UCSF on YouTube- Videos on Caregiving Tips, Value of Autopsy

UCSF’s Memory and Aging Center recently launched a channel on YouTube. “The videos…are intended to educate patients, caregivers and health professionals about the various forms of neurodegenerative diseases.” The “goal is twofold: promote earlier, accurate diagnoses — in order get more patients into research studies and clinical trials; and to help families cope with these devastating illnesses.”

“The value of autopsy” video may be of interest to everyone. The four videos with “Practical Tips for Caregivers” may be of interest to all caregivers. Most of the dementia-related videos are very short. Over half of the videos are on FTD (Frontotemporal Dementia) and CJD (Creutzfelt-Jakob Disease).

You can find the channel or webpage here:
http://www.youtube.com/UCSFMemoryandAging

The introductory video is less than two minutes long: “Why YouTube: the effort to diagnose and treat dementias.” It features Dr. Bruce Miller.

There are 20 videos available at the present time. I believe more will be added over time. Let me know if you learn anything! Here’s what available today:

After watching some of these videos, online friend Nan said:

* I learned a crucial difference in alzh.disease and frontal-temporal-dementia….. Alzheimer’s robs memory, while FTD robs emotions.

* Another good point was that the patient seems to be”happily unaware” that he/she has a brain problem.  I’ve said even recently to a friend that perhaps a silver lining to the PSP cloud may be that my husband seems unaware of the severity of his limitations. I think inside their brain the pwpsp may not realize how very slowly they are moving, or how impaired their reasoning/judgement may be.   I have to scold myself for getting frustrated in saying the same thing to my husband day after day – such as, “wait until you feel the bed/or chair with your legs before you sit down.” He continues to just plop down unless we’re right there to assist. In all, the frustration is more on MY part most of the time. He seems to be oblivious to it. He also has to be told so frequently to step inside the U-step walker instead of keeping it so stretched out that he has no real control over it. He says it doesn’t ‘work” right, but that’s only because his arms are completely stretched out and he is standing at least arms’ length from it!!

* I learned from the videos that there are hundreds of kinds of dementia out there. I am amazed at that.

* Finally, from just watching 4 or 5 of the videos, I learned that a gait belt is very necessary in assisting the pwpsp in moving about. We’ve basically used his actual belt in the same manner they model, but I think we shouldn’t be doing that anymore!

I’ve given an overview below of the videos.

Robin


 

General

 
The value of autopsy 
Autopsy of CJD patients offers families closure, as it is the only means for providing a definitive diagnosis. Autopsied brain tissue is also the most valuable source of information for neuroscientists studying brain degenerative diseases. [Robin’s note: this video features Dr. Michael Geschwind. Though several specific things are said about CJD, the message in this video applies to all neurodegenerative diseases.] 
01:59 Practical Tips for Caregivers 
[Robin’s note: though several titles mention CJD, the videos themselves say nothing about CJD!] Tips on moving someone from the bed to a chair 
Occupational therapist Karen Gniadek and physical therapist Jennifer Woodruff demonstrate helping a CJD patient move from the bed to a chair. [Robin’s note: use of a gait belt is recommended.] 
01:36 Tips for helping a CJD patient sit up in bed 
Occupational therapist Karen Gniadek and physical therapist Jennifer Woodruff demonstrate helping a CJD patient sit up. 
00:48 Tips on changing the bed of a CJD patient [Robin’s note: though the title mentions CJD, this is not a CJD-specific video!] 
Occupational therapist Karen Gniadek demonstrates how to change the bed of a bedridden CJD patient. 
02:04 

Tips for helping a CJD patient walk [Robin’s note: though the title mentions CJD, this is not a CJD-specific video!] 
Occupational therapist Karen Gniadek and physical therapist Jennifer Woodruff demonstrate helping a CJD patient walk. 
00:59 

Dementia 

What is dementia? 
Dementia is a progressive, degenerative disease of the brain that affects multiple brain functions. Alzheimer’s disease is the classic disease, but there actually are hundreds of dementias. [Robin’s note: this video features Dr. Bruce Miller. He says there are probably 100 dementias.] 
00:40 – very short 

Dementia’s varying impacts on memory and emotion 
The two most common forms of dementia in people under the age of 70 are Alzheimer’s disease and frontotemporal dementia. The Alzheimer’s disease patient doesn’t remember what he had for breakfast. The frontotemporal dementia patient behaves abnormally — she’s inappropriately familiar with people, is indifferent to questions and speaks rudely. The explanation for the differences can be seen under the microscope. [Robin’s note: this seems to be a follow-on of the preceding short video.] 
02:29 

