1. Slide 1 Dementia and Stroke Central South Regional Stroke Program September 2007 Funded by the Ministry of Health and Long-Term Care

2. Slide 2 Session Overview The types of stroke. The types of stroke. The common changes that result from stroke. The common changes that result from stroke. The connection between stroke and dementia. The connection between stroke and dementia. The behaviour changes that result from dementia The behaviour changes that result from dementia Strategies to assist in working with residents with dementia Strategies to assist in working with residents with dementia

3. Slide 3 What is a Stroke An interruption of the supply of blood and oxygen to an area of the brain. An interruption of the supply of blood and oxygen to an area of the brain. This causes the brain cells in an area to die, and reduces the brain function in that area. This causes the brain cells in an area to die, and reduces the brain function in that area. The area of the body controlled by the damaged area in unable to function properly. The area of the body controlled by the damaged area in unable to function properly. There are two types of stroke. There are two types of stroke. http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

4. Slide 4 What is a Stroke? A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996 A stroke can happen when a blood clot blocks a blood vessel in the brain. 80% of strokes are this type.

5. Slide 5 What is a Stroke? A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996 A stroke can also happen when a blood vessel breaks and results in bleeding in the brain. 20% of strokes are this type.

6. Slide 6 Risk factors you can do something about… High blood pressure High blood pressure High blood cholesterol High blood cholesterol Heart disease Heart disease Diabetes Diabetes Being overweight Being overweight Excessive alcohol use Excessive alcohol use Physical inactivity Physical inactivity Smoking Smoking Stress Stress

7. Slide 7 What does a resident who has had a stroke look like in LTC?

8. Slide 8 What are some of the losses due to stroke? paralysis or weakness on one side of the body; paralysis or weakness on one side of the body; vision problems (double vision); vision problems (double vision); trouble speaking or understanding language; trouble speaking or understanding language; http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

9. Slide 9 What are some of the losses due to stroke? inability to recognize or use familiar objects; inability to recognize or use familiar objects; tiredness; tiredness; depression; depression; http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

10. Slide 10 What are some of the losses due to stroke? exaggerated or inappropriate emotional responses; exaggerated or inappropriate emotional responses; difficulty learning and remembering new information; and difficulty learning and remembering new information; and changes in personality. changes in personality. http://www.hc-sc.gc.ca/iyh-vsv/diseases-maladies/stroke-vasculaire_e.html#ef

11. Slide 11 Stroke Statistics There are between 40,000 and 50,000 strokes survivors in Canada each year. There are between 40,000 and 50,000 strokes survivors in Canada each year. 10% (4-5,000) of strokes survivors each year require long-term care. 10% (4-5,000) of strokes survivors each year require long-term care. 40% (16-20,000) of strokes survivors each year are left with a moderate to severe impairment. 40% (16-20,000) of strokes survivors each year are left with a moderate to severe impairment. http://ww2.heartandstroke.ca/Page.asp?PageID=33&ArticleID=1078&Src=n ews&From=SubCategory

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13. Slide 13 Dementia is a syndrome…that includes loss of memory, judgment and reasoning, and changes in mood, behaviour and communication abilities. Dementia is a syndrome…that includes loss of memory, judgment and reasoning, and changes in mood, behaviour and communication abilities. Alzheimer’s Society of Canada

14. Slide 14 What is dementia? 1.  in memory 2.And at least one of the following: a) Difficulty with language b) Difficulty with voluntarily moving despite having normal muscle function c) Difficulty recognizing and identifying objects or persons d) Difficulty with planning, reasoning, problem solving and judgment. The Diagnostic and Statistical Manual published by the American Psychiatric Association

15. Slide 15 Types of Dementia Adapted from Feldman H, Levy A, Hsiung G, et al. A Canadian Cohort Study of Cognitive Impairment and Related Dementias (ACCORD): Study Methods and Baseline Results. Neuroepidemiology 2003;22: 265-274. Alzheimer’s 47.2% Mixed Dementia 33.7% Vascular Dementia 8.7% Dementia with Lewy bodies (1.9%) Frontotemporal dementia (5.4%) Other (3.1%)

16. Slide 16 How many people have dementia? (Canadian Study of Health and Aging Working Group, 1994). Age Community Institution ≥ 658%15% ≥ 7511%48% ≥ 8535%65%

17. Slide 17 Vascular dementia is related to stroke and can cause a loss in memory, reasoning, thinking, attention span and independence with activities of daily living. Alzheimer Society of Canada Health and Quality of Life Outcomes 2004, 2:52

18. Slide 18 Vascular dementia results when a critical part of the brain does not receive enough oxygen. http://www.emedicinehealth.com/stroke- related_dementia/article_em.htm

