Friday, September 27, 2013

WHAT IS SUNDOWNING AND WHAT CAN BE DONE?

Anyone with acute or chronic confusion may become more confused, restless, agitated and anxious in the late afternoon and especially after dark when the sun goes down or seasonally when there are fewer hours of sunlight.  This may happen whether the person is living at home ore in a facility.  The sundowning behavior can worsen following a move or change in routine.  Individuals with sundowning behavior become more demanding, upset, suspicious, disoriented and see, hear, believe things that aren't real or pace/wander.

Those with Alzheimer's Disease act as if their biological clocks are "reset."  These individuals may stay up all night alert and full of energy despite all interventions to encourage them to sleep in bed; then, they will continually doze on/off during the day.  The reasons for these changes in the sleep-wake cycle in Alzheimer's Disease is not known.

The reason for sundowning behavior is also not known. One theory is that there are fewer environmental clues at night when daylight and eyesight is diminished.  Some scientists believe it may be related to the biological clock in the brain which regulate the amount of hormones and other chemicals important for brain function.  If the biological clock is not properly functioning, the brain itself may not be able to properly function as well.

What can be done for those with abnormalities to the sleep-wake cycle?  It can be a very frustrating problem to deal with, but the following suggestions may be worth a try:

1) ACCOMODATE TO THEM.  Granted, this may be the most difficult and costly approach.  Accommodating to the person's new routine must include keeping them in a locked/secured environment and awake night staff for full supervision as well as ongoing stimulation during their awake periods. They could rest and snooze throughout the day to insure they are adequately rested.

2) MEDICATIONS.  It may be appropriate for the doctor to review all medications to consider discontinuing any non-essential medications which may have an effect on sleep.  Other medications that may reduce anxiety, relax muscles or induce sleep may be considered.

3) ASSESS PAIN.  Pain keeps people from sleeping, or may wake them up from sleep.  With some forms of dementia, communicating or expressing one's pain may be impaired.  Those with complex medical problems in addition to dementia may also be affected by musculoskeletal or other source of pain.  In some cases, a trial of a relatively benign pain medication such as Tylenol may be justified.  If sleep problems are in part due to arthritic pain, aspirin or Tylenol may decrease musculoskeletal pain so that the person can sleep more comfortably.

4) ADDRESS NIGHT TIME TOILETING.  Many older persons awaken many times a night to urinate and then are unable to return back to sleep.  Identify if there might be a urinary infection, provide a bedside urinal or commode to minimize walking through the house activity.  With less physical activity involved to manage night time urination, individuals may fall back to sleep more easily.

5) UTILIZE NIGHT LIGHTS.  Elderly individuals may also have low vision which is exacerbated at night.  A small night light helps to orient and minimize agitation if the individual wakes up and becomes frightened by strange surroundings.  Night lights can also be placed to mark the pathway to the bathroom.

6) KEEP A STANDARD, DAILY ROUTINE.  While caregivers may change from day to day, it is helpful to keep a standard daily routine for any individual with dementia.  A standard daily program for wake-up time, meals, medications, toileting and bedtime routines should be followed by all caregivers to provide consistency.  The daily routine should also include physical activity and other mentally stimulating activities which will help to reset the awake-sleep cycle as well as maintain optimal function. A consistent program reduces anxiety so that an individual will also learn to anticipate what will happen next rather than begin to worry or become anxious wondering when they will eat, get their meds, toilet or go to bed.  Make a written program which is followed by all caregivers 7 days/week.

Wednesday, September 18, 2013

Dementia: When to worry

Have you ever gone to the pantry to get something then can't remember why you went there?  Can't remember where you put your phone or keys?  Have trouble remembering someone's name?  Are you worried about your memory?  Then join the crowd and perhaps worry less.  The type of memory problems described above are entirely consistent with normal brain function in someone over 55 (or younger) and are in no way indicative of dementia.  Many people consult doctors about their poor memory and are concerned they may be in the early stages of dementia.  If YOU ALONE are concerned about your memory, there is most likely less concern about dementia than if close family members are concerned.

True dementia does involve short term memory loss with retention of long term memories, but it's more than just that.  In general it can be said that dementia involves memory impairment PLUS some inability to function independently in one's daily routine, social activities, or relationships.  These independent functions might include:
  • Impairment of complex tasks such as balancing a checkbook
  • Impairment of reasoning such as difficulty dealing with new and unfamiliar situations
  • Impaired spatial functions (Dementia testing often will involve asking the subject to draw a clock face with a given time on it, or copy a pattern on paper)
  • Impaired language such as using the wrong words to describe things
Of those who have  dementia, about 70% have Alzheimer's disease, 10-20% have Vascular (stroke related) dementia and 10-15% have Lewy body dementia (an accelerated form of Alzheimer's).  Other diseases such as Parkinson's or brain tumors can also result in related dementias.

