of cognitive culty with executive function and was out a variety of treatable decline at risk for undue influence. medical conditions that can cause memory impairment, The Clock Drawing Test Keeping client active: walking, water aerobics, determine a diagnosis, and reflected difficulties with frontal and swimming, classes at the Senior Center review Michael’s current temporal-parietal functioning and medications. A sense of purpose: meaningful activities and took the care manager a couple of nurturing relationships minutes to administer. The Geriatric The care manager Depression Scale evaluated Michael was able to get the client Strategies: Ordering 2 waters and 2 diet B’s emotional functioning and took worked into the neurolo- cokes at lunch as soon as the waitress/waiter less than 10 minutes to administer. gist’s schedule the follow- comes to the table. Then focus on the menu He received a score of 7 out of 15 ing week, drove the client and let client order both lunches. Say no to suggesting clinical depression at the to the appointment and antique shopping, going to the bank and the time of the assessment. participated in the appoint- ABC store but suggest other options. Distract ment, sharing her Folstein him away from things that can harm him Services and (MMSE), Clock Drawing financially and physically. Interventions and Geriatric Depression In addition to care management Scale results. The neurologist then difficulty but difficulty with and referral to dementia specialists, used the Montreal Cognitive Assess- decision- making and judgment. other interventions have been shown ment (MoCA) designed as a screening This included misjudgments about to improve care for clients. These instrument for mild cognitive dys- alcohol and no recollection after include companion/caregiver services, function. The tool assesses different consumption, which was why he support and education for family care- cognitive domains including attention needed 12 hours of supervision givers, and medication interventions and concentration, executive func- a day at this point. At this point such as client reminders and refilling tions, memory, language, visuocon- Michael B was no longer drinking, prescriptions. Other medication con- structional skills, conceptual thinking, was losing weight, and his blood siderations influencing outcomes in- calculations, and orientation. A score pressure was under control. The clude drug therapy complexity (more of 26 or above out of 30 is considered neurologist also prescribed the anti- than one drug or more than one dose a normal. It took the neurologist ap- depressant, Effexor, 75 mg, once a day) and medication management for proximately 10 minutes to administer day to treat his depression. clients having difficulty remembering the MoCA. Michael received a score to take their medications. of 22 out of 30. Routine blood work continued on page 6

page 5 of Geriatric Care Management Spring/Summer 2011

Dementia, Diabetes, chael’s current cognitive functioning, a difference. Care managers can Hypertension and Alcohol he did deserve a rigorous neurological incorporate their knowledge of Abuse: A Case Study of evaluation to determine the cause(s) dementia and co-morbidities to Medical Co-morbidities of the dementia and its relationship to manage these clients and provide continued from page 5 alcohol abuse. An in-home detox pro- care that can improve both client and family outcomes. The care manager then took gram was set up and the client had a successful outcome. With the supports Michael to his primary care MD visit. * The client’s name and identity have been His physician wanted to tighten up the in place he no longer drinks alcohol, changed to provide confidentiality. control on his diabetes now that he had his blood pressure is consistently a supportive team in place to help him. below 120/80, his most recent blood References He wrote new orders for insulin and sugar was 119, his AST went from requested that the care manager fax 258 (normal: 0-49 IU/L) in October Alcohol Alert. U.S. Department of Health and Human Services. January 2005, Number 64. him the blood sugar results weekly. 2010 to 31 in April 2011, and his ALT They then met with Michael’s friend (normal: 0-55 IU/L) went from 118 in Cukierman-Yaffe T. Relationship Between and financial POA as well as his at- October 2010 to 39 in April 2011. Baseline Glycemic Control and Cognitive torney, activating the health care and Function in Individuals With Type 2 Diabetes The discussion of the client’s and Other Cardiovascular Risk Factors. financial powers of attorney and set- psychosocial needs is outside the Diabetes Care. 2009, 32: 221-226. ting up a cash management system so scope of this article. However, Geldmacher D. Alzheimer disease prevention: the care manager could take cash out addressing psychosocial as well as on a weekly basis for household ex- Focus on cardiovascular risk, not amyloid? medical needs using an integrated Copyright 2010 The Cleveland Clinic penses. The care manager then set up team of nurse and social work care Foundation. a training program for the caregivers managers increases the effectiveness working with Michael with custom- Knutson K, et al. Better Outcomes for Clients of care management. A holistic team ized goals and strategies to better help with Dementia in a Retirement Community approach to addressing all of the Setting. GCM Journal. 2004, Fall: 9-13. them work with him (See Figure 3: client’s needs is critical. Client Goals and Strategies). Kuller L, et al. Relationship of hypertension, The discussion of emotional blood pressure and blood pressure control Discussion burden of family caregivers is outside with white matter abnormalities in the women’s health initiative memory study. A clinically questioning approach the scope of this article. However, Journal of Clinical Hypertension. 2010, 10: by the care manager is essential. an entire article could be devoted to 1751-1776. Communicating with all family this topic. By helping this client the care manager was able to decrease the Oveisgharan S. Hypertension, Executive members, friends, and health care Dysfunction, and Progression to Dementia: professionals and asking questions caregiving burden and improve the The Canadian Study of Health and Aging. and more questions until all possible quality of life of his friends as well Arch Neurol. 2010, 2: 187-192. information is gathered is desired. as his two family members who were both working full time and living at a Struble L and Sullivan B. Cognitive Health in When more than one chronic illness is Older Adults. The Nurse Practitioner. 2011, present, care managers need to get the distance. April: 25-34. help of appropriate medical specialists who specialize in dementia care. Conclusion Learning about the relationships with This article is based on a Karen Knutson was the president the other chronic illnesses, the stage specific case study, while providing and founder of OpenCare, the first of those illnesses, the unmanaged an overview on the relationship of private geriatric care manage- and uncontrolled symptoms, dementia and select medical co- ment company in the Charlotte pharmacotherapy, functional morbidities. Strategies and goals area. She is currently the Profes- sional Development Specialist limitations, family dynamics, and need are suggested to reduce excess of SeniorBridge, providing care for care coordination all help to frame dementia in a specific client with the management and licensed home the picture of what is going on with medical co-morbidities of diabetes, the client. care services in Charlotte, North hypertension, and alcohol abuse. Carolina. Karen has her master’s It is usually assumed when a cli- Providing care management for in nursing, specializing in older ent is an alcoholic and has dementia clients with dementia and medical adults and a master’s in business that it is the effect of alcohol abuse co-morbidities can be of major benefit administration. She is the past that causes the dementia. In this case as it includes the complex, integrated president of the National Asso- study, the client’s dementia (memory daily care that the client and family ciation of Professional Geriatric and frontal functions) contributed to require on a long-term basis. It can Care Managers and the current his behavior of alcohol abuse. While also be very rewarding for the care Editor-in Chief of the Geriatric we may never fully know the impact manager, as it provides an opportunity Care Management Journal. of medical co-morbidities on Mi- to demonstrate how we can make

