Leading Age CEU Application
Title of Program: Supporting People with Cognitive Impairment in Independent and Assisted Living
Date of Program: January 7, 2016
Time/Duration of Program: 1.5-hour webinar, 9:30-11 am. I hour CEU, .5 hour Q&A
Instructor Qualifications: Cordula Dick-Muehlke, Ph.D., is a licensed clinical psychologist with 30 years of experience in working with older adults. She received her doctorate in clinical psychology from Fuller Graduate School of Psychology in 1993. Please see the attached curriculum vitae for more information.
Description of Course: Show how course directly relates to either the business operations or the care of residents in the facility.
Recent research has shown that 7 out of 10 residents in residential care (e.g., assisted living, board and care homes) are cognitively impaired.[1] Of the 522,990 individuals in this study, 28% were cognitively normal, 29% were mildly impaired, 23% moderately impaired, and 19% severely impaired. Given the desire of older adults to age in place, that is, to remain in the most independent setting possible even when cognitive difficulties suggest this may not be possible, providers struggle with how to best support the individual and ease transitions into higher levels of care. To increase attendee empathy for individuals developing or living with cognitive impairment in independent (IL) and assisted (AL) living, this session will describe multiple factors that interfere with early identification, diagnosis, and treatment, such as (1) fear of Alzheimer’s disease (AD), (2) stigma within senior living communities and society at large, (3) misperceptions about AD, (4) variability in cognitive symptoms, (5) early emergence of anosognosia (i.e., unawareness), and 6) behavioral changes. To further sensitize attendees to the experiences of individuals developing cognitive impairment, the speaker will share direct comments from people living with mild cognitive impairment (MCI) or AD. Based on this increased empathy, the speaker will present a variety of strategies to support individuals living in IL or AL who develop and/or have cognitive impairment and their spouses/families, including (1) ways to facilitate identification, diagnosis, and treatment, both when individuals/families are willing to pursue an evaluation and when they are reluctant, (2) support services (e.g., in-home care, counseling), sufficient and trained staff, and activities, (3) education of residents/families as prevention. The course is designed to empower attendees with the emotional capacity, knowledge, and tools to more effectively and compassionately support people with cognitive impairment in IL and AL.
III. Objective of Course: What is the student expected to know upon completion of this course?
As a result of participating in this course, attendees will be able to
a. Identify at least three factors that make it challenging for residents to acknowledge symptoms of cognitive impairment and pursue diagnosis. See Section II, (3)(a-d) below.
b. Identify at least two ways to facilitate a cognitive evaluation in a resident who is reluctant See Section II (4)(a)(iii) below.
c. Identify at least three key strategies for managing cognitive impairment effectively in IL and AL. See Section II (4)(c)(i-vii) below.
IV. Teaching Methods: Explain the types of teaching methods to be used.
This presentation will include a lecture using PowerPoint slides, followed by an interactive discussion about the challenges of supporting people with cognitive impairment in independent and assisted living.
A handout of the PPT presentation will also be provided to all webinar participants.
V. Course Content: Hour-by-hour detail of course outline, including instructor for each segment.
Presenter for entire session: Dr. Cordula Dick-Muehlke
Section I – Extent and Range of Cognitive Impairment in IL and AL (5 minutes)
(1) Extent of cognitive impairment in IL and AL
a. Unknown how many residents in independent living are cognitively impaired
i. Prevalence rates of MCI vary greatly (3-42%), making it difficult to understand the burden of this condition to society at large[2]
b. Of the 522,990 individuals in the 2010 National Survey of Residential Care Facilities, 28% were cognitively normal, 29% were mildly impaired, 23% moderately impaired, and 19% severely impaired
Section II – Developing Empathy for the Experience of Cognitively Impaired Residents (40 minutes)
(2) Empathy as a starting point for supporting cognitively impaired residents
a. Empathy defined[3]
b. Empathy vs. sympathy[4]