Dementia-like symptoms that can appear to be similar in behavior (but are not) can include age related mild cognitive impairment (MCI), delirium or depression.  Those with simple age related cognitive impairment may have some memory difficulty and they may think a little more slowly, but the ability to function with day to day activities remains intact.  Patients with delirium have a sudden onset of new mentation symptoms and this is usually reversible. On the contrary, the onset of dementia is gradual and will worsen with time.   Depression can also mimic dementia-like symptoms.  Depressed individuals may perform poorly on standardized dementia tests due to lack of motivation and/or poor effort.  Medications can also create brain function changes that simulate dementia; alcohol, antihistamines, psychiatric medications, sedatives and others can impair memory and cognitive function.

Getting evaluated for dementia first involves talking to your primary care physician about your symptoms.  Then a brief brain function screening test can be administered.  If the screening test score results in a cause for concern, then blood testing for reversible causes like vitamin B12 deficiency or thyroid deficiency can be performed.  The value of brain imaging in diagnosing early dementia is controversial since the most common causes of Alzheimer's disease and Lewy Body disease will show no abnormality on imaging tests.  Neuropsychological testing is frequently valuable in anyone who is having a new brain function problem.  This testing involves several standardized cognitive skills tests administered by a neuropsychologist. 

At best, medication treatment for dementia can provide a modest improvement in symptoms and can slow down the rate at which dementia progresses.  Dementia is frequently accompanied by depression so antidepressant medication can be beneficial as well as other stimulating activities such as Physical, Occupational and Recreational therapies aimed at cognitive rehabilitation, exercise and mental stimulation. 

The benefits of social support for all individuals, families and caregivers affected by dementia related disease cannot be emphasized enough.  The prognosis from early symptoms to morbidity may last as long as ten years or more.  Joining support groups, dividing up caregiving duties and finding proper medical care or placement is imperative for the well-being of the affected individual as well as their loved ones.

Staying at home with support, placement in Skilled Nursing, Dementia Care Units or Board and Care facilities are all choices families may make for their loved ones.  Please visit the Villa Care Homes website to see how small board and care facilities can manage residents with dementia with a regimented daily program and high level of care/supervision. www.VillaCareHomes.com

Monday, September 2, 2013

Stroke Recovery: Alternative Treatments: Acupuncture

Stroke is the second most common cause of death (after coronary heart disease) and the leading cause of adult disability in the US today.  Approximately 700,000 strokes occur each year in the US leaving 500,000 survivors with residual disability.  Forty percent of those survivors have moderate impairment and functional limitations related to motor function and basic mobility, while 15-30% are severely disabled.  Physical therapists and other professionals focus recovery on relearning normal patterns of movement or facilitating a rebalance of muscle tone.  In an attempt to further improve outcomes of stroke rehabilitation alternative treatments such as acupuncture or electroacupuncture (EA) are being evaluated for their efficacy in improving functional recovery after stroke.  Acupuncture/EA has been used in eastern medicine for thousands of years to enhance stroke recovery.  It has only been in the last decade that studies of brain function with computed tomography (CT) scan and magnetic resonance imaging (MRI) has substantially expanded our understanding of neuronal recovery and their modulation by various rehabilitation interventions.

The mechanism by which acupuncture increases cerebral blood flow is not fully understood but immunohistochemical analysis in animals suggests an enhanced expression of vascular endothelial growth factor.  Clearly, post stroke outcome is dependent on stroke severity in the acute phase and that patients with intact cortical function have an advantage to better participate with motor recovery.  The location of the lesion site plays a significant role in the responsiveness to any therapeutic intervention as does the type of stroke: ischemic vs. hemorrhagic.    During the functional reorganization of  neural pathways following a stroke, therapeutic techniques rely on the neuroplasticity of the brain to achieve improved motor abilities and functional outcomes

Current evidence for clinical efficacy of acupuncture/EA for stroke recovery is promising but still controversial; it's efficacy as an adjunct to standard post-stroke rehabilitation programs can be demonstrated with accurate treatment intervention using electrical stimulation over acupuncture points, proper selection of patient and functional outcomes measures.  Additionally, acupuncture/EA may be helpful in treating pain, sleep disturbance, anxiety, depression, or other conditions which are common in stroke and often a barrier to recovery.

Sunday, September 1, 2013

92 Million Older Americans Expected by 2060

Over one in eight Americans is age 65 or older, according to the latest statistics from the U.S. Census Bureau.  The number of "older Americans" is approximately 41.4 million - an 18 percent increase from 2000.  The 65 and older population is also expected to more than double to 92 million in 2060, according to a new report from the U.S. Department of Health and Human Services entitled, "A Profile of Older Americans 2012."  The report also states that the population of those 85 years and older is projected to nearly triple from 5.7 million in 2011 to 14.1 million in 2040.

The report also provides the latest national demographic information on issues ranging from health care and health insurance coverage to disability and activity limitations for older Americans.  More information is at:  http://www.aoa.gov/AoARoot/Aging Statistics/Profile/2012/docs/2012profile.pdf

The Villa Care Homes are poised to care for those with disabilities associated with advanced aging.  Our program is successful because of the consistency in care, anticipation of needs and knowledgeable, loving caregivers.  We strive to coordinate the physical, emotional, psychological and spiritual needs of each of our residents.  We collaborate as a team together with the physician, resident and family members.  Please call to arrange a tour at any time. http://www.VillaCareHomes.com