Category: Dementia

Vascular Dementia Step wise Progression and Risk Factors

Posted on by Michael Brown

There are different types of dementia, and each has its own symptoms associated with it.  I have written other blog posts on dementia in the past:

This post will concentrate on vascular dementia.  I always tell my students and pharmacy residents that we are all only one stroke away from becoming a dementia patient. 

Vascular dementia can strike at any time.  This type of dementia occurs when the brain does not receive an adequate supply of blood.  The decrease in blood flow can cause brain cells to die, resulting in problems with cognition. 

Vascular dementia is the second most common type of dementia.

Types of Vascular Dementia

Stroke related – A stroke is caused by an abrupt blockage of the arteries feeding the brain.  This can happen as a result of a blood clot (ischemic stroke) or when a vessel in the brain bursts leading to a brain bleed (hemorrhagic stroke).  Approximately 20% of stroke victims develop dementia within six months.  It is important to note that once a person has a stroke, they are at a higher risk of having additional strokes.  The risk of dementia increases with each stroke. 

Subcortical dementia – Small vessels deep within the brain can become stiff and twisted, leading to a decrease in blood flow.  This may lead to nerve bundle damage.  This damage occurs deeper in the brain, and because of this, the symptoms differ from stroke-related dementia.

Mixed dementia – Often Alzheimer’s disease and vascular dementia overlap.  The symptoms involved can be similar to either of the dementia types when this occurs.

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Stages of Vascular Dementia

The symptoms of vascular dementia can vary depending on the brain region affected by the lack of blood flow.
Although vascular dementia may have stages of progression, some may be skipped depending on the severity of the insult. For example, a significant stroke affecting a more substantial part of the brain may almost immediately lead to a person progressing to the later stages.

It is important to remember that unlike Alzheimer’s disease, vascular dementia may not progress slowly.  The patient may get much worse after a stroke occurs.  In subcortical dementia, gradual progression is possible due to a slow deterioration of the brain’s white matter.

Common early-stage symptoms of vascular dementia:

  • Slower thought processing.
  • Difficulty following simple directions, such as making a recipe.
  • Trouble with concentration with periods of confusion.
  • Problems planning, organizing, making decisions, and solving problems.

The patient may also have difficulties with:

  • Memory
  • Speaking
  • Visual perception

Patients in the early stages often show changes in mood, including depression, anxiety, and apathy.  If the patient is aware of their diagnosis, they may be more susceptible to depression.  Rapid mood swings are also frequent in these patients.

Later stage symptoms:

 As dementia progresses, the level of confusion and disorientation increases.  Communication may stop entirely, and the patient often loses control of their bodily functions.  As this occurs, they will become more dependent on caregivers. 

These patients may become violent, even if they have never been aggressive in the past.  They may demonstrate an altered sleep-wake cycle, which makes caring for them difficult. 

Eating becomes challenging, and they become more susceptible to falls. 

The average life span for a person with vascular dementia is about five years, but this can vary depending on the incidence and severity of strokes.  These patients usually die as a result of a heart attack or stroke.

Vascular Dementia Risk Factors

There are several risk factors involved in developing vascular dementia. Some are preventable, and others are not.

  • Age – The strongest risk factor is age. After age 65, a person’s risk of developing vascular dementia doubles every five years.  It is uncommon to find this condition in people under the age of 65.
  • History of heart attacks and strokes – This is an obvious risk factor.
  • High Cholesterol – Patients with high cholesterol are at greater risk for heart disease.
  • Hypertension – This is another risk factor for heart disease and stroke.
  • Diabetes – Diabetic patients often have comorbid heart disease.
  • Smoking – Smokers are at a higher risk of hypertension, heart disease, and stroke.
  • Obesity – Patients who are overweight and don’t get an adequate amount of exercise are at a higher risk of heart disease.
  • Arrhythmias – People with arrhythmias such as atrial fibrillation are at a higher risk of stroke.

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How to Help Prevent Vascular Dementia

The best way to reduce your risk of developing vascular dementia is to take care of your general health.  I know I sound like a broken record at times, but being healthy has many advantages. 

 

  • Exercise often and maintain a healthy weight.
  • Control blood pressure.
  • Control blood sugar if suffering from diabetes.
  • Quit smoking.
  • Control your cholesterol.

Vascular dementia is an unfortunate disease that affects our elderly.  Although different patients have different symptoms at times, many of the signs are similar to Alzheimer’s dementia.  The main difference is the speed of the progression. Vascular dementia tends to be stable for some time and then worsens after a stroke. Alzheimer’s disease slowly progresses over time.