19. Slide 19 What symptoms may be present in vascular dementia? Problems concentrating and communicating Problems concentrating and communicating Depression accompanying the dementia Depression accompanying the dementia Symptoms of stroke, such as physical weakness or paralysis Symptoms of stroke, such as physical weakness or paralysis Seizures Seizures http://www.alzheimers.org.uk/Facts_about_dementia/What_is_dementia/info_vascular.htm

20. Slide 20 What are the symptoms of vascular dementia? Memory problems (although this may not be the first symptom) Memory problems (although this may not be the first symptom) A ‘stepped’ progression, with symptoms remaining at a constant level and then suddenly deteriorating A ‘stepped’ progression, with symptoms remaining at a constant level and then suddenly deteriorating Periods of acute confusion Periods of acute confusion http://www.alzheimers.org.uk/Facts_about_dementia/What_is_dementia/info_vascular.htm

21. Slide 21 Other symptoms may include: Hallucinations (seeing things that do not exist) Hallucinations (seeing things that do not exist) Delusions (believing things that are not true) Delusions (believing things that are not true) ‘Wandering’ and getting lost ‘Wandering’ and getting lost Physical or verbal aggression Physical or verbal aggression Restlessness Restlessness Incontinence Incontinence http://www.alzheimers.org.uk/Facts_about_dementia/What_is_dementia/info_vascular.htm

22. Slide 22 Communication Strategies Eliminate distractions (e.g. TV, radio) Eliminate distractions (e.g. TV, radio) Approach the person slowly and from the front; establish and maintain eye contact Approach the person slowly and from the front; establish and maintain eye contact Use short, simple sentences Use short, simple sentences Speak slowly Speak slowly Give one instruction at a time Give one instruction at a time Ask “yes/no” rather than “open-ended” questions Ask “yes/no” rather than “open-ended” questions Repeat messages using the same wording Repeat messages using the same wording Paraphrase repeated messages Paraphrase repeated messages Avoid interrupting the person; allow plenty of time to respond Avoid interrupting the person; allow plenty of time to respond Encourage the person to “talk around” or describe the word he is searching for. Encourage the person to “talk around” or describe the word he is searching for. Small et.al., (2003) Effectiveness of Communication Strategies Used by Caregivers of Persons With Alzheimer’s Disease During Activities of Daily Living, Journal of Speech, Language and Hearing Research; 46, 2:353

23. Slide 23 ADL Strategies

24. Slide 24 Eating Offer one food at a time Offer one food at a time Use contrasting colours for food, plate, placemat Use contrasting colours for food, plate, placemat Try lighter weight utensils & cup Try lighter weight utensils & cup Serve more finger foods Serve more finger foods Check for dentures, problems with chewing Check for dentures, problems with chewing http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

25. Slide 25 Eating Provide a relaxing eating area Provide a relaxing eating area Provide adequate fluids - serve jello, popsicles, juices, and ice cream to increase fluids Provide adequate fluids - serve jello, popsicles, juices, and ice cream to increase fluids If appetite is poor, contact your registered staff or doctor If appetite is poor, contact your registered staff or doctor Some residents benefit from dietary supplements (Ensure) Some residents benefit from dietary supplements (Ensure) http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

26. Slide 26 Bathing Ensure privacy and respect Ensure privacy and respect Have the bath water ready beforehand. Have the bath water ready beforehand. Ensure that the water is not cold. Ensure that the water is not cold. Let the resident touch the water. Let the resident touch the water. Use gentle touch and cueing Use gentle touch and cueing http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

27. Slide 27 Bathing Save shampooing until last (avoid showering the face) Save shampooing until last (avoid showering the face) Avoid bath oils that make the tub slippery Avoid bath oils that make the tub slippery Use coloured decals/mat to indicate the tub bottom Use coloured decals/mat to indicate the tub bottom Cover up mirrors if they disturb the patient Cover up mirrors if they disturb the patient http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

28. Slide 28 Dressing Lay articles of clothing out in sequence Lay articles of clothing out in sequence Pick clothes that fit easily Pick clothes that fit easily Keep the dressing routine as consistent as possible Keep the dressing routine as consistent as possible If the patient wants to wear the same thing over and over, obtain duplicates If the patient wants to wear the same thing over and over, obtain duplicates http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

29. Slide 29 Toileting Make sure that the toilet is visible from the resident’s bed or hallway Make sure that the toilet is visible from the resident’s bed or hallway clearly mark the bathroom door with a sign clearly mark the bathroom door with a sign Provide adequate lighting along the pathway to the bathroom Provide adequate lighting along the pathway to the bathroom http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

