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  

CChristensen,    2009  

Best-­‐prac'ce  Life  Expectancy    for  Women  in  Selected  Countries  from  1840  to  2007  

 

Linear  regression  trend  depicted  by  solid  grey  line  with  a  slope  of  0.24  per  year  

Gain  in  life  expectancy  is  3  months  per  year  or    2  ½  years  every  decade  

Christensen,  2009  

Age-­‐specific  Contribu'ons  to  the  Increase  in  Record  Life  Expectancy  in  Women  

1850-­‐2007  

Dementia Syndrome

Declines in 2 or more cognitive capacities Normal level of consciousness and alertness Onset in adulthood

Common Causes of Dementia

Alzheimer disease 66% Vascular dementia 15-20% Dementia with Lewy bodies 8-15% Fronto-temporal dementia 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  

13%  

9%    All  ages  

70%  

66%  

11%  

18%  

10%  

0.3%  

37%      >  64  

Primary  Care  

Acute  Hospital  

Nursing  Home  

Assisted  Living  

Public  Housing  

Home  Health  

Popula'on    >  64  

Popula'on    <  65  

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  

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  

1.  Focus on function NOT memory

2.  Behavioral/psychiatric symptoms of dementia increase likelihood of placement

3.  Medical co-morbidity increases complexity geometrically

Care Challenges BEYOND Diagnosis

Humanizing Dementia 1.  Framing the diagnosis for the family and

resident in an accepting manor

2.  Rehab approach: -Identify strengths and weaknesses

2. Avoid infantilizing 3. Discussing the disease with the person

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

Care Challenges BEYOND Diagnosis

Making Quality of Life Decisions

1.  Leadership

2.  Imbuing a culture

3.  Modeling

4.  Reviewing successes and failures (feed forward system approach)

The Opportunities