There are things you can do to decrease your chances of getting vascular dementia.  Stay healthy and visit your physician yearly.  If you have hypertension, diabetes, or heart disease, try to keep them under control.  Exercise and eat whole foods whenever possible.

Being healthy is a decision that will pay dividends as you age.  We can’t protect our bodies from everything, but we can improve our odds.

If you have any questions about this post or any other, please feel free to send me an email.  Have a great rest of your summer, and be happy, healthy, and safe!

 

 

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Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

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How to Handle a Combative Dementia Patient

Posted on by Michael Brown

There are many challenges involved in caring for a patient with dementia. At times these patients may become combative. This is a regular aspect of the disease and may happen even in patients who were not aggressive earlier in their lives. 

How do you deal with combative dementia patients? 

I work as a pharmacist in a geriatric psychiatric unit. We care for these patients when caregivers are unable to. Our goal is to stabilize them and return them into the community.  

This post will give you pointers on what to do when faced with aggression from a dementia patient. 

Be Prepared and Keep Calm

It is essential to be prepared for unusual behaviors from dementia patients. Due to damage occurring in the brain, these patients often display unexpected behaviors.  

Be calm when they become aggressive and speak to them in a soft, comforting tone. Always remember that this is part of the disease process and not a personal attack against you. 

Although your instincts may lead you to retaliate when dealing with an aggressive dementia patient, this can make the situation worse. Try to learn from each situation and keep yourself and the patient safe. 

Try to Identify Possible Causes of the Aggression

There are some basic things to rule out when patients begin to act out. Be sure basic needs are met. These include: 

 Pain – uncontrolled pain can cause individuals to lash out. They often are not able to communicate. It is vital to look for non-verbal signs of distress, including: 

  • Facial grimacing. 
  • Moaning. 
  • Guarding certain areas or withdrawing from touch. 
  • Writhing or constant movement. 
  • Increase in blood pressure or respiratory rate. 

 

 Constipation-this can make anyone uncomfortable, including dementia patients. Be sure they follow a toileting schedule and pay attention to the frequency of bowel movements. 

 

Urinary tract infections – These can be a cause of pain and discomfort and are more common in elderly patients. Monitor the patient for smelly, cloudy, or discolored urine. If these signs appear and the patient is acting differently, they should be seen by a medical professional for an evaluation. 

Try to keep the patient comfortable. Maintain a reasonable room temperature and create a good place for the patient to relax.  

  

Sleep – We all can become grumpy if we don’t get enough sleep.  Follow the basic sleep hygiene guidelines listed below. 

 

  • Follow a sleep schedule. Try to get the patient to sleep at the same time each night. 
  • Avoid letting the patient take long naps during the day. 
  • Do not give the patient large amounts of fluid close to bedtime. This can increase nighttime awakening. 
  • Be sure the room where the patient sleeps is dark, quiet, cool, and comfortable.  

It is important to note that sleeping pills other than melatonin are not appropriate for dementia patients. Drugs such as diphenhydramine (BenadrylTM) and other sedating antihistamines make dementia worse. Read my blog post on anticholinergics and dementia for more information. 

 

 

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Calm the Environment

Excessive noise and activity can agitate patients.  

The nurses on our unit are quick to ask staff to quiet down when it becomes noisy or hectic.

Keep music soft, and try to have people speak quietly.

If too many people are around the patient, ask some of them to relocate temporarily. If the patient is starting to act out, try moving them to a different room.

Keep track of what works and doesn’t.

Every patient is different. 

 

Redirect

Many times you can calm a dementia patient by merely redirecting them. Read them a story, show them pictures or watch a TV show with them. Avoid activities that demand too much thought or concentration. Most dementia patients will become frustrated if they are asked to participate in activities that are too difficult for them to perform. Find activities that the person enjoys. Redirection is one of the best tools available to you. 

Smile and be Kind

Sometimes a simple smile can do wonders—all of us like people to smile at us.

A gentle touch can also help.

Avoid startling the patient. Approach them from the front so they can easily see you coming.

Show them you care.   

Give Them Time Alone

If nothing seems to be working, consider giving the patient some time alone.

Be sure the patient is safe and keep an eye on them.

They may just need to cool down.

Some alone time in a quiet place may be what is necessary.  

Take Care of Yourself First

If you are taking care of a dementia patient, you will likely be under a lot of stress.

The most important thing for you to do is keep healthy, both physically and mentally.

You will not be an effective caregiver if you get burned out or become sick yourself.  

If you need a break, find help!  

Taking care of these patients often causes one to be up in the middle of the night. Try to find a family member or friend to help when needed.

We all need a break at times. 

