Dementia, Diabetes, Hypertension and Alcohol Abuse:
A Case Study of Medical Co-morbidities
Karen Knutson, MSN, MBA
Michael B, a 63-year-old single retired business executive with dementia, diabetes, hypertension, and a history of alcohol abuse, living in Charlotte, North Carolina, was referred for care management services by a friend. Michael’s older brother Eric, a retired attorney, lives in Hawaii and had not seen Michael in two years. Michael’s younger sister Linda, a teacher and Michael’s health care POA, lives in California and had not seen him in the past year. Both brother and sister were scared and worried. They usually called him after work in the evening which was often when Michael was drinking. They didn’t know what else they could do. His sister said that Michael had become suspicious of people who were trying to help him. He told her that he thought she wanted to come and see him to declare him incompetent. Michael’s friends and family reported to the care manager as she interviewed them that they were experiencing difficulty in their relationships with Michael and relationships with one another as they tried to help him.
Early in 2009 Michael participated in a residential treatment program for two months, but was drinking again within 48 hours of returning home. He went to a second residential treatment program for 3 months, came back home, began drinking again, and after an incident at work was forced to resign in January of 2010. Michael finally allowed the care manager into his house on her fourth visit to the house. He had a lovely home full of artwork and sculpture that he had collected over the years. The care manager found him overwhelmed during the course of two visits to complete the evaluation because, as he said, “my house is out of control, and I can’t seem to maintain it.”
Newspapers, mail, catalogs, dirty dishes, glasses, and garbage were on the floor of every room on the lower level. The food in the refrigerator was spoiled, and the freezer was a block of ice. The sink was stopped up, and the kitchen was bug infested. Specific prescriptions ordered were never filled and others including his insulin had not been reordered in the past four months. He was not taking his medications, and he was not testing his blood sugar. The care manager checked his blood sugar and it was 543, which was a seriously high level. He had lost his credit cards, calendar, and wallet and was unaware of his financial spending. He had accrued $25,000 in debt on one credit card that he thought he had paid off. He also looked at a bill for the purchase of art and couldn’t remember what he purchased or why. His cable was cut off because of an unpaid balance.
The Challenges of Sorting It Out
Sorting out the relationships between dementia and other chronic illnesses can be difficult. A clearer understanding of the client’s medical co-morbidities can help the care manager develop a more comprehensive understanding and approach to care planning.
Relationship of dementia and diabetes
Rates of dementia are higher in people with diabetes than in those without. The strongest effect has been noted in vascular dementia; however, there is an association with Alzheimer’s disease as well. Impaired fasting glucose levels are approximately twice as common in people with Alzheimer’s disease and diabetes than with diabetes alone. One study found that a 1% rise in A1c (i.e.: from 6.0% to 7.0%) was associated with a significant decline in scores on three different tests of mental functioning. The risk of dementia goes up significantly if clients maintain an A1c in the 8% range. The microvascular changes in diabetes are greatly underrated as a brain disorder, and the author of one research article even suggested we consider Alzheimer’s disease “type 3 diabetes.”
Relationship of dementia and hypertension
Studies have found that high blood pressure in middle age is associated with increased risk of dementia later in life. One study found that successful hypertension control reduced the risk of dementia. The same triggers for heart disease – high blood pressure, obesity, and diabetes seem to increase the risk of dementia too. Historically, the association was with “vascular dementia” where memory problems were linked to small strokes. New studies recognize a mix of two dementias. Blood pressure readings of 140 over 90 or higher can also seem to spur Alzheimer’s disease-like processes. The clinical approach at present is to maintain as low a blood pressure as possible to prevent dementia as well as stroke. There are no other potentially effective therapies.
Relationship of dementia and alcoholism
Most studies have indicated that excessive alcohol consumption leads to cognitive impairment but the pathological mechanism remains unknown. A common theme in the literature was that most patients of alcohol abuse are in denial. One study compared the cognitive impairment of alcohol-dependent patients to the cognitive impairment of patients with Alzheimer’s disease. In that study all domains of cognition were impacted to the same degree. After an extensive Medline search of dementia and alcoholism, the author was unable to find any studies indicating that cognitive impairment leads to excessive alcohol consumption. Because alcohol is a toxin that is especially harmful to the liver, elevated liver enzymes are the bio-markers for excessive alcohol consumption. An elevation of the liver enzymes, aspartate aminotransferase (AST) and/or alanine aminotransferase (ALT) occur when liver cells are damaged or destroyed. Liver disease is the most likely diagnosis if the AST level is more than twice that of ALT.
