A Paradigm Flip: Aging Care=DementiaCare Peter V. Rabins, MD, MPH Department of Psychiatry Johns Hopkins School of Medicine
Popula'on Pyramid for Germany in 1956, 2006, 2050
Christensen, 2009
Best-‐prac'ce Life Expectancy for Women in Selected Countries from 1840 to 2007
Gain in life expectancy is 3 months per year or 2 ½ years every decade
Linear regression trend depicted by solid grey line with a slope of 0.24 per year
Christensen, 2009
Age-‐specific Contribu'ons to the Increase in Record Life Expectancy in Women 1850-‐2007
Christensen, 2009
Dementia Syndrome Declines in 2 or more cognitive capacities Normal level of consciousness and alertness Onset in adulthood
Common Causes of Dementia Alzheimer disease Vascular dementia Dementia with Lewy bodies Fronto-temporal dementia
66% 15-20% 8-15% 5%
Diagnostic Features of Alzheimer Disease Slowly progressive dementia No other etiology identified: non-contributory neurological examination, laboratory evaluation and brain imaging Decline in memory plus either: -aphasia -apraxia -agnosia -(dysexecutive function )
3 ‘Stages’ of Alzheimer Disease 1. Decline in memory -personality change -executive function impairment 2. Cortical phase -aphasia -apraxia -agnosia 3. Physical Decline -incontinence -gait disorder -swallowing/feeding -muteness
Prevalence of Demen@a By SeCng
Popula'on < 65 Popula'on > 64
Home Health Public Housing
0.3% 10%
18% 11%
Assisted Living
66%
Nursing Home
70% 37% > 64 9% All ages
Acute Hospital Primary Care
13%
Propor'on of Community-‐Living Adults Age 65 and Older with Selected Physical Health Condi'ons in Two Michigan Home Care Programs, N= 18,939 Physical Health Condi'ons
Prevalence Rate (%)
Chronic lung disease, including emphysema and asthma
27.0
Hypertension
69.2
Diabetes
32.9
Arthri@s
73.3
Stroke
27.0
Coronary artery disease
29.1
Cardiac dysrhythmia
22.2
Conges@ve heart failure
35.0
Pain Moderate daily pain
22.5
Severe daily pain
25.1 Source: Li and Conwell, 2007
Care Challenges BEYOND Diagnosis 1. Focus on function NOT memory 2. Behavioral/psychiatric symptoms of dementia increase likelihood of placement 3. Medical co-morbidity increases complexity geometrically
Humanizing Dementia 1.â&#x20AC;Ż Framing the diagnosis for the family and resident in an accepting manor 2.â&#x20AC;Ż Rehab approach: -Identify strengths and weaknesses 2. Avoid infantilizing 3. Discussing the disease with the person
Care Challenges BEYOND Diagnosis 4. Family expectations are increasing 5. Non-cognitively impaired residents are an increasing minority 6. Increasing pressure to NOT use medications to treat behavioral/ psychiatric symptoms
Making Quality of Life Decisions
The Opportunities 1. Leadership 2. Imbuing a culture 3. Modeling 4. Reviewing successes and failures (feed forward system approach)