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Know Your Limits

In some cases, you may be unable to care for the patient yourself.

If the situation becomes unsafe for either you or them, it is time to consider placement into a memory care facility.

This is not a sign of failure on your part. We all have our limits. Memory care facilities are staffed with individuals who know how to care for your loved one. They take care of these patients every day.

Caregivers in these facilities are trained to recognize behaviors that require medication.

Remember, your health and well-being are important too. 

I have spent the last four years working on a unit that cares for geriatric patients with psychiatric issues. Many of these patients have dementia. There are several forms of this disease, but all of these patients become dependent on others for their care eventually.   

Working with these patients has been one of the most rewarding aspects of my pharmacy career. Being involved in the final chapter of a patient’s life has a special meaning to me. 

I hope this post has helped if you are caring for a loved one with dementia. I want you always to remember that there is help out there for you if you are struggling.  

Safety is always the most important goal.   

I have listed some resources below if you need help.  

You can always contact me with questions at [email protected].

If I don’t know the answer to your question, I will find it for you. 

 

 

Have a great week, and stay safe. Be sure to read our other blog posts to help you live a happy, healthy life, and please sign up for our newsletter below.   

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Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

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Feel free to send Michael a message using this link.

 

 
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Woman in sensory room holding fiber optics

Snoezelen Therapy for Dementia Patients

Posted on by custom
Woman in sensory room holding fiber optics

Disclosure:  This post may contain affiliate links, meaning, at no additional cost to you, I may earn a commission if you click on, or make a purchase through a third-party link.

The world population is ageing and, because of this, the incidence of dementia has risen.  According to the World Health Organization, approximately 50 million people have dementia worldwide, and 10 million new cases are diagnosed every year.  The incidence of dementia is expected to reach 131 million people by 2050.1

  Dementia has a tremendous impact on both the patient, and the family.    Patients with dementia are unable to remember things, have a difficult time solving problems, and can become easily frustrated.  Their sleep-wake cycle may become reversed and, at times, they may even become violent to the ones they love.  Dementia occurs in older people but is not a normal part of the ageing process.

Dementia patients may reach a point where they need to be hospitalized due to behaviors which are not able to be controlled by their caregivers.  Some of these behaviors include agitation, depression, aggression, and apathy.

I have been working on a unit which cares for dementia patients for three years.  During this time, I have learned a great deal about this condition as well as common and not so common treatments.  I have written other blog posts relating to dementia but this post will concentrate on the use of Snoezelen therapy for these patients.

A Snoezelen room is a controlled multisensory environment (MSE).  Equipment in these rooms cause a variety of stimulation including tactile, auditory, olfactory and visual.  Snoezelen rooms should provide a calm and comfortable environment for the patients.  These rooms can be used for patients with autism, brain injuries, developmental disabilities as well as dementia.  MSE’s are not inexpensive to set up.  Associated costs could run from $10,000 to $30,000 and even more if complex, high-end equipment is used.

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Assessing Unmet Needs

The Unmet Needs Model suggests negative behaviors in dementia may result from the inability to communicate one’s needs to caregivers.  There are ways in which we can attempt to learn what these unmet needs are by trial and error.  In the hospital setting, we often talk about the following possibilities that may make the patient uncomfortable.

  • Pain – This one is difficult to assess. There are pain signs such as grimacing.  The patient may also be suffering from a urinary tract infection, or other ailment.
  • Constipation – Keep track of bowel movements. Constipation can be uncomfortable, and is usually easy to treat.
  • Hunger – Offer food. Attempt to learn the patient’s food preferences by speaking to those close to the patient.
  • Thirst – Offer fluids.
  • General Comfort – How the patient is sitting, temperature, clothing, etc.

If these don’t help, the patient may be suffering from boredom.  This is where the Snoezelen room can help.  Always remember, dementia patients are people like us who have a disease and it is important to view them as such.  What works for one patient, may not be effective for another.  Get to know what the patient prefers and keep track of successful interventions.  Always start with the basic needs described above.  If the patient is in pain or uncomfortable due to being constipated, a Snoezelen room experience will likely have little effect on behavior.

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Benefits of Multisensory Environments in Dementia Care

Later stage dementia patients are usually unable to seek out enriching and meaningful activities on their own.  In fact, left to their own devises, they would quickly decline.  Most of the time, they are completely dependent on others for their care.  Older people are also less able to perceive sights, sounds, tastes, and smells which increases their risk of sensory deprivation.3

This can have a negative impact on health and wellbeing.4

Some believe that sensory experiences are able to trigger positive memories.  This may promote a feeling of pleasure for the patient.  Think about this in your own life.  I believe we’ve all experienced being taken back in time when we’ve smelled something that triggers a positive time in our lives, or heard a song that takes us back to a happy time.5

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The goal of the multisensory environment is to positively effect the dementia patient using sensory channels that are still intact. 