30. Slide 30 Toileting Encourage a toileting routine to avoid incontinence e.g. every 2 hours Encourage a toileting routine to avoid incontinence e.g. every 2 hours Continually evaluate the level of assistance needed Continually evaluate the level of assistance needed Remember that urinary tract infections are common in elderly people; if a fever persists for more than 24 hours, contact your doctor Remember that urinary tract infections are common in elderly people; if a fever persists for more than 24 hours, contact your doctor http://depts.washington.edu/adrcweb/UnderstandingAD/Strategies.shtml#dressing

31. Slide 31 Mobility Increase daily exercise & activity level Increase daily exercise & activity level provide safe access to the outdoors provide safe access to the outdoors decrease or increase the resident's stimulation decrease or increase the resident's stimulation add familiar items to the resident’s room add familiar items to the resident’s room

32. Slide 32 Mobility Remind residents to use their walking aid due to memory problems, Remind residents to use their walking aid due to memory problems, Remind/teach residents about the need to use walker brakes, Remind/teach residents about the need to use walker brakes, It is important to use these strategies to decrease the risk of falls It is important to use these strategies to decrease the risk of falls

33. Slide 33 Always remember that you can request an OT referral from CCAC if you need assistance with finding the right strategy.

34. Slide 34 Jerry Jerry is a 68 year old man who has been living at Cozy Acres for the last 6 months. Jerry entered the nursing home after his wife was admitted to hospital. Jerry has had episodes of forgetfulness (left the stove on, and tap running) and impulsivity and needs help completing multi-step activities since his stroke 2 years ago. Jerry is well-liked by everyone and gets around Cozy Acres independently with his walker.

35. Slide 35 Jerry Recently Jerry has been found wandering around the facility. He usually finds his way back but sometimes needs staff to bring him back to his unit. Jerry at times forgets to use his walker and becomes angry when staff reminds him that he needs to use it at all times. Jerry has said that he feels that they are just trying to “boss him around” and that he really does not need the walker, even though he has had 2 falls in the last week.

36. Slide 36 Jerry Today when you entered Jerry’s room he did not recognize who you were. You initially thought he was joking with you. What do you think is going on with Jerry? What else could be happening with Jerry? What are you going to do next?

37. Slide 37 Next Steps… You are the eyes, ears and voice of your facility. You are the eyes, ears and voice of your facility. Be aware of the diagnosis of your residents Be aware of the diagnosis of your residents Take this information and use it with your residents. Take this information and use it with your residents. Share this information with other staff. Share this information with other staff.

38. Slide 38 More Information Acute Changes and Stroke Acute Changes and Stroke Continence and Stroke Continence and Stroke Dementia and Stroke Dementia and Stroke Falls and Stroke Falls and Stroke Pain and Stroke Pain and Stroke Please contact: Rebecca Fleck or Kim Young Community and Long Term Care Specialist Central South Regional Stroke Program 905-521-2100 x 44127

39. Slide 39 Acknowledgements Best Practices long term care advisory group Best Practices long term care advisory group Best Practices long term care evaluation group Best Practices long term care evaluation group Barb McCoy and Deb Bryson, Psycho –geriatric consultants, Hamilton Barb McCoy and Deb Bryson, Psycho –geriatric consultants, Hamilton Mary-Lou Vander Horst, Regional Best Practice Coordinator Long-Term Care Central South Region Mary-Lou Vander Horst, Regional Best Practice Coordinator Long-Term Care Central South Region Wendy McDougall, Regional Best Practice Coordinator Long-Term Care, Central West Region Wendy McDougall, Regional Best Practice Coordinator Long-Term Care, Central West Region Central South Regional Stroke Program Central South Regional Stroke Program Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuro- ambulatory Centre Maryann Watts, Hamilton Health Sciences, Clinical Manager Neuro- ambulatory Centre Melanie Fall Stratton, Regional Stroke Program, Program Manager, Melanie Fall Stratton, Regional Stroke Program, Program Manager, Kim Young, Regional Stroke Program, Community and Long-term Care Specialist Kim Young, Regional Stroke Program, Community and Long-term Care Specialist Lisa Colizza, Regional Stroke Program, Regional Stroke Development Specialist Lisa Colizza, Regional Stroke Program, Regional Stroke Development Specialist Nancy van Essen, Regional Stroke Program, Stroke Rehabilitation Coordinator Nancy van Essen, Regional Stroke Program, Stroke Rehabilitation Coordinator Carol Pereira, Regional Stroke Program, LTC Project Coordinator Carol Pereira, Regional Stroke Program, LTC Project Coordinator

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