An A- Z Guide to Simplify and Optimize
Dementia Care
Objectives
• Understand the value of timely detection and learn simple
approaches to cognitive screening in routine practice
– Tools for health equity and cultural competence
• Gain knowledge of best practices in medication and non-medication
treatments for patients with dementia
• Recognize key management priorities throughout the continuum
of dementia
• Understand the risks associated with caregiving and how to connect
caregivers to evidence-based therapies, resources and services
• Leave with a full clinical toolbox
2
Alzheimer’s Disease:
Challenges and Opportunities
Alzheimer’s: A Public Health Crisis
• Scope of the problem
– 5.2M Americans with AD in 2013
– Growing epidemic expected to impact 13.8M Americans by
2050 and consume 1.1 trillion in healthcare spending
– Almost 2/3 are women (longer life expectancy)
– If disease could be detected earlier incidence would be
much higher
• Pre-clinical stage 1-2 decades
• Some populations at higher risk
– Older African Americans (2x as whites)
– Older Hispanics (1.5x as whites)
Alzheimer’s Association Facts
and Figures 2014
4
The Lens of Health Equity
• Take into consideration health
disparities and inequities
• Seek the attainment of the
highest level of health for all
people
• Help create a new style of
“curb cut” by promoting
cultural competence
5
Base Rates
• 1 in 9 people 65+ (11%)
• 1 in 3 people 85+ (32%)
Age Range
Percent with Alzheimer’s
< 65
4%
65 -74
13%
75 -84
44%
85 +
38%
Alzheimer’s Association Facts
and Figures 2014
6
Patients with Dementia
• A population with complex care needs
2.5 chronic
conditions
(average)
5+
medications
(average)
3 times more
likely to be
hospitalized
Many
admissions
from
preventable
conditions,
with higher
per person
costs
• Indisputable correlation between chronic conditions and costs
Alzheimer’s Association Facts
and Figures 2014
7
Challenges & Opportunities
• AD poorly recognized by providers
– Only 50% of patients receive formal diagnosis
• Millions unaware they have dementia
– Diagnosis often delayed on average by 6+ years
after symptom onset
– Significant impairment in function by time it is
recognized
• Poor timing: diagnosis frequently at time of crises,
hospitalization, failure to thrive, urgent need for
institutionalization
Boise et al., 2004; Boustani et al., 2003; Boustani et al., 2005; Silverstein & Maslow, 2006
8
Diagnostic Challenges
• Societal
– Ageism, lack of understanding re: normal aging
– Fear and stigma
– Healthcare inequities
– Expectation that MD will identify/diagnose health problems
• Systemic/Institutional
– Low priority
– Few incentives
– Lack of procedural support
– Limited specialists available (e.g., neurology, neuropsychology)
– May lack access to (or awareness of) community resources
9
Diagnostic Challenges
• Medical
– Time
– Lack of definitive tests
– Many patients unaware, do not self-identify symptoms
– Skepticism re: efficacy of medication treatments
– Limited cultural competence
– Lack of awareness re: benefits of non-medication interventions
– Fear of delivering wrong diagnosis, bad news
– Implications for physician/patient relationship
10
Myth:
People don’t want to know they have
Alzheimer’s disease
Fact:
100
90
80
Most people
want
advanced
notice
70
60
% 50
40
30
20
10
0
Alz-Eu Harvard
Turnbull
Holroyd
Blendon et al., 2012; Holroyd et al., 2002; Turnbull et al., 2003
Diagnostic Challenges
International Physician Survey
• Lack of definitive tests (65%, top barrier)
• Lack of communication between patients / caregiver and
physicians
– 75% reported discussion initiated by patients/caregivers
– 44% “after they suspected the disease had been present for a
while”
– 40% said patients/caregivers did not provide enough
information to help them make a diagnosis
• Patient / Family denial (65%) & social stigma (59%)
International Alzheimer’s Disease Physician Survey, 2012
Diagnostic Challenges
“Beyond mountains, there are mountains.”
Haitian Proverb
If we don’t diagnose, does it
still exist?
Rationale for Timely Detection
1. Patient Care / Outcomes
2. Time
3. Money
15
Patient Outcomes
1. Improved management of co-morbid
conditions
–
Underlying dementia = risk factor for poor compliance with ALL treatment
goals (e.g., diabetes, hypertension, CHF, anticoagulation)
2. Reduce ineffective, expensive, crisis-driven
use of healthcare resources
–
Unnecessary hospitalization (dehydration/malnourishment, medication
mismanagement, accidents and falls, wandering, etc.)