Dementias: Caregiving and diagnosis 
Early diagnosis, early intervention and developing new therapies are the passion of UCSF neuroscientists. At the same time, they realize they will not have a cure tomorrow. A lot of their daily work involves taking care of patients, offering support to their families, protecting them from the bad decisions that might be made. “A lot of what we do is related to care giving and diagnosis.” [Robin’s note: this video features Dr. Bruce Miller.] 
00:36 – very short 

Dementia as a window into the mind 
The various forms of dementia affect different regions of the brain. Their impact reveals the role that the affected brain tissue normally carries out. Peer into the anatomy of the brain with a leader in the field. [Robin’s note: this video features Dr. Bruce Miller. The focus is on AD. FTD is also mentioned.] 
00:51 – very short 

FTD-related 

FTD: the most common dementia in those under 60 
Frontotemporal dementia is an early-onset dementia, and is believed to be the most common form of dementia in people under the age of 60. It peaks in the 50s and 60s, in the prime of life. 
00:49 – very short 

Frontotemporal dementia offers insight into emotions 
Frontotemporal dementia usually emerges in the right side of the brain, where it causes dramatic changes in behavior and emotions, including disinhibition and apathy. When FTD emerges on the left side of the brain, it causes a slow disintegration of language and speech. In some of these patients, visual creativity emerges, even while their minds are deteriorating. Eventually the disease spreads across the brain. 
03:33 

Loss of moral reasoning and sense of self in FTD 
Moral reasoning, like everything else that is complex and sophisticated in humans, involve Moral reasoning, like everything else that is complex and sophisticated in humans, involves the brain’s frontal lobes. The region is affected in frontotemporal dementia. Early in the disease process, FTD patients sometimes carry out illegal activities, such as embezzling and shoplifting, and display insensitivity to others. Overall, they lose their normal sense of self. 
02:33 

Frontotemporal dementia’s affect on behavior and language 
Frontotemporal dementia has three major subtypes, which emerge in different regions of the brain. Early on in the disease process, one form affects behavior, another language abilities, another loss of words (usually beginning with animals). This latter form of the disease includes a subgroup of patients who experience a dramatic increase in visual creativity, even as their minds are deteriorating. 
01:43 

Frontotemporal dementia: apparent in the workplace 
The ability to interact well with other people is generally a key factor in success in the workplace. The first signs of frontotemporal dementia often are revealed this environment. Patients make inappropriate comments, insult colleagues and fail to be sympathetic to other people’s concerns. 
01:02 

Caregivers of FTD patients 
Frontotemporal dementia affects regions of the brain that cause aberrant changes in behavior and emotion. Loved ones face great challenges, first dealing with the puzzling symptoms and efforts to get an accurate diagnosis, and later facing the fact that the personality of the person they have loved is no longer present. The disease presents leaves families isolated and challenges by health care issues. 
05:26 

Potential therapeutic targets in misprocessed proteins 
In dementias, nerve cells and the connections between them, die. Scientists believe that the abnormal accumulation of certain proteins within nerve cells are involved. In Alzheimer’s disease, there are plaques of amyloid protein. In FTD, there is clumping of a protein called tau. Recently, scientists discovered that a protein called ubiquitin is involved in some cases of FTD. Researchers’ long term goal is to determine the role of such proteins in the disease processes and, where appropriate, develop treatments that alter the structure or accumulation of the culprit proteins. [Robin’s note: this video features Dr. Adam Boxer. The focus is FTD.] 
04:11 

CJD-related 

CJD: a window into more common dementias 
Michael Geschwind, MD, PhD, of the UCSF Memory and Aging Center, discusses Creutzfelt-Jakob disease, a rare neurodegenerative diseases that offers a window into the more common forms of dementia, including Alzheimer’s disease and frontotemporal dementia. 
03:59 

CJD: The Great Mimicker 
Creutzfeldt-Jakob disease is considered the “great mimicker.” Its effects, on many areas of the brain, cause symptoms also seen in other neurological diseases. They can include memory loss or difficulty with balance and walking, dizziness, behavioral change, visual disturbance, and involuntary movements. 
02:57 

Symptoms of FTD often mislead caregivers 
The public knows dementia as a disease of memory loss, characterized by forgetfulness, an inability to keep track of personal possessions, a loss of navigational skills. This is the case in Alzheimer’s disease, but in frontotemporal dementia the early signs generally involve behavioral and emotional changes. As a result, caregivers some times don’t know to consult a neurologist. They seek guidance from church leaders, family practice doctors, counselors or therapists. 
00:45

Do people near the end “starve to death” or “die of thirst”?