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Leading Age CEU Application
(3) Developing empathy for cognitively impaired residents
a. Sociocultural realities
i. Alzheimer’s disease is the most feared disease among Americans 60+[5]
1. Reasons for fearing Alzheimer’s disease4
a. Forgetting loved ones
b. Becoming a burden to family
c. Being unable to care for oneself
d. Losing one’s personality
e. Having an experience with someone who has Alzheimer’s
ii. Stigma
1. Stigma defined as a mark of disgrace associated with a particular circumstance, quality, or person [6]
a. Perpetuated by negative descriptions of dementia and affected individuals (e.g., dead already, a shell)
2. Stigma in senior living communities and society at large
3. One out of four people with dementia hide their symptoms out of fear of stigma[7]
a. On trying to fake it – Rhoda, diagnosed with MCI
4. Consequences of stigma (e.g., delayed diagnosis, isolation, shame, hesitation to use services)
iii. Misperceptions about Alzheimer’s disease and other dementias among older adults, healthcare professionals and long-term care providers
1. Professionals and the lay public tend to dismiss cognitive symptoms as a part of normal aging
2. Cultural beliefs (e.g., mental illness, curse, punishment from God, due to stress/anxiety) often delay diagnosis until a crisis occurs
b. Early symptoms
i. Earliest symptoms can be difficult to differentiate from normal aging
ii. Cognitive symptoms vary
1. Impairments in episodic memory (e.g., remembering recent events and conversations), semantic memory (e.g., naming), executive functioning (e.g., planning, decision-making), and visual-spatial abilities (e.g., getting lost in familiar places, difficulty judging distance) are common in Alzheimer’s disease
2. Other dementias present differently, e.g., early hallucinations in DLB, significant personality/behavior changes with relatively preserved memory in FTD
iii. Anosognosia is common, even in MCI
1. An inability to recognize the presence and extent of cognitive and functional disability
a. In one study, 54% of people with MCI were classified as anosognosic[8]
b. Only 30% of persons with mild AD were classified as being fully aware of their condition, with the remainder showing either “shallow awareness” (59%) or no awareness (11%)[9]
2. Anosognosia results in resistance to diagnosis and treatment, heightened risk for dangerous behaviors (e.g., unsafe driving), and financial mismanagement
iv. Behavioral changes emerge earlier than recognized
1. Apathy and depression are common in MCI, as well as anxiety and irritability[10],[11]
c. Lived Experience – What do people with MCI and early AD say about their experience?
i. Viewing things differently – Bob, diagnosed with MCI, and Sherry, spouse
ii. A seven-year journey – Joan, diagnosed with MCI
iii. The diagnosis “fractured me” – Alan, diagnosed with AD
iv. Living in limbo – Steve, diagnosed with MCI
v. Living a different life – Jeri, diagnosed with MCI
d. Coping
i. Struggle to preserve identity[12] (e.g., Steve, it’s (MCI) not me)
ii. Identity construction/pursuit of alternative meaning[13]
iii. Fluctuations between acknowledgment (e.g., information-seeking) and resistance (e.g., normalizing) [14]
Section II: Person-Centered Support Strategies for Cognitively Impaired IL and AL Residents (40 minutes)
(4) Emergence of cognitive impairment in independent living
a. Early identification, diagnosis and treatment
i. Intervene before symptoms become so severe as to compromise the person’s safety
1. Ensure that all staff are trained in the warning signs for Alzheimer’s disease and report any changes in condition
ii. Partner with the resident
1. Approach with empathy and be sensitive to fears, including fear of having to relocate
a. Use non-threatening terms, e.g., memory/thinking changes, rather than labels, e.g., mild cognitive impairment, Alzheimer’s disease, dementia
2. If living with a spouse, engage that individual
3. If living alone, engage the family with the resident’s permission
a. Ask all residents at move-in to sign a release allowing contact with family if symptoms that may compromise safety (e.g., continued driving, poor decision-making) occur
i. Engage company attorney in developing a form that meets HIPAA requirements
b. Keep a log of red flag symptoms
iii. Refer for an evaluation
1. Educate resident/spouse/family, emphasizing the positive
a. Identification/treatment of reversible causes (i.e., symptoms do not necessarily indicate dementia but may be related to psychiatric/medical illness, vitamin deficiency, etc.)