page 6 of Spring/Summer 2011 Geriatric Care Management

Alzheimer’s Disease Co-morbidities By M. Reza Bolouri, M.D.

Alzheimer’s disease is a hensive approach but also an ongoing is an effective non-pharmacological chronic, progressive neurodegen- plan to support the individual with AD approach to depression. erative brain disorder that affects a and its co-morbidities. patient’s memory, language, judg- Anxiety ment, decision-making, planning, Depression Anxiety affects 20% of patients and organizing. Depression affects 20% to 32% with dementia. In the initial stages of Alzheimer’s disease (AD) of patients with dementia, though the disease is the fear of losing control. remains the most common cause of more prevalent in vascular dementia Generalized anxiety disorder occurs in dementia. There are currently 5.3 as compared to AD. The diagnosis 5% of patients with AD. As the disease million Americans affected by the and treatment of depression in patients progresses, the anxiety level can fluc- disease, and as the aging population with dementia is quite challenging as tuate depending on the living situation increases without a disease-modi- it can be an early manifestation of de- and the patient’s support structure. fying treatment, it is projected to be mentia or cause of the dementia called Patients may present with restlessness, 15 million by 2050. pseudo-dementia. The depression can irritability, fatigue, and sleep distur- AD is a complex disease; fluctuate and the presentation may bance. Anxiety like depression can be hence, the treatment can at times be vary, such as difficulty with attention measured using standard scales such complicated and often challenging and focusing, apathy, anxiety, and agi- as Worry scale, which is a self-report to the treating physicians. Success- tation as opposed to feelings of guilt, in mild dementia, and Rating Anxiety ful treatment of patients with AD re- insomnia, hypersomnia, or suicidality. in Dementia relies on all available data quires a thorough understanding of There may also exist an undiagnosed to rate the anxiety. This includes the the patient and the family dynamic. bipolar depression that needs atten- caregiver report and patient observa- AD, like any other chronic condi- tion, as the treatment is somewhat dif- tion. Treatment of anxiety includes tion, may have other medical and ferent. There are social interven- psychiatric co-morbidities that need several scales to tion such as milieu to be addressed. Treating the AD assess depression therapy, addressing in patients with AD is a complex the patient’s specific with anti-dementia drugs is a small disease; hence, part of the comprehensive man- dementia, such as stressors or environ- agement of AD. The discussion of Geriatric depres- the treatment mental factors, and medical co-morbidities are beyond sion scale, Ham- can at times be pharmacotherapy, al- ilton depression, though this approach the scope of this article; however, complicated and the psychiatric co-morbidities such and Cornell scale needs to be addressed as depression, anxiety, delusions, for depression. often challenging with extreme cau- hallucinations, agitation, and ag- The treatment to the treating tion as patients with of depression in dementia are sensi- gression will be discussed. Some physicians. patients may have an undiagnosed dementia includes tive to tranquilizers. personality disorder that resurfaces pharmacotherapy The initial approach as the patient’s ability to compen- and psychosocial should b a trial of sate diminishes. modalities, although ECT has been SSRI antidepressants, as most drugs used for severe cases. The SSRIs in this class also treat anxiety success- The physicians who treat pa- remain the mainstay of treatments and fully. In generalized anxiety disorders, tients with AD need to keep in mind have a better safety profile, as these Buspirone can also be helpful. that the management of this disease patients are prone to medication side is more than just memory medica- effects. In the case of bipolar depres- Psychosis tion. Even among the patients with sion, treatment with mood stabilizers Delusions and hallucinations AD, the presentation and the course may improve the patient’s mood. This have been present in 15% to 20% of of the disease varies. Therefore, may be one of the reasons that Depak- the successful management of AD ote has been effective in treating some patients with dementia and increase requires a comprehensive approach patients with dementia. Psychosocial with the disease progression. Hospital- not only to the memory but also stimulation, such as supportive thera- induced psychosis, such as delirium the co-morbidities. Care managers py, focusing on positive aspects of life, during a hospital stay secondary to a provide an invaluable resource to happy memories, enjoyable experi- urinary tract infection or pneumonia, both the development of a compre- ences, and previous accomplishments, continued on page 8