The three main avenues by which a multisensory experience can be achieved are.

  1. Daily care routines such as bathing, feeding, and administering medications 7

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  1. Sensory enhancements of the patients living environment. This may include special units in long-term care facilities which provide staff specially trained to care for dementia patients, special activities geared towards these residents and involvement of the family.9

  1. Specially designed rooms or MSEs.10

Studies have shown that MSEs can be beneficial for dementia patients.  Some of these benefits include.

  1. Decreased agitation and disruptive behavior.

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I would like to point out that some of the medications utilized to combat aggressive and disruptive behavior can cause agitation.  

  1. Increased alertness14

  1. Increased social interaction, reduced apathy, and better mood.15

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  1. Better communication with others.18

  1. Improved functional performance19

These positive attributes of MSEs leads to a more relaxed, engaged patient who gets along better with his or her peers. 

Research also shows caregivers who utilize MSEs for their dementia patients have better job satisfaction and a better relationship with their patients.

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This leads to improved patient care and reduced caregiver burnout.

Obstacles to Adding a Snoezelen Room to a Facility

Many facilities do not have the financial resources or space to implement a Snoezelen room.  As mentioned earlier in the post, these spaces can get expensive.  The institutions who have these rooms often under-utilize them.  Another problem is deciding how to design such a space.  There is much debate on exactly what to put into these rooms and research is still being conducted in this area. 

Anti-suicide regulations can also hinder certain facilities from adding a Snoezelen room.  This is especially true of psychiatric facilities where dementia patients may end up due to negative behaviors.

Perspectives of an Expert

I have the pleasure of sharing an office with an occupational therapist.  Kendra Munroe, OTR/L works with our patients daily and was the person who designed our sensory room.  Our main piece of equipment is a Vecta which was purchased from TFH Special needs Toys.  This company specializes in sensory-focused equipment and toys which promote learning and living skills.

The Vecta Full Mobile Sensory Station can turn any room into a relaxing, distracting and empowering multi-sensory room. 

According to Kendra, the sensory room “provides a safe and contained spot where the patients can explore”.  She explains that you want to have different things available to engage their senses.  Some examples include music that is tailored to the specific patients tastes, as well as things they can see or touch.  Kendra also believes it is important to include things related to nature. 

We provide weighted blankets by Salt of the Earth as well as quilts, stuffed animals, robotic pets, and a weighted baby doll to provide a realistic sensory experience.

Munroe stated that certain things are often neglected in sensory rooms, specifically regarding the geriatric population.  She mentioned things that provide proprioceptive and vestibular input in particular. “This is why we put a glider in,” Kendra explains.  We purchased a specific glider that locks in place when the patient attempts to stand.  The Thera-Glide safety glider decreases fall-risk and rocks back and forth which is soothing to the patient.

Kendra does point out that there may be dangers involved with sensory rooms.  She emphasizes that we must be trauma-informed with any of our treatment.  We must be aware that small, enclosed spaces may bother some patients.  We also need to be sure there are no objects or equipment available that the patient may throw due to confusion. 

Dementia patients should never be left alone in a sensory room.  They may become confused because the room is unfamiliar to them.  They may damage the equipment, or injure themselves.

Munroe ended by saying that we really didn’t have many guidelines available to us when setting up our sensory room.  We tried to provide a mixture of adult and pediatric sensory experiences that we believed would be most beneficial to our patient population.

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I am a big supporter of sensory rooms.  My thought is we should utilize all other treatment modalities prior to resorting to medications for dementia patients.  All drugs come with side effects and currently there are no medications indicated for the behavioral and psychological symptoms of dementia. 

Always try to meet the basic needs of the patient before moving on to other therapies.  Assess for pain, hunger, thirst, constipation and comfort. 

As a society, we have a responsibility to care for our ailing population.  This includes the mentally ill.  Unfortunately, none of us are immune from this debilitation condition.  We can all learn about it, and try to limit our risk of developing dementia.  I will continue to write about this subject as I believe it is very important.

If you have any questions regarding Snoezelen rooms or dementia in general please reach out to me.  I have access to some of the best professionals in this area. 

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Michael Brown in Lab Coat with arms crossed

Michael J. Brown, RPh, BCPS, BCPP

Mr. Brown is a Clinical Pharmacist specializing in pharmacotherapy and psychiatry.

Read Michael’s story here.

Feel free to send Michael a message using this link.

 

 
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