This is an excerpt of a post recently published on the Society for PSP’s Forum, an online discussion group.  The author is my online friend Ed Plowman.  Though he writes about his wife Rose with progressive supranuclear palsy, his comments apply to those nearing the end with any disorder.  Ed addresses whether those nearing the end suffer from starvation or thirst.

Robin

—————-

Excerpt of a post by Ed Plowman
Society for PSP Forum
Mon May 05, 2008 11:05 pm

Two hospice doctors and a hospice nurse explained to me what the final days for Rose will be like if she no longer can swallow or take fluid, and remains adamant about no feeding tube or IV hydration. Morphine likely will be administered. (I was with a dying friend recently who was on morphine; he seemed completely normal, not in a “drugged stupor” — a common misconception about the effects of morphine, as I understand it — and we conversed normally for hours with each other and members of his family. He knew the end was near, he seemed relaxed and calm.)

My youngest daughter said she could not stand by while her mother starves to death or dies of thirst. The hospice docs explained that with morphine, that doesn’t happen. The patient has no desire to eat, and often has no sensation of thirst. Moistening the lips and mouth will alleviate discomfort from “dryness.” After the patient stops eating, the body normally will begin the shutdown process; it will produce and release from the pituitary gland endorphins, or endomorphines — a natural form of morphine. These biochemicals give the patient a calming sense of wellbeing. Eventually, in many cases, when the respiratory system begins to shut down, the patient falls asleep, breathing becomes shallow, and the end is peaceful. (That’s how it was with the dying friend I mentioned above.)

The end script is not exactly the same for everyone, of course. But the hospice staff said they’ve not seen any of their patients, many of whom could not eat or drink at the end, die of hunger or thirst as many people commonly envision.

I think it’s important that the family gather together in harmony, compassion, and loving appreciation as the end nears. It wouldn’t hurt to recount a few unforgettable positive memories involving the loved one. Some families sing favorite hymns; someone may feel led to say a prayer of thankfulness for what the loved one has meant in the lives of family members. The loved one with PSP may not be able to speak or even move. But he or she will hear and understand all that is said and done. This can be a precious, joyful time for him or her.

I believe we are fast approaching this time of transition at our house.

ed p.

“Avoid confusion in the hospital – Ten tips”

A Yale Medical School publication lists ten tips to avoid confusion in the hospital.  These tips certainly apply to those with dementia as well as the elderly, and this is probably helpful for anyone (neurodegenerated or not!) in the hospital.

Robin
——————————

elderlife.med.yale.edu/public/prevention.php

Avoid Confusion in the Hospital – Ten Tips

Do you have an elderly relative in the hospital?

By taking these ten steps, you may be able to reduce the risk of delirium:

1. Bring to the hospital a complete list of all medications (with their dosages), as well as over-the-counter medicines. It may help to bring the medication bottles as well.

2. Prepare a “medical information sheet” listing all allergies, names and phone numbers of physicians, the name of the patient’s usual pharmacy and all known medical conditions. Also, be sure all pertinent medical records have been forwarded to the doctors who will be caring for the patient.

3. Bring glasses, hearing aids (with fresh batteries), and dentures to the hospital. Older persons do better if they can see, hear and eat.

4. Bring in a few familiar objects from home. Things such as family photos, a favorite comforter or blanket for the bed, rosary beads, a beloved book and relaxation tapes can be quite comforting.

5. Help orient the patient throughout the day. Speak in a calm, reassuring tone of voice and tell the patient where he is and why he is there.

6. When giving instructions, state one fact or simple task at a time. Do not overwhelm or over stimulate the patient.

7. Massage can be soothing for some patients.

8. Stay with the hospitalized patient as much as possible. During an acute episode of delirium, relatives should try to arrange shifts so someone can be present around the clock.

9. If you detect new signs that could indicate delirium — confusion, memory problems, personality changes — it is important to discuss these with the nurses or physicians as soon as you can. Family members are often the first to notice subtle changes.

10. Find out more about delirium. The American Psychiatric Association’s “Patient and Family Guide to Understanding and Identifying Delirium” is available on line.
[Robin’s note:  the link to this APA document doesn’t work and a search of that website revealed nothing by this name.]