Integrating the Client’s History
Returning to the client in the case study, the care manager gathered information including the time of onset of Michael’s cognitive deficits, the progression of his symptoms, and family history of dementia from his siblings, friends and medical providers. The care manager uncovered that Michael had a five-year history of dementia symptoms. Over the past two years he began eating and drinking excessively, made art and sculpture purchases of over $100,000, and was reported by friends to have poor judgment on a number of issues. At one time he had a regular routine of eating, drinking, and shopping. Over the past two years his eating, drinking, and shopping spiraled out of control. Michael was not in denial of his drinking. He did not remember that he had already had his normal routine of 1-2 drinks an evening, and began having 2 additional drinks. He then transitioned from having wine with dinner to purchasing vodka by the 1.7 liter bottle. When the care manager did her assessment he was spending $40/day on alcohol. He told the care manager that he couldn’t understand why he became an alcoholic after he turned 60 years of age.
Integrating Observation and Functional Assessment Instruments
The care manager used the Folstein Mini-Mental State Exam (MMSE) to evaluate Michael’s cognitive functioning on the first visit. He received a score of 26 out of 30. He was experiencing difficulty with orientation, short-term recall, and was not fully oriented to his environment. However, he had good attention/calculation skills and good language skills. While his long-term memory was good, he had significant difficulty with short-term memory and could not always remember what had just happened. His difficulties with activities of daily living (forgetting to take his medication, fill and reorder prescriptions) were due in part to his inability to recall recent experiences and required prompting and assistance by another person.
While the Folstein (MMSE) serves as a good, first-line general screening tool and takes only 10 minutes to administer, it does have its limitations since it focuses on a selection of concrete thinking skills and does not test the executive function skills of organizing, planning, judgment, problem-solving, insight, and reasoning (See Figure 1: Executive Function). These are crucial abilities, as they help Michael make decisions in regards to personal care, health care, financial, and legal matters. Impairment of these skills increases the risk that he will make serious mistakes or even be exploited by others. It was the impression of the care manager that Michael was experiencing difficulty with executive function and was at risk for undue influence.
The Clock Drawing Test reflected difficulties with frontal and temporal-parietal functioning and took the care manager a couple of minutes to administer. The Geriatric Depression Scale evaluated Michael B’s emotional functioning and took less than 10 minutes to administer. He received a score of 7 out of 15 suggesting clinical depression at the time of the assessment.
Services and Interventions
In addition to care management and referral to dementia specialists, other interventions have been shown to improve care for clients. These include companion/caregiver services, support and education for family caregivers, and medication interventions such as client reminders and refilling prescriptions. Other medication considerations influencing outcomes include drug therapy complexity (more than one drug or more than one dose a day) and medication management for clients having difficulty remembering to take their medications.
Returning to the client in the case study, the care manager spoke to Michael’s sister and brother about setting up caregiver services immediately for 12 hours per day, 7 days a week in addition to ongoing medication management by an RN care manager on a weekly basis. Michael also needed assistance with financial management and possible transportation. The next step was to recommend a neurologist who specializes in dementia for a dementia workup to rule out a variety of treatable medical conditions that can cause memory impairment, determine a diagnosis, and review Michael’s current medications.
The care manager was able to get the client worked into the neurologist’s schedule the following week, drove the client to the appointment and participated in the appointment, sharing her Folstein (MMSE), Clock Drawing and Geriatric Depression Scale results. The neurologist then used the Montreal Cognitive Assessment (MoCA) designed as a screening instrument for mild cognitive dysfunction. The tool assesses different cognitive domains including attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. A score of 26 or above out of 30 is considered normal. It took the neurologist approximately 10 minutes to administer the MoCA. Michael received a score of 22 out of 30. Routine blood work and a PET scan were ordered as well as an EEG. The neurologist told Michael that whatever was going on with his brain, his drinking was accelerating it. He suggested an in-home detox program as Michael refused to go through a hospital based program, and prescribed Ativan 5 mg three times a day on a tapering schedule while he quit drinking alcohol. He also recommended that he stop driving.
On the second visit the neurologist reviewed the lab results including thyroid function, folic acid, and B12 levels, which were normal. After reviewing the PET CT scan the neurologist gave him a primary diagnosis of early onset Alzheimer’s disease (See Figure 2: Frontal and Temporal Atrophy on PET scan). He explained that early onset Alzheimer’s presents a very confusing picture and is frequently misdiagnosed. He said that often the individual acts erratically or irresponsibly because they not only have short term memory difficulty but difficulty with decision- making and judgment. This included misjudgments about alcohol and no recollection after consumption, which was why he needed 12 hours of supervision a day at this point. At this point Michael B was no longer drinking, was losing weight, and his blood pressure was under control. The neurologist also prescribed the anti-depressant, Effexor, 75 mg, once a day to treat his depression. The care manager then took Michael to his primary care MD visit. His physician wanted to tighten up the control on his diabetes now that he had a supportive team in place to help him. He wrote new orders for insulin and requested that the care manager fax him the blood sugar results weekly. They then met with Michael’s friend and financial POA as well as his attorney, activating the health care and financial powers of attorney and setting up a cash management system so the care manager could take cash out on a weekly basis for household expenses. The care manager then set up a training program for the caregivers working with Michael with customized goals and strategies to better help them work with him (See Figure 3: Client Goals and Strategies).