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Alzheimer’s Disease improve by treating the patients with pose a real challenge to the treating Co-morbidities antidepressants such as SSRIs. Bipolar physician, as the patients are not continued from page 7 depression can also present with aware of their illness. Unfortunately psychosis during manic episodes. As the diagnosis of this co-morbidity is could be the first manifestation of mentioned earlier, psychosis could be a quite difficult and the treatment almost dementia in an elderly population. manifestation of an underlying medical impossible. Caregivers, as part of The delusions are usually persecutory condition that needs a thorough a care management team, may help and misidentification as part of the investigation. in the ongoing assessment of these triad, the agnosia seen in patients with behaviors and be utilized to intervene AD. Paranoid delusion of intruders Agitation and Aggression with both behavioral restructuring and and missing personal possessions Among patients with dementia, maintenance of a pharmacotherapy are common. Some patients do not program as prescribed. recognize family members or their own 27% exhibit agitation and/or aggressive behavior. There are two categories of home, and some report seeing dead Conclusion relatives, animals, and children in the agitation/aggression in dementia: one The psychiatric co-morbidities in house as part of visual hallucinations. with psychosis, such as delusions and patients with AD could be either part The psychotic symptoms are often hallucination, and the other without of the dementia or an undiagnosed accompanied by agitation and psychosis. Agitation/aggression condition. In either case, it is the aggressive behavior. The psychosis should be thoroughly investigated as is often elicited from the patient or it can signal an underlying medical second most important issue that caregiver and by the use of scales such condition or a patient need that cannot needs to be addressed and treated. as BEHAVE-AD, dementia psychosis be properly communicated, such as It is important to keep in mind that scale, or NPI (Neuropsychiatric hunger, thirst, pain, or a need for the treatment of dementia is not just Interview). The treatment of psychosis toileting. It can also be secondary to memory treatment that has been the in dementia is quite challenging as the underlying dementia, depression, main focus of dementia treatment. the new data reports increased risk or anxiety. These symptoms are The successful management of of cardiovascular-related death in particularly important, as it can be a patients with dementia in general and elderly patients with dementia. As concern for patient and/or caregiver Alzheimer’s dementia in particular is long as the psychosis is not disruptive safety. Patients with severe agitation treating all symptoms of disease. Once to the patient and family, it does not are often angry with others, especially the assessment is completed and AD have to be treated. Behavioral and with the caregiver. They often resist is confirmed, an ongoing care plan environmental interventions, such as help, such as shower, getting dressed, may be developed, supervised, and avoiding confrontation and argument, or toileting. Patients with dementia modified, as appropriate, using the gentle touching, and environmental often get agitated in a new environment services of care managers working modifications are the first line such as hospital or a new facility, or in conjunction with clients, family therapy and should be employed in with new caregivers, or due to drug members, and other members of the combination with psychopharmalogical side effects. For example, certain larger care team. therapy. This requires a tremendous tranquilizers and anticholinergic drugs patience on the part of the caregiver, as that are used for bladder control can it tends to occur quite frequently. cause agitation in these patients. So the Dr. M. Reza Bolouri is board certified by the American Board In the cases where some form cause should be sought and addressed of Psychiatry and Neurology of antipsychotic treatment must be first. The environmental modification and founder of the Alzheimer’s used for patient and family safety, the and supportive therapy is the mainstay newer antipsychotic drugs such as of the treatment. Physical restraints Memory Center, combining the Abilify, Seroquel, Zyprexa, Geodon should be the last resort only in cases practice of general and behavioral or Risperdal are recommended. where the patient is a danger to himself neurology with innovative research These drugs have a better side effect or others. The medications such as and new drug development with profile on extra pyramidal symptoms antidepressants, mood stabilizes, and emphasis in neurodegenerative such as Parkinsonism, sedation, if needed, antipsychotics can be used, brain disorders. He is a member anticholinergic side effects, and again with special attention to the of the American Academy of orthostatic hypotension and tardive potential side effects. Neurology and served on the dyskinesia. Older antipsychotic One important psychiatric co- Western Carolina Alzheimer’s drugs such as Haldol and Thorazine morbidity that is often overlooked by Association Board from 2007 to the should be avoided at all costs. The physicians caring for patients with present. Dr. Bolouri has taken a patients and their families should be dementia is undiagnosed personality leadership role in serving the local informed of the black box warnings disorder that can explain many of geriatric community and people related antipsychotic drugs. It is also the behavioral disturbances that with dementia and has published important to recognize depression- accompany a difficult patient. The numerous professional articles. induced psychosis, which may patients with personality disorder

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Frontal Lobe Disorders and Dementia* By Patricia Gross, Ph.D., ABPP-CN