Adapted from onlinehealth.com, May 02, 2000

End of Life: Helping with Comfort and Care

I’m on the National Institute on Aging’s email alert list for new publications from the NIA.** This week, I received an alert about a new publication on “End of Life.” Chapters include: Providing Comfort at the End of Life, Finding Care at the End of Life, Dementia at the End of Life, Understanding Health Care Decisions, What Happens When Someone Dies, Things to Do After Someone Dies, Getting Help for Your Grief, and Planning for End-of-Life Care Decisions. You can download the publication online, read it online, or order a (free) print copy. Here’s the information I received:

NEW from the National Institute on Aging!
“End of Life: Helping with Comfort and Care”

Providing Comfort at the End of Life with Help from the National
Institute on Aging

When someone close to us is nearing the end of life, there may be
many questions. How can I offer comfort and support? Is there one
“best” place for caregiving? Are there some approaches to making
decisions that can be helpful? Do people with dementia have special
needs at the end of life? End of Life: Helping with Comfort and Care,
a new publication from the National Institute on Aging (NIA), part of
the National Institutes of Health (NIH), can help answer these
questions and others.

Older people need increasingly more care as they near the end of
life. Families and friends want to provide comfort, but may not know
what to do or say. This new publication can help. Written in a
compassionate tone, End of Life: Helping with Comfort and Care
features large print, helpful questions to ask, and resources for
those who want to learn more.

To preview, download or print End of Life: Helping with Comfort and
Care, go to:
www.nia.nih.gov/HealthInformation/Publi … /endoflife

You can also order a free print copy:

Order online at:
www.nia.nih.gov/HealthInformation/Publi … /endoflife

Call the NIA Information Center at 1-800-222-2225, OR
E-mail us at [email protected].
[Robin’s note: the phone is answered and emails are replied to M-F 9-5. You can leave a message after hours.]

Please pass the word to others who may be interested!

Sincerely,
The staff of the National Institute on Aging Information Center

** Robin’s note: You can receive these alerts as well by clicking on “Sign up for Email Alerts” on this webpage http://www.nia.nih.gov/Alzheimers/ — this is the AD Education and Referral Center’s webpage.

FDA Warning on Botox (2/8/08)

This may of interest to those using botox to treat dystonia and contractures. I read about this FDA warning from Friday on an MSA-related online discussion group today.

Here’s the FDA warning to the public: (it’s short)

http://www.fda.gov/bbs/topics/NEWS/2008/NEW01796.html

FOR IMMEDIATE RELEASE
February 8, 2008

Consumer Inquiries:
888-INFO-FDA

FDA Notifies Public of Adverse Reactions Linked to Botox Use
Ongoing safety review of Botox, Botox Cosmetic and Myobloc taking place

The U.S. Food and Drug Administration today notified the public that Botox and Botox Cosmetic (Botulinum toxin Type A) and Myobloc (Botulinum toxin Type B) have been linked in some cases to adverse reactions, including respiratory failure and death, following treatment of a variety of conditions using a wide range of doses.

In an early communication based on the FDA’s ongoing safety review, the agency said the reactions may be related to overdosing. There is no evidence that these reactions are related to any defect in the products.

The adverse effects were found in FDA-approved and nonapproved usages. The most severe adverse effects were found in children treated for spasticity in their limbs associated with cerebral palsy. Treatment of spasticity is not an FDA-approved use of botulism toxins in children or adults.

The adverse reactions appear to be related to the spread of the toxin to areas distant from the site of injection, and mimic symptoms of botulism, which may include difficulty swallowing, weakness and breathing problems.

The FDA is not advising health care professionals to discontinue prescribing these products.

The agency is currently reviewing safety data from clinical studies submitted by the drugs’ manufacturers, as well as post-marketing adverse event reports and medical literature. After completing a review of the data, the FDA will communicate to the public its conclusions, resulting recommendations, and any regulatory actions.

The notification is in keeping with the FDA’s commitment to inform the public about its ongoing safety reviews of drugs. The early communication, which includes background information and advice for health care professionals, can be viewed at: http://www.fda.gov/cder/drug/early_comm … toxins.htm

And here’s info for healthcare professionals: (it’s understandable)

http://www.fda.gov/cder/drug/early_comm … toxins.htm

Early Communication about an Ongoing Safety Review
Botox and Botox Cosmetic (Botulinum toxin Type A) and
Myobloc (Botulinum toxin Type B)

This information reflects FDA’s current analysis of available data concerning these drugs. Posting this information does not mean that FDA has concluded there is a causal relationship between the drug products and the emerging safety issue. Nor does it mean that FDA is advising healthcare professionals to discontinue prescribing these products. FDA is considering, but has not reached a conclusion about whether this information warrants any regulatory action. FDA intends to update this document when additional information or analyses become available.