16
Patient Outcomes
3. Treat reversible causes
–
NPH, TSH, B12, hypoglycemia, depression
4. Improve quality of life
–
–
Patients can participate in decisions regarding their future care
Decrease burden on family and caregivers
5. Intervene to promote supported independence as
long as possible
–
–
RTC support/counseling intervention
Non-pharm intervention reduces NH placement by 30% and delays
placement for others by 18+ months
Mittelman et al., 2006
17
Time
• Simple screening tests can be done by
rooming nurse
–
Brain as 6th vital sign
• Recommended tool takes 1.5 – 3 minutes
–
•
Only conducted annually and in context of signs and
symptoms
Mini-Cog does not disrupt workflow & increases
capture rate of cognitive impairment in primary
care
Borson et al., 2007
18
Money
• AD most expensive condition in the nation
–
•
Cost effectiveness of early dx/tx?
–
•
$203 billion in 2013, $1.2 trillion in 2050
Large scale studies ongoing
Economic Models
– No med known to alter costs of care
– Disease education/support interventions increase
caregiver capability, save money, and delay NH
– Even if assume small # of people benefit (5%), $996
million in potential savings for MN over 15 years
Alzheimer’s Association Facts and Figures 2014; Long et al., 2014
19
Impact of Optimal Practices
Timely Detection
• Reduces utilization through comorbidity
management
Post-Diagnosis
Education and Support
• Reduces behavioral symptoms
• Delays institutionalization
• Increases treatment plan compliance
Effective Care
Management
• Delays institutionalization
• Reduces neuropsychiatric symptoms
• Reduces costs
Team-Based Care
• Reduces acute episodes
• Improves health outcomes
Care Transitions
• Improves health outcomes
• Improves care quality
• Reduces hospital, ER utilization, and care costs
Caregiver Engagement
& Support
• Improves overall well-being of person w/ dementia
• Increases caregiving longevity and well-being
16
Changing National & Local Landscape
• National Alzheimer’s Project Act (NAPA)
– Awareness, readiness, dissemination, coordination
• Annual Wellness Visit
– For first time, “detection of cognitive impairment” is
core feature of the exam
• MN healthcare systems implementing tools
–
–
–
–
HealthPartners
Park Nicollet
Essentia
Allina
21
Rethinking Everyday Practice
• Brain historically ignored, not a focus of
routine exam
– Is this logical? Consider base rates of dementia
• Dementia is simply “brain failure”
– Heart failure
– Kidney failure
– Liver failure
• Brain as 6th Vital Sign
22
Introduction to
ACT on Alzheimer’s
ACT on Alzheimer’s
statewide
300+
60+
O R G A N I Z AT I O N S
INDIVIDUALS
volunteer
driven
collaborative
I M PA C T S O F A L Z H E I M E R ’ S
BUDGETARY
SOCIAL
PERSONAL
24
Collaborative Goals/Common
Agenda
Five shared
goals with a
Health Equity
perspective
25
ACT Tool Kit
• Consensus-based, best
practice standards for
Alzheimer’s care
• Tools and resources for:
– Primary care providers
– Care coordinators
– Community agencies
– Patients and families
26
ACT Tools
27
ACT Tools
28
www.actonalz.org
Clinical Practice Tips
30
Case Study: Sam
• 76 y/o retired teacher (master’s degree)
• Daughter c/o short-term memory is poor, patient
acknowledges problem but does not feel it is significant
– Repeats himself, multiple phone calls b/c can’t find belongings
•
•
•
•
•
•
Other family members have noticed changes
Began 2 years ago, getting worse
Hx of hypertension and DM, both fairly well controlled
Wife died unexpectedly last year, lives alone
Conversational presentation fairly intact
Oriented x3 but vague awareness of current events
31
Case Study: Colleen
•
•
•
•
•
66 y/o retired accountant for family business
Presents to primary care with memory complaints
Daughter agrees that short-term memory is poor
Began 2 years ago, seems to be worsening
Hx of Low blood sugar, heart attack x1, repeat ER visits and
hospitalizations for atrial flutter
• Frequent medication changes, managing independently
• Lives with husband who is still running the family business
Signs and Symptoms of AD
•
•
•
•
•
•
•
•
•
•
•
•
•
Memory loss
Confusion
Disorientation to time or place
Getting lost in familiar locations
Impairment in speech/language
Trouble with time/sequence relationships
Diminished insight
Poor judgment/problem solving
Changes in sleep and appetite
Mood/personality/behavior changes
Wandering
Deterioration of self care, hygiene
Difficulty performing familiar tasks, functional decline
Alzheimer’s Association, 2009
33
Practice Tips
• Unfortunately, most of us do not recognize signs
and symptoms until they are quite pronounced
– Attribution error: “What do you expect? She is 80
years old.”