When assessing individuals output, though repetition of language his family. He had to be cajoled into for dementia a number of potential may be preserved. This appears to eating. He was eventually taken to a co-morbid processes must be kept in be a time-limited expression of the hospital E.D. where he was diagnosed mind. One of the lesser understood acute stage. The cognitive abulia, or with depression. He was then placed areas of neurobehavioral dysfunction slowed processing, can be a long- on a V.A. inpatient psychiatric unit. is that of the frontal lobe disorders. standing effect of the Strictly speaking, these disorders do syndrome. not constitute a dementia, as memory The akinesia One Sunday, he fell skills, simple mathematics abilities, associated with downstairs after attending and visuospatial skills are typically this syndrome intact. IQ scores can be normal. leads to almost church with his family. Although However, functionally these patients no spontaneous somewhat dazed at first, Mr. can display declines in activities of movement. Because Morales claimed to feel fine and of the position of daily living (ADLs) and instrumental refused to be taken to an E.D. In activities of daily living (IADLs) the brain insult, the equivalent of various forms lower extremity the following days, Mr. Morales of dementia. There are three such weakness and loss became progressively reclusive. syndromes: the medial frontal disorder of leg sensation with resulting gait characterized by akinesia, the frontal disturbance can convexity disorder characterized by occur. Incontinence can result with His affect was markedly flat and his apathy, and the orbital frontal disorder bilateral medial frontal lesions. If voice quality when he did speak was characterized by disinhibition. It is not caused by an infarct, the condition monotone, aprosodic, with very low common to find one of these disorders may stay static or resolve over a voice volume. On the unit, he failed to in isolation. Neurologic insults period of days to months. The medial answer most questions, just staring at typically affect broad areas of the frontal lobe syndrome can easily be the examiner. He occasionally voiced brain; often a person will present with mistaken for the “waxy flexibility” of soft repeated “no”s. The nursing staff a combination of these conditions. In catatonia or severe depression, as the had great difficulty keeping him out this paper, case examples that illustrate following case illustrates. of his room during the day, as he only these syndromes in isolation and Case Example: Hector Morales wanted to lie in bed, though he did not treatment implications of the disorders was a retired 63-year-old man who sleep during the day. He was continent will be discussed. lived with his sister’s family his of bowel and bladder. Although he whole life. He had a 6th grade was capable of performing ADLs he Medial Frontal needed prompting to initiate or to Syndrome education, had been a janitor, and had never married or had children. complete them. He took no part in the The medial frontal disorder is He was fairly reclusive but would patient meetings. Individual or group more rarely seen because it involves a participate in activities with his sister psychotherapy could not be attempted. more protected area of the brain: the and her family. He had no psychiatric He did not respond to various medial surfaces of the cingulate gyri, or medical history, and was on no antidepressant medications over a or the medial basal region inferior medications. One Sunday, he fell fairly long inpatient stay. and anterior to the third ventricle. downstairs after attending church with Eventually a CT scan revealed It is most often caused by a focal his family. Although somewhat dazed a small medial frontal infarct. He infarct in the area of the anterior at first, Mr. Morales claimed to feel slowly regained the impetus to move cerebral artery or a tumor growing in fine and refused to be taken to an E.D. and to speak more than “no,” though the area. In the acute phase, akinetic In the following days, Mr. his language remained sparse and muteness can result from transcortical Morales became progressively he continued to participate in no motor aphasia. In this condition, reclusive. He refused to come out of activities. Psychiatrists on the unit there is little spontaneous verbal his room and barely said anything to continued on page 10

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Frontal Lobe Disorders a mental set. He may get quickly He was alert, but had flat staring and Dementia off-track in making a statement or affect. He was a little nervous, but continued from page 9 performing an ADL. He may be denied feeling depressed or irritable. speculated that premorbidly he had stimulus bound. For example, when Speech was fluent with very low a schizoid personality disorder, not asked to place hands at “10 past 11” volume and generally linear but feeling the need to associate with on a clock drawing, he may draw slightly slow thought processes. Ms. anyone. The personality disorder hands to the numbers 10 and 11 Tarlow reported that when she took was exacerbated by the acute medial Case Example: Mr. Tom Tarlow him in, her brother weighed only 106 infarct. Although he still required was a 60-year-old man with an AA pounds because his wife had starved assistance and prompting to perform degree who was seen with his sister him. His appetite was now good and ADLs, his family was willing to care Lisa Tarlow. He was married 10 years he gained 40 pounds in the last year. for him and took him home on no to his third wife from whom he was Ms. Tarlow said that he lay in the medications. in the process of divorce. She had yard 2½ hours after his heart attack in The Geriatric Care Manager been very abusive over many years 2008 because his wife would do noth- (GCM) could assist the family by sug- and most recently had beaten him ing for him. She said that her brother gesting a neurological workup had never been violent and with a neurobehavioral clinic had never abused any of his or specialist, which had not wives. His wife accused him been done. A trial of medi- The primary behavioral of trying to run over her with cation to improve initiation a truck. He did not speak up might prove worthwhile. expression of the patient with a frontal convexity syndrome in court to deny the charge The GCM could provide a when accused by his wife caregiver or suggest adult is apathy. The family’s feeling and said almost nothing when day care, as he would need that the patient is apathetic questioned by the judge. He supervision during daylight was convicted of the charge hours. It would be extremely may be the result of the lack difficult to impel an indi- of initiation with this and was placed on one year probation and assigned to 6 vidual with a medial frontal syndrome. syndrome to do any activities, months anger management but he might be encouraged treatment. to walk slowly on a tread- Mr. Tarlow’s wife mill or ride a stationary bicycle for over the head with a cane. A CT scan admitted to police after the court exercise. He would need prompting to of the brain showed microvascular conviction that she had lied about maintain any activity more than a few ischemic changes and an old left basal the charge. His wife claimed he had minutes, however. Family may benefit ganglia infarct. He lived on and off attacked her when he was the one from a referral to a stroke group or the with his sister and nephew for the last who had physical damage from her Alzheimer’s Association. 4 years due to the spousal abuse, and attack, including broken fingers and moved in with them a year prior to this bruising at the back of the head. That Frontal Convexity evaluation. case was dismissed. Currently Mr. Syndrome His medical history included Tarlow would not eat, dress, bathe, The primary behavioral coronary artery disease, status post or do any activity without prompting. expression of the patient with a frontal myocardial infarction with CABG 2 His sister reported that he “just sits convexity syndrome is apathy. The years prior, dyslipidemia, recurrent and watches TV all day.” He did not family’s feeling that the patient is Major Depressive Disorder, closed drive since his sister took him in. apathetic may be the result of the head trauma, history of a small lacunar On neuropsychological testing, lack of initiation with this syndrome. infarct in the left basal ganglia, most of Mr. Tarlow’s scores, including The affected patient appears to be peptic ulcer disease, COPD, and those for verbal and visual learning indifferent and unmotivated, or hypertension. He was on aripiprazole and memory, were normal. The only unwilling to take appropriate action. 10 mg ½ tablet QAM, citalopram deficient scores were in visuomotor Psychomotor retardation is often hydrobromide 40 mg 1½ tablets attention and language generation moderately severe. When angered, QAM, hydroxyzine pamoate 25 mg tests, probably representing slowed the patient may respond with a more BID PRN, co-trimoxazole DS BID, processing from the left basal ganglia normal speed of activation, though Plavix 75 mg daily, omeprazole 20 infarct. Planning and organization outbursts tend to be short-lived and the mg daily, pravastatin 40 mg daily, skills were mildly impacted. The test apathy usually recurs quickly. There pancrealipase 1 tab daily, amlodipine pattern suggested an atypical dementia is a tendency toward distractibility 10 mg daily, gabapentin 300 mg daily, despite the lack of memory deficits. and the patient often cannot maintain and atenolol 25 mg daily. There was a significant frontal lobe