FDA has received reports of systemic adverse reactions including respiratory compromise and death following the use of botulinum toxins types A and B for both FDA-approved and unapproved uses. The reactions reported are suggestive of botulism, which occurs when botulinum toxin spreads in the body beyond the site where it was injected. The most serious cases had outcomes that included hospitalization and death, and occurred mostly in children treated for cerebral palsy-associated limb spasticity. Use of botulinum toxins for treatment of limb spasticity (severe arm and leg muscle spasms) in children or adults is not an approved use in the U.S.

These serious systemic adverse reactions occurred following treatment of a variety of conditions using a wide range of botulinum toxin doses. FDA is currently reviewing safety data from clinical studies submitted by the manufacturers of Botox, Botox Cosmetic and Myobloc, as well as post-marketing adverse event reports and the medical literature.

Botox (botulinum toxin type A) is approved for treatment of conditions such as blepharospasm (spasm of the eyelids), cervical dystonia (severe neck muscle spasms), and severe primary axillary hyperhydrosis (excess sweating). Botox Cosmetic, also botulinum toxin Type A, is approved for temporary improvement in the appearance of moderate to severe facial frown lines.

Myobloc (botulinum toxin Type B) is approved for the treatment of adults with cervical dystonia; the safety and effectiveness of Myobloc for cervical dystonia in children have not been established.

FDA is aware of the body of literature describing the use of botulinum toxins to treat limb spasticity in children and adults. The safety, efficacy and dosage of botulinum toxins have not been established for the treatment of limb spasticity of cerebral palsy or for use in any condition in children less than 12 years of age.

The current prescribing information (labeling) for Botox, Botox Cosmetic and Myobloc describes adverse reactions occurring in regions near the site of injection for each product’s approved uses, such as dysphagia (difficulty swallowing) after injections to treat cervical dystonia, or ptosis (drooping eye lids) after injections for glabellar frown lines or for strabismus and blepharospasm.

The Warnings sections of the labeling for both botulinum toxin products note that important systemic adverse effects, including severe difficulty swallowing and difficulty breathing have occurred in patients with neuromuscular disorders after local injection of typical doses of botulinum toxin. FDA now has evidence that similar, potentially life-threatening systemic toxicity from the use of botulinum toxin products can also result after local injection in patients with other underlying conditions such as those with cerebral palsy associated limb spasticity. Systemic toxicity has been reported in children, several of whom required feeding tubes and/or ventilation (breathing) support.

Until such time that FDA has completed its review, healthcare professionals who use medicinal botulinum toxins should:

* Understand that potency determinations expressed in “Units” or “U” are different among the botulinum toxin products; clinical doses expressed in units are not comparable from one botulinum product to the next

* Be alert to the potential for systemic effects following administration of botulinum toxins such as: dysphagia, dysphonia, weakness, dyspnea or respiratory distress

* Understand that these effects have been reported as early as one day and as late as several weeks after treatment

* Provide patients and caregivers with the information they need to be able to identify the signs and symptoms of systemic effects after receiving an injection of a botulinum toxin

* Tell patients they should receive immediate medical attention if they have worsening or unexpected difficulty swallowing or talking, trouble breathing, or muscle weakness

What does FDA know now about these data?

The FDA has reviewed post-marketing cases from its Adverse Event Reporting System (AERS) database and from the medical literature of pediatric and adult patients diagnosed with botulism following a local injection with a marketed botulinum toxin product.

The pediatric botulism cases occurred in patients less than 16 years old, with reported symptoms ranging from dysphagia to respiratory insufficiency requiring gastric feeding tubes and ventilatory support. Serious outcomes included hospitalization and death. The most commonly reported use of botulinum toxin among these cases was treatment of limb muscle spasticity associated with cerebral palsy. For Botox, doses ranged from 6.25 to 32 Units/kilogram (U/kg) in these cases. For Myobloc, reported doses were from 388 to 625 U/kg.

The reports of adult botulism cases described symptoms including patients experiencing difficulty holding up their heads, dysphagia and ptosis. Some reports described systemic effects that occurred distant from the site of injection and included weakness and numbness of the lower extremities. Among the adult cases that were serious, including hospitalization, none required intubation or ventilatory support. No deaths were reported. The doses for Botox ranged from 100 to 700 Units and for Myobloc from 10,000 to 20,000 U.

This early communication is in keeping with FDA’s commitment to inform the public about its ongoing safety reviews of drugs. FDA will communicate to the public its conclusions, resulting recommendations, and any regulatory actions after the review of the data are completed.

Report serious adverse events to FDA’s MedWatch reporting system by completing a form on line at http://www.fda.gov/medwatch/report/hcp.htm, by faxing (1-800-FDA-0178), by mail using the postage-paid address form provided online (5600 Fishers Lane, Rockville, MD 20853-9787),
or by telephone (1-800-FDA-1088)