– Subjective impressions FAIL to detect dementia in
early stages
• Clinical interview
– Let patient answer questions without help
– Remember: Social skills remain intact until late stage dementia
– Easy to be fooled by a sense of humor, reliance on old
memories, or quiet/affable demeanor
Practice Tips
• Red flags
–
–
–
–
–
–
–
Repetition (not normal in 7-10 min conversation)
Tangential, circumstantial responses
Losing track of conversation
Frequently deferring answers to family member
Over reliance on old information/memories
Inattentive to appearance
Unexplained weight loss or “failure to thrive”
Practice Tips
• Family observations:
– ANY instances whatsoever of getting lost while driving, trouble
following a recipe, asking same questions repeatedly, mistakes
paying bills
– Take these concerns seriously: by the time family report
problems, symptoms have typically been present for quite a
while and are getting worse
• Raise your expectation of older adults:
– If this patient was alone on a domestic flight across the country
and the trip required a layover with a gate change, would
he/she be able to manage that kind of mental task on his/her
own?
• If answer is “not likely” for a patient of any age: RED FLAG
Practice Tips
• Intact older adult should be able to:
– Describe at least 2 current events in adequate detail (who,
what, when, why, how)
– Describe events of national significance
• 9/11, New Orleans disaster, etc.
– Name or describe the current President and an immediate
predecessor
– Describe their own recent medical history and report the
conditions for which they take medication
Cognitive Screening
38
Is Screening Good Medicine?
2014 US Preventative Services Task Force (USPSTF)
• Purpose: Systematically review the diagnostic accuracy of
brief cognitive screening instruments and the benefits/harms
of medication and non-medication interventions for early
cognitive impairment.
• Limitation: Limited studies in persons with dementia other
than AD and sparse reporting of important health outcomes.
• Conclusion: Brief instruments to screen for cognitive
impairment can adequately detect dementia, but there is no
empirical evidence that screening improves decision making.
Long et al., 2014
39
Provider Perspective
“Avoiding detection of a serious and life
changing medical condition just because there
is no cure or ‘ideal’ medication therapy seems,
at worst, incredibly unethical, and, at best, just
bad medicine.”
George Schoephoerster, MD
Family Practice Physician
40
Clinical Provider Practice Tool
• Easy button workflow for:
1. Screening
2. Dementia work-up
3. Treatment / care
www.actonalz.org/provider-practice-tools
41
Cognitive Screening
• Initial considerations
– Timing
• Routine, annual check-ups or only when patients
become obviously symptomatic?
– Best practice recommendation: Annual screening at 65+
– Screening meant to uncover insidious disease
– Doesn’t add much if you can already detect impairment in
basic conversation
– Research
• Which tools are best?
• Balance b/w time and sensitivity/specificity
Cognitive Screening
– Clinic flow
• Who will administer screen?
– Rooming nurses, social workers, allied health professionals,
MDs
• What happens when patients fail?
43
Screening Measures
• Wide range of options
–
–
–
–
Mini-Cog™ (MC)
Mini-Mental State Exam© (MMSE)
St. Louis University Mental Status Exam™ (SLUMS)
Montreal Cognitive Assessment™ (MoCA)
• All but MMSE free, in public domain, and online
Borson et al., 2000; Folstein et al., 1975; Nasreddine 2005; Tariq et al., 2006
Alternative Screening Tools
• Virtually all screening tools based upon a
euro-centric cultural and educational model
• Consider: country and language of origin,
type/quality/length of education, disabilities
(visual, auditory, motor)
• Alternative tools my be less biased
45
Screening Administration
• Try not to:
– Use the words “test” or “memory”
• Instead: “We’re going to do something next that
requires some concentration”
– Allow patient to give up prematurely or skip
questions
– Deviate from standardized instructions
– Offer multiple choice answers
– Be soft on scoring
– Score ranges already padded for normal errors
– Deduct points where necessary – be strict
Mini-Cog™
Contents
• Verbal Recall (3 points)
• Clock Draw (2 points)
Advantages
• Quick (2-3 min)
• Easy
• High yield (executive fx,
memory, visuospatial)
Borson et al.,
2000
Subject asked to recall 3 words
Leader, Season, Table
+3
Subject asked to draw clock,
set hands to 10 past 11
+2
DATE_________ ID_________________________AGE____GENDER M F LOCATION ______________________ TESTED BY________
MINI-COG ™
1) GET THE PATIENT’S ATTENTION, THEN SAY: “I am going to say three words that I want you to remember now and later. The words are
Banana
Sunrise
Chair.