page 10 of Spring/Summer 2011 Geriatric Care Management syndrome, apathetic type. He initiated can occur due to the proximity of the privilege of sticking their fingers in very little, including failing to initiate first cranial nerve to the orbital area. A the hole in his head for two-bits each. self-care. Thus, functionally he had grasp reflex with involuntary grasping The following is a subtler a moderate dementia. His reasoning, of objects may be present in some example of the orbital frontal judgment, and insight appeared patients. syndrome. particularly limited. He was much Historically, the best known more passive indicating a personality Case Example: Art Kelly was example of the orbital frontal a 64-year-old retired realtor. He change due to head trauma and basal syndrome was that of Phineas Gage. ganglia infarct. thought he had memory problems for At age 25, Gage was working as a 6 months, though his wife said it over The GCM would be likely to well-regarded foreman on the Union- a 3-year-period. He was independent advise a neuropsychiatric or neurology Pacific railway. He was hammering a with ADLs and IADLs, and drove evaluation to determine appropriate tamping rod into a hole in the ground without difficulty. His medical medications to improve his initiation primed with explosives when the rod history included polycythemia and his cognition. The GCM could accidently blew up into his face. It vera, diabetes mellitus Type II, help Mr. Tarlow’s sister provide penetrated the left zygomatic arch and severe obstructive sleep apnea, structured daily programming hypercholesterolemia, for him to keep him physically hemochromatosis, and mentally more active. ischemic cardiomyopathy, Suggestions such as laying out The orbital frontal syndrome is hypertension, and a history clothes and grooming items characterized by impulsivity and of pulmonary embolism the night before may help. He disinhibition. Social disability may with hypercoagulable state. would need constant prompt- be the most prominent disability He was on chronic warfarin ing through his ADL routine as well as furosemide 40 due to his motor impersis- in these patients. They are often mg daily, insulin glargine tence. He needed 24-hour unemployable due to the social human 100 unit/ml 30 units supervision for his safety. A deficits. The patient may be SC BID, lisinopril 20 mg caregiver in the home would hyperactive or hypomanic. ½ tablet daily, metformin allow his sister to work and HCl 500 mg daily, participate in social activities. methylprednisolone 4 mg as Alternatively, adult day care or directed, metoprolol tartrate assisted living on a memory unit might exited at the left prefrontal area of 25 mg ½ tablet BID, potassium be considered. Exercise and other the brain “passing back of the left chloride 20 mEq SA daily with food, structured assisted activities would eye, and out at the top of his head,” and simvastatin 40 mg ½ tablet QHS. help maintain his physical health and cauterizing the tissue as it passed Mr. Kelly’s wife reported he well-being. Repetitive activities under through. Although Gage was thrown supervision were suggested, such as had odd behavior that frustrated her. backwards onto the ground, shortly For example, she wrote a note to sweeping the deck or raking leaves. A he was able to get up. referral to the Alzheimer’s Association him and placed it on top of his cap Gage had been well-regarded by would help his sister. and keys so he would see it before his supervisors and work crew alike he left the house. He did not read Orbital Frontal before the accident. A contemporary the note, putting it aside because it Syndrome account reported that prior to the was on a Christmas label. He stated, accident “Gage was an ordinary “Why should I read it? It wasn’t even The orbital frontal syndrome sober Yankee, intelligent, …with Christmas!” On another occasion, he is characterized by impulsivity and no peculiar or bad habits,” but after directed a friend to the correct golf disinhibition. Social disability may be he was “fitful, irreverent, indulging course where they had a reservation the most prominent disability in these at times in the grossest profanity… but he then drove another friend to patients. They are often unemployable impatient of restraint or advice the wrong golf course. She said due to the social deficits. The patient when it conflicts with his desires… he often stated that a mistake he may be hyperactive or hypomanic. obstinate, devising many plans of made occurred because, “It wasn’t Lability with prominent irritability operation, which are no sooner important to me.” During the testing, or euphoria can occur. There may be arranged than they are abandoned he made repeated inappropriate jokes sexual jesting or other inappropriate in turn for others appearing more about the examiner making him do comments. Neurological and feasible.” He was unable to continue pushups, which made no sense in the neuropsychological deficits are not working. Gage was involved in context of the testing. common with this syndrome, though multiple bar brawls, and made anosmia or lack of the sense of smell his living by allowing others the continued on page 12