b. If MCI/dementia
i. Available treatments (i.e., medications) are most effective when started early
ii. Lifestyle strategies, particularly exercise,[15] can help stave off progression (i.e., pitch prevention)
2. Tips for getting a reluctant individual checked
a. The Medicare Annual Wellness Visit
i. Preventive primary care visit that incorporates cognitive screening
b. Enlist the right influencer (e.g., a particular staff member who the resident trusts)
c. If spouse/family cooperative, use a “do it together” approach, e.g., everyone should get a memory screening; let’s both have one
d. Enlist the doctor directly if you have appropriate consent or ask the spouse/family to do so
3. When the spouse/family are reluctant
a. Use empathy and education
b. Hold a family conference
i. Be able to provide concrete examples of concerns
ii. Offer what flexibility you can, but stick to your limits and do not extend services beyond those you are licensed to provide within a particular level of care
c. Note that next webinar in series will focus on family issues
b. Emergence of cognitive impairment in AL
i. In addition to above, discussed for IL, ensure that your community is using tool that is sensitive to very early cognitive impairment (i.e., is MCI) at move-in, upon change of condition, and at reassessment
1. Mini-Mental Status Examination (MMSE) is not sensitive to MCI (i.e., sensitivity of 62%, specificity of 63%), somewhat better for mild dementia (i.e., sensitivity 76%, specificity 89%)[16]
2. Preferred tool is the Montreal Cognitive Assessment (MoCA), www.mocatest.org with a sensitivity of 90% for MCI, 100% for Alzheimer’s disease; specificity of 87%[17]
3. Functional Assessment Tool: Another tool that can be used to monitor change, based on family/direct care staff report[18]
c. Managing cognitive impairment in IL/AL
i. Set clear expectations with residents and the family at the time of initial move-in regarding when transitions in care are necessary
1. Educate residents, when possible, and families regarding the benefits of greater/specialized care
a. Further discussion of family issues will occur during the next webinar
ii. If possible, arrange for support services (e.g., in home care) to delay need for move/transition from IL as appropriate
iii. Provide psychosocial support (e.g., social work visits, counseling) to residents and families dealing with cognitive impairment
iv. Provide sufficient and highly trained staff
1. Staff AL at a level necessary to provide appropriate care for the high number of residents with MCI/early dementia
a. Will be more than required by licensing
b. 24/7 nursing support is a best practice given the high level of medical comorbidities among cognitive impaired residents
2. Invest in dementia training to ensure that staff interact appropriately and compassionately with cognitively impaired residents
a. Do not just provide the required number of hours
i. Online training is efficient but should be supplemented with face-to-face training involving practice
v. If memory care is available at your community, use it as “day care” temporarily to transition AL resident
vi. Communicate regularly with resident/family (i.e., “no surprises”)
1. Proactively involve AL resident/family in care planning
a. Gain buy-in in the care plan and reinforce
vii. Provide access to appropriate activities/social opportunities to reduce isolation
1. Innovative activity offerings for IL/AL residents with MCI
a. Focusing on brain health
b. Adapted to limitations
2. Intentional engagement of residents in IL/AL
a. Given the high prevalence of apathy and depression in MCI, residents are likely to stay in their rooms without encouragement
(5) Education as prevention
a. Develop an educational program for residents/families about cognitive impairment
i. To reduce stigma within the community
ii. To prepare residents/families
Section VI: Question & Answer/Dialogue with the Speaker (15 minutes)
V. Address and/or Geographic Area Where the Course Will Be Presented: Webinar
VI. Method of Course and Speaker Evaluation by Participants (explain how participants will evaluate the course): Evaluation form
VII. Method of Evaluating Participants: No evaluation of participants.
VIII. Types of Records to be Maintained and Address Where Records are maintained: Attendance reports and evaluations are maintained at Aging Services of California, 1315 I Street, Suite 100, Sacramento, CA 95814
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[1] Zimmerman, C., et al. (2014). Health Affairs, 33, 658-66
[2] Ward, A., et al. (2012). Alzheimer’s and Dementia, 8, 14-21
[3] Strous, R. D., et al. (2006). European Journal of Internal Medicine, 17, 387-93
[4] http://dictionary.reference.com/help/faq/language/d23.html
[5] Alzheimer’s Association (2014). 2014 Alzheimer’s disease facts and figures. Chicago: Author
[6] Concise Oxford English Dictionary
[7] Alzheimer’s Disease International (2012). 2012 World Alzheimer’s report. London: Author
[8] Tremont, G., & Alosco, M. L. (2011). International Journal of Geriatric Psychiatry, 26, 299-306
[9] Vogel, A., et al. (2010). Journal of Neuropsychiatry and Clinical Neurosciences, 22, 93- 99
[10] Teng, E., et al. (2007). Dementia and Geriatric Cognitive Disorders, 24, 253-9
[11] Apostolova, L. & Cummings, J. (2008). Dementia and Geriatric Cognitive Disorders, 25, 1597-612
[12] MacRae, H. (2010). Qualitative Health Research, 20, 293-305.
[13] Preston, L., et al. (2007). Aging & Mental Health, 11, 131-143.
[14] MacQuarrie, C. R. (2005). Aging & Mental Health, 9, 430-441.
[15] Grande, G., et al. (2014). Journal of Alzheimer’s Disease, 39, 833-839.
[16] Mitchell, A. J. (2009). Journal of Psychiatric Research, 43, 411-431
[17] Nasreddine et al., (2005). Journal of the American Geriatrics Society, 53, 695-699
[18] Reisberg, B. (1988). Psychopharmacology Bulletin, 24, 653-59