Please say them for me now.” (Give the patient 3 tries to repeat the words. If unable after 3 tries, go to next item.)
(Fold this page back at the TWO dotted lines BELOW to make a blank space and cover the memory words. Hand the patient a pencil/pen).
2) SAY ALL THE FOLLOWING PHRASES IN THE ORDER INDICATED: “Please draw a clock in the space below. Start by drawing a large
circle.” (When this is done, say) “Put all the numbers in the circle.” (When done, say) “Now set the hands to show 11:10 (10 past 11).” If
subject has not finished clock drawing in 3 minutes, discontinue and ask for recall items.
-------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------------------------- --------------
-------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------------------------- -------------------------------- ------------3) SAY: “What were the three words I asked you to remember?”
_
Score the clock (see other side for instructions):
(Score 1 point for each) 3-Item Recall Score
Normal clock
Abnormal clock
Total Score = 3-item recall plus clock score
2 points
0 points
Clock Score
0, 1, 2, or 3 = clinically important cognitive impairment likely;
4 or 5 = clinically important cognitive impairment unlikely
48
CLOCK SCORING
NORMAL CLOCK
A NORMAL CLOCK HAS ALL OF THE FOLLOWING ELEMENTS:
All numbers 1-12, each only once, are present in the correct
order and direction (clockwise).
Two hands are present, one pointing to 11 and one pointing to
2.
ANY CLOCK MISSING ANY OF THESE ELEMENTS IS SCORED
ABNORMAL. REFUSAL TO DRAW A CLOCK IS SCORED
ABNORMAL.
SOME EXAMPLES OF ABNORMAL CLOCKS (THERE ARE MANY OTHER KINDS)
Abnormal Hands
Missing Number
.................................................................................................................................................................................................................................
Mini-CogTM, Copyright S Borson. Reprinted with permission of the author, solely for clinical and teaching use. May not be modified or
used for research without permission of the author (soob@uw.edu). All rights reserved.
49
Mini-Cog
Pass
• >4
Fail
• 3 or less
Borson et al., 2000
Mini-Cog Research
• Performance unaffected by education or language
• Borson Int J Geriatr Psychiatry 2000
• Sensitivity and specificity similar to MMSE (76% vs.
79%; 89% vs. 88%)
• Borson JAGS 2003
• Does not disrupt workflow & increases rate of
diagnosis in primary care
• Borson JGIM 2007
• Failure associated with inability to fill pillbox
• Anderson et al Am Soc Consult Pharmacists 2008
Mini-Cog: Sam
http://youtu.be/CRQEighdb0w
52
Mini-Cog Scoring: Sam
Mini-Cog Scoring: Sam
Mini-Cog: Colleen
http://youtu.be/DeCFtuD41WY
55
Colleen’s Clock
Colleen’s Score
Mini-Cog Exercise
Form groups of 2
• Administer MiniCog to each other
• Score sample clocks
58
Clock #1
Clock #2
Clock #3
Clock #4
Clock #5
Clock #6
Clock #7
Clock #8
Clock #9
SLUMS
Tariq et al., 2006
SLUMS
High School Diploma
Less than 12 yrs education
Pass
> 27
> 25
Fail
26 or less
24 or less
Tariq SH, Tumosa N, Chibnall et al. Comparison of the Saint Louis University mental
status examination and the mini-mental state examination for detecting dementia
and mild neurocognitive disorder--a pilot study. Am J Geriatr Psychiatry. 2006
Nov;14(11):900-10.