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Frontal Lobe Disorders specific minor irritations and crises References and Dementia for her husband. A referral to the Barrash, J., Tranel, D., & Anderson, S.W. continued from page 11 Brain Injury Association as opposed (2000.) Acquired personality disturbances to the Alzheimer’s Association was associated with bilateral damage to the Mr. Kelly demonstrated more likely to help her because the ventromedial prefrontal region. Developmental virtually no cognitive deficits on disinhibited frontal lobe syndrome Neuropsychology, 18(3), 355-381. testing, and in particular, memory shared more features with brain Bechara, A., Damasio, H., & Damasio, A.R. scores were all normal. Many injured patients with disinhibition (2000.) Emotion, decision-making, and the scores were above average. The than with those with dementia. orbitofrontal cortex. Cerebral Cortex, 10, 295-307. only mild impairments were in conceptual skills, initial problem Conclusions: Bechara, A., Damasio, A.R., Damasio, H, & strategizing, and psychomotor Anderson, S.W. (1994.) Insensitivity to future The examples cited above consequences following damage to human speed. He had a very mild cognitive provide opportunities for care prefrontal cortex. disorder that was likely due to a managers to assist families in the focal prefrontal lacune. He had early identification of possible frontal Cognition, 50, 7-15. behavioral components consisting lobe disorders and the chance to Bechara, A., Damasio, H., Damasio, A.R., of impulsivity, inability to integrate direct clients to resources capable & Lee, G.P. (1999.) Different contributions data, poor reasoning, and limited of assessing the cause or causes of of the human amygdala and ventromedial behavioral changes. Armed with the prefrontal cortex to decision-making. Journal insight, judging his errors as of Neuroscience, 19, 5473-5481. “unimportant.” There were emotional findings of appropriate assessment, components consisting of increased the care manager may work with both Cummings, J. (1985.) Behavioral disorders clients and family members to design associated with frontal lobe injury. In Clinical jocularity and irritability. The deficits Neuropsychiatry, Grune & Stratton: Orlando, reflected a mildly disinhibited frontal programs of support to optimize pp. 57-67. lobe syndrome with an indifference client capability while working within defined deficits. Damasio, A.R., & Van Hoesen, G.W. (1983.) response; technically, he had a Emotional disturbances associated with personality change. The indifference Neuropsychological evaluation focal lesions of the limbic frontal lobe. In K. response referred to the fact that Mr. is an important tool to help the care Heilman & P. Satz (Eds.), Neuropsychology of human emotion. New York: Guilford Press. Kelly did not attach importance to manager bring the best resources any errors that he perceived or that to the client for the right reasons. Eslinger, P.J., Grattan, L.M., & Geder, L. were pointed out to him. With a thorough neuropsychological (1995.) Impact of frontal lobe lesions on assessment, the care manager can rehabilitation and recovery from acute brain In this situation, the GCM determine what cognitive strengths injury. Neurorehabilitation, 5, 161-182. might help Mrs. Kelly to provide remain that can be used to assist the Malloy, P.F., Bihrle, A., Duffy, J., & Cimino, appropriate context for her husband. client and family and what cognitive C. (1993.) The orbitomedial frontal syndrome. Again, a neurological evaluation or weaknesses may be remediated with Archives of Clinical Neuropsychology, 8, 185-201. neuropsychiatric evaluation might various tools or interventions. The determine an appropriate cognitive family can have questions answered Martzke, J.S., Swan, C.S., & Varney, N.R. medication. He was likely to relating to changes in behavior, (1991.) Posttraumatic anosmia and orbital frontal damage: Neuropsychological and continue to attach no meaning to emotion, and personality. Potential neuropsychiatric correlates. his errors, but there was a higher for natural recovery may be assessed likelihood of making fewer errors if if the frontal lobe disorder is in the Neuropsychology, 5, 213-225. the couple agreed on certain house acute stage. Evaluations from other Ready, R.E., Ott, B.R., Grace, J., & Cahn- rules. Increasing the organization professionals may be recommended. Weiner, D.A. (2003.) Apathy and executive in the household could help him dysfunction in mild cognitive impairment and Alzheimer’s disease. American Journal of stay on track. For example, his Geriatric Psychiatry, 11(2), 222-228. appointments might be written on Rolls, E.T., Hornak, J., Wade, D., & McGrath, a large calendar, posted in red. A J. (1994.) Emotion-related learning in patients particular bright-colored Post-it with social and emotional changes associated note could be used specifically for with frontal lobe damage. Journal of Mr. Kelly. His thinking ability was Neurology, Neurosurgery, and Psychiatry, 57, 1518-1524. adequate to learn technological solutions such as following a Sarazin, M., Pillon, B., Giannakopoulos, P., programmed schedule on a computer et al. (1998.) Clinicometabolic dissociation of cognitive functions and social behavior in or an iPhone. Mrs. Kelly would frontal lobe lesions. Neurology, 51, 142-148. need help with problem-solving Stuss, D.T., Benson, D.F., Kaplan, E.F., et al. (1983.) The involvement of orbitofrontal cerebrum in cognitive tasks. *Names in this paper are not those of identified individuals. Neuropsychologia, 21, 235-248.