A clinically questioning approach by the care manager is essential. Communicating with all family members, friends, and health care professionals and asking questions and more questions until all possible information is gathered is desired. When more than one chronic illness is present, care managers need to get the help of appropriate medical specialists who specialize in dementia care. Learning about the relationships with the other chronic illnesses, the stage of those illnesses, the unmanaged and uncontrolled symptoms, pharmacotherapy, functional limitations, family dynamics, and need for care coordination all help to frame the picture of what is going on with the client.
It is usually assumed when a client is an alcoholic and has dementia that it is the effect of alcohol abuse that causes the dementia. In this case study, the client’s dementia (memory and frontal functions) contributed to his behavior of alcohol abuse. While we may never fully know the impact of medical co-morbidities on Michael’s current cognitive functioning, he did deserve a rigorous neurological evaluation to determine the cause(s) of the dementia and its relationship to alcohol abuse. An in-home detox program was set up and the client had a successful outcome. With the supports in place he no longer drinks alcohol, his blood pressure is consistently below 120/80, his most recent blood sugar was 119, his AST went from 258 (normal: 0-49 IU/L) in October 2010 to 31 in April 2011, and his ALT (normal: 0-55 IU/L) went from 118 in October 2010 to 39 in April 2011.
The discussion of the client’s psychosocial needs is outside the scope of this article. However, addressing psychosocial as well as medical needs using an integrated team of nurse and social work care managers increases the effectiveness of care management. A holistic team approach to addressing all of the client’s needs is critical.
The discussion of emotional burden of family caregivers is outside the scope of this article. However, an entire article could be devoted to this topic. By helping this client the care manager was able to decrease the caregiving burden and improve the quality of life of his friends as well as his two family members who were both working full time and living at a distance.
This article is based on a specific case study, while providing an overview on the relationship of dementia and select medical co-morbidities. Strategies and goals are suggested to reduce excess dementia in a specific client with the medical co-morbidities of diabetes, hypertension, and alcohol abuse. Providing care management for clients with dementia and medical co-morbidities can be of major benefit as it includes the complex, integrated daily care that the client and family require on a long-term basis. It can also be very rewarding for the care manager, as it provides an opportunity to demonstrate how we can make a difference. Care managers can incorporate their knowledge of dementia and co-morbidities to manage these clients and provide care that can improve both client and family outcomes.
* The client’s name and identity have been changed to provide confidentiality.
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Karen Knutson was the president and founder of OpenCare, the first private geriatric care management company in the Charlotte area. She is currently the Professional Development Specialist of SeniorBridge, providing care management and licensed home care services in Charlotte, North Carolina. Karen has her master’s in nursing, specializing in older adults and a master’s in business administration. She is the past president of the National Association of Professional Geriatric Care Managers and the current Editor-in Chief of the Geriatric Care Management Journal. Figure 1: Executive Function Poor organizing skills Poor planning, impaired attention, losses in train of thought Poor judgment: cannot determine good ideas Poor problem solving: impaired short term memory Poor insight: doesn’t recognize deficits Poor reasoning: cannot think through matters Figure 2: Frontal and Temporal atrophy on Pet Scan Behavioral disinhibition Addictive behavior Apathy and loss of sympathy and empathy Perseverative or compulsive behavior Excessive eating and drinking Figure 3: Client Goals and Strategies Goals: Avoiding alcohol and major shopping purchases (art, sculpture, antiques) Managing client’s average blood sugars and blood pressure to decrease risk of cognitive decline Keeping client active: walking, water aerobics, swimming, classes at the Senior Center A sense of purpose: meaningful activities and nurturing relationships Strategies: Ordering 2 waters and 2 diet cokes at lunch as soon as the waitress/waiter comes to the table. Then focus on the menu and let client order both lunches. Say no to antique shopping, going to the bank and the ABC store but suggest other options. Distract him away from things that can harm him financially and physically.
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Reprinted with permission from Aginglife.org. Advocare Care Management is the place to go when caring for an aging loved one.