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Zald, D.H. (2007.) Orbital versus dorsolateral prefrontal cortex: anatomical insights into content versus process differentiation models of the prefrontal cortex. Annals of the New York Academy of Sciences, 1121, 395-406. A Different Dementia: Zald, D.H., & Andreotti, C. (2010.) Neuropsychological assessment of the Different Challenges orbital and ventromedial prefrontal cortex. Neuropsychologia, 48(12), 3377-3391. By Sharon Mayfield, BSN

Dr. Patricia Gross is a Summary of age or younger and might still board certified clinical be employed. The symptoms are neuropsychologist with over This article demonstrates often misunderstood as the disease 25 years of experience in the different challenges that caregivers progresses, and misdiagnosis occurs diagnosis and treatment of and an experienced nurse are faced about 50% of the time. One of the brain disorders and dementia. with when their loved ones/clients hallmarks of this dementia is that the She obtained her doctoral have an FTD (frontotemporal person with FTD lacks empathy or degree at the University of disorders). The behaviors associated with this disorder do not respond to sympathy for the caregiver even when Southern California and her the usual techniques the caregiver is in postdoctoral fellowship at the such as distraction. pain or critically UCLA Neuropsychiatric Institute The diagnosis almost ill. Another key (now the Geffen Institute). She always causes The symptoms feature, unlike practiced in Charlotte with the deterioration in the are often with Alzheimer’s Carolinas Healthcare System relationship between misunderstood disease, is that there for 19 years and spent one year the caregiver and may not be any working for the Army at the the person with the as the disease short-term memory Landstuhl Regional Medical disease because of progresses, and loss. I have learned Center in Germany. Since 2009, the indifference and misdiagnosis many lessons while she has been a neuropsychologist changes to their assisting families at the W.G. Hefner VA Medical personalities. occurs about 50% in their caregiving Center in Salisbury, NC. Dr. I have been of the time. roles and will Gross co-authored research on working with share some of my the first Alzheimer’s drug and people who experiences. participated in FDA trials for have Alzheimer’s disease and Some behavioral changes were galantamine, the fourth dementia related dementias for many years present in a gentleman that I took on a medication. She served as as a registered nurse, assisted shopping trip to the local president of the Western living administrator, and hospice Wal-Mart. Our conversation in the Carolina Alzheimer’s Association palliative care admissions nurse, car was normal except for occasional from 1999 to 2002, and on the and consider myself fairly familiar word searching. But because I have Board from 1996 to 2008. She with different techniques to make learned to “speak” dementia, he felt has published in numerous caregiving easier. This past year I understood without any anxiety. Once professional journals. have encountered a number of cases inside the store, his social disinhibi- that are not dementias affecting the tion began to surface. He met the posterior parts of the brain as with Greeter like a long lost friend, shaking Alzheimer’s, but affect the temporal his hand and giving him a hug. I and frontal lobes. People who have took a deep breath and thought this frontotemporal disorders (FTD) was a good omen. The next man we present different symptoms and the encountered was rather large and tall. caregiving approaches that have Before I could intervene, my compan- worked in the past with people who ion remarked for all to hear, “He is as have Alzheimer’s disease do not big as a barn! Say do you eat hay?” I necessarily apply. maneuvered us away from that scene Frontotemporal lobe disorders and into the next aisle where two are often described as a slowly children were bouncing the balls from progressive deterioration of social a display. “Put those balls back,” he skills and changes in personality shouted. I had to say, ”Now you did or impairment of language. not wear your referee shirt so you These clients often are 65 years continued on page 14

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A Different Dementia: and hide the car keys to keep them sense. She appeared unkempt, as she Different Challenges from him to be sure that she has had become resistant to grooming continued from page 13 some money for parking, etc. She and bathing. She was about 55 years can’t give orders!” was surprised to discover that he old when her husband had noticed had intercepted the delivery of the that things were not right and was The next adventure occurred new checks and had removed several diagnosed at age 58. This lady would when he needed to use the bathroom. checks from the middle of the check greet me like an old friend, and I told him I would wait for him just books for his later use. initially I could take her to get her outside of the restroom. Then I could hair and nails done if I stayed by her hear him introducing himself to He has had a companion that takes him out for lunch one day side in the stylist chair and kept up the everyone and I could just picture him conversation. shaking their hands. One man came a week, and the presumption had out and saw me with a worried look. been that he could take him on She seemed to be deteriorating He asked if he could help. I asked some errands so that his wife would quickly. Her husband was her sole him to direct the man he had just not have to do these errands after caregiver and he tried very hard to “met” out to me, as he could not find work. He has brought his wife’s keep all the conversations light and his way out of the restroom. silver certificates to purchase a bird silly (she responded to silly). He felt Later we encountered this most at ease when she was same man with his wife. He seat belted in the car listening to music that they loved. too, must have had some Her husband was her sole experience with dementia She could no longer because he greeted my caregiver and he tried very figure out the order for client by name and shook hard to keep all the conversations doing tasks. She was totally his hand and introduced him light and silly (she responded continent but could not figure to his wife. What a good to silly). He felt most at ease out the toileting sequence. encounter! But before we She would begin to pace could get out the door he had when she was seat belted in the around as her bladder filled. asked another gentleman for car listening to music When they were out in $2.00 and the man had his that they loved. public a public restroom with billfold out before I could signage aided in giving her add that he was kidding. enough clues so that she could Luckily this was another complete the task. At home person with experience with persons house. He once went to the bank, she would pace around the apartment, with dementia, as he said he would and with only his driver’s license seemingly not hearing requests to help lend him a couple of bucks anytime. and no account number or checks, her to the bathroom. Then something All this occurred in a forty-minute was assisted by the bank staff to would “click” and she would go to shopping trip. I was grateful to leave withdraw money. the bathroom, navigate the button and the store intact without any shop Sometimes he compulsively eats zipper on her jeans and successfully lifting, which he had done in the and drinks. He drank 14 containers sit down on the commode and void. past when his wife had taken him of V8 juice in 5 days. He often This cycle continued about every 2 -3 shopping. It was still challenging. calls his wife at work 20 times a day hours. If the pacing was interrupted, Contrast that episode with to ask her to bring home more ice she would strike out. another client who lives to shop cream. He does not have short-term Sometimes she would strike out and is fixated on having access to memory loss to account for this, for no apparent reason. It got very money. It occupies his mind most but once he is on a task like this he difficult for her husband to take her of the time. Before he had been persists until his goal is obtained. out in public, as sometimes she would definitively diagnosed, he had run up He cannot be diverted from his not get back in the car, and he would quite a gambling and shopping debt cause. He smokes continuously. have to pace around with her hoping on line. Even though he had been an Despite all of this, he can carry nobody thought he was trying to accountant, he seemed completely on a good conversation at other kidnap her. She also had some visual unaware of his spending. His wife times and appears perfectly normal deficits that prevented her from seeing has had to return to work to help to when he is groomed to go out. depths, and she was unaware of others pay off the credit card debts. She has Another lady that I worked with around her. also tried to take steps to be sure that had difficulty with language. She Her husband was very concerned this spending is not repeated. She has would search for words and often that she was not stimulated enough. also had to lock her purse in the trunk used words that did not make any She had been very artistic and had

page 14 of Spring/Summer 2011 Geriatric Care Management made beautiful quilts and had lived replied that the usual drugs like abroad and enjoyed many different Ativan, Respiradol, and Haldol Sharon Mayfield attended the cultures. She was apathetic toward may make things worse. Bruce Ohio Valley General Hospital most activities. But researchers say Miller, MD stated that we have to School of Nursing and received that they are not bored. use these drugs now to deliver care her BSN from West Liberty University, West Liberty, WV. When she paced, it was as until there is something better. She has owned and operated her though she was in a trance. Intrusion I have found the best way own assisted living community by others at such times resulted in to improve the quality of life of as well as worked as Director aggressive behaviors. One effective the families that I have worked of Operations for Hunt Assisted tactic for me during these times was with has been to make sure that Living. She is a former hospice to try to blend into the background the primary caregivers have had nurse. while monitoring for safety. I even some respite and support. They resorted to wearing clothing that often have shared relief when Sharon currently owns blended in with the sofa. I, too, was not able to provide the Seniors Helping Seniors franchise in Charlotte, NC Sadly the lady in the above care and experienced the same where she matches seniors scenario had symptoms that escalated resistance from their loved ones. who need non-medical care very quickly. In the course of three I encouraged them to seek out support groups for frontotemporal with other seniors who can months she went from shopping with provide it. She has a special me at the mall to a secured dementia diseases. (However, even though the Western North Carolina interest in providing care for the unit that required that a 24/7 “caregiver,” especially those caregiver be with her. She physically Chapter of the Alzheimer’s Association has 58 support groups, who are dealing with dementia. aged in appearance and lost weight, there is currently only one that as she only ate when she paced. She focuses on FTD. Although there eventually became incontinent and are only 50 centers for FTD in the was very resistant to being changed. entire country, it is thought that Medications were changed, and this form of dementia may occur she underwent a stay in a geriatric as often as Alzheimer’s disease.) behavioral unit. When she takes her medication and it has time to get into Another caregiver found her system, she can have a social side some solace in yoga and goes and is able to arrange fabric strips to into his “yoga state” when he has her liking. Her doctor describes her to deal with his wife’s difficult condition as being one of “global periods. All would agree that brain deterioration” with frontal you will not be successful if you lobe involvement. There some are stressed and exhausted. A reports that state the life expectancy local caregiver, Bill Matson, has of people with frontotemporal lobe written about his struggles in the disease is half that of those with Mooresville Tribune. He states, “I Alzheimer’s disease. often sign my correspondence by saying ‘from the foxhole’ because There has not been much that’s how I feel.” progress in finding medications that are effective in managing I can only begin to appreciate FTD symptoms. There has been the battle that is waged every day some success with SSRI (selective by these caregivers. There is no serotonin reuptake inhibitors), cure but my mission is to try to but some medications used with ensure that this disease is not fatal Alzheimer’s have been thought for the caregiver as well. to make the symptoms worse. I spoke with a researcher at the Duke Conference about the dilemma regarding medication when there is this extreme resistance to care. He

page 15 PRE-SORTED STANDARD US POSTAGE PAID Tucson AZ 3275 West Ina Road, Suite 130 Permit No. 630 Tucson, Arizona 85741