69
SLUMS: Colleen
http://youtu.be/jyp0ShPiUH8?list=UUOPv8U5bHcdDCm4edmQDY9g
70
SLUMS Scoring: Colleen
• Interactive scoring exercise
71
SLUMS Scoring: Colleen
72
SLUMS Scoring: Colleen
73
SLUMS Scoring: Colleen
74
MoCA
Nasreddine et al., 2005
MoCA
Pass
• > 26
Fail
• 25 or less
Nasreddine 2005
76
MoCA: Sam
http://youtu.be/ryf8SG0NQLQ?list=UUOPv8U5bHcdDCm4edmQDY9g
77
MoCA Scoring: Sam
• Interactive scoring exercise
78
MoCA Scoring: Sam
79
MoCA Scoring: Sam
80
MoCA Scoring: Sam
81
MoCA Scoring: Sam
82
Screening Tool Selection
Montreal Cognitive Assessment (MoCA)
• Sensitivity:
• Specificity:
90% for MCI, 100% for dementia
87%
St. Louis University Mental Status (SLUMS)
• Sensitivity:
• Specificity:
92% for MCI, 100% for dementia
81%
Mini-Mental Status Exam (MMSE)
• Sensitivity:
• Specificity:
18% for MCI, 78% for dementia
100%
Larner 2012; Nasreddine et all, 2005; Tariq et al., 2006; Ismail et al., 2010
Family Questionnaire
www.actonalz.org/pdf/Family-Questionnaire.pdf
Cognitive Screening Flow Chart
85
Cognitive Impairment
Identification Flow Chart
86
Dementia Work-up
and Diagnosis
87
Dementia Work-Up
88
89
Dementia Work-Up
• H&P
• Objective cognitive measurement
• Diagnostics
– Labs
– Imaging ?
– More specific testing (e.g., neuropsychometric)?
• Diagnosis
• Family meeting
Dementia Diagnoses
FTD
Alzheimer’s disease: 60-80 %
• Includes mixed AD + VD
Lewy Body
Dementia
Lewy Body Dementia: 10-25 %
Vascular
Dementia
– Parkinson spectrum
Alzheimer’s
Disease
Vascular Dementia: 6-10 %
– Stroke related
Frontotemporal Dementia: 2-5 %
– Personality or language
disturbance
Delivering the Diagnosis
• General guidelines:
– Include a family member in the visit if at all possible
– Talk directly to the person with dementia
– Speak at a slower, relaxed pace using plain words
• Try not to fill the time with words – less is more
– Explain why tests were ordered and what results
mean
– Ask at least 3 times whether the patient / family has
any questions
– Acknowledge how overwhelming the information
feels; provide empathy, support, reassurance
92
Delivering the Diagnosis
• Focus on wellness, healthy living, and
optimizing function
– Sleep
– Exercise
– Social and mental stimulation
– Nutrition and hydration
– Stress reduction
– Increase structure at home
Zaleta & Carpenter 2010
93
Delivering the Diagnosis
• Connect patient/family to community
resources
– Care for both patient and caregiver
– Examples: Senior linkage line, Alzheimer’s
Association
• Discuss follow-up
– Want to see patient and family member at regular
intervals (e.g., q 6 months) for proactive care
– Discuss involvement of care coordinator
• Provide written summary of visit
94
Common Questions
•
•
•
•
•
How is Alzheimer’s different from dementia?
Is there any treatment? What can we do?
How fast is this going to progress?
How often do we see you?
What’s next?
95
Delivering the Diagnosis: Sam
https://www.youtube.com/watch?v=vy2ZC5ZSZL8
96
Delivering the Diagnosis: Sam
• Discussion
– Observations? Reactions?
– What was done well?
– What could have been done differently, better?
– What elements would you incorporate into your
practice?
– If Sam was American Indian what, if anything,
would you do differently?
97
Dementia Care
and Treatment
98
Care and Treatment
99
Care and Treatment
100
Treatment: Medications
• Cholinesterase inhibitors
– Donepezil, Rivastigmine, Galantamine, Cognex
– Possible side effects: nausea, vomiting, syncope,
dizziness, anorexia
• NMDA receptor antagonist
– Memantine
– Possible side effects: tiredness, body aches,
dizziness, constipation, headache
101
Care and Treatment
• The care for patients with Alzheimer’s has very
little to do with pharmacology and more to do
with psychosocial interventions
• Involve care coordinator
• Connect patient and family to experts in the
community
– Example: Alzheimer’s Association
– Refer every time, at any stage of disease, and for
every kind of dementia
– Stress this is part of their treatment plan and you
expect to hear about their progress at next visit
102
After A Diagnosis
- Partnering with
doctors
- Understanding the
disease
- Planning ahead
- How to ask for help
- Using community
resources
- Role of care
coordinator
ACT EMR Tools
• Use EMR to automate and standardize:
– Screening
– Work-up
– After visit summary with dementia education
– Orders and referrals
– Community supports
www.actonalz.org/provider-practice-tools
104
Screening
105
Labs and Orders
106
Consults and Referrals
107
Consults and Referrals
108
Pharmacological Treatment
109
Managing Mid to
Late Stage Dementia
110
Managing Dementia Across the
Continuum
www.actonalz.org/provider-practice-tools
111
Mood and Behavioral Symptoms
• Neuropsychiatric symptoms common:
– 60% of community dwelling patients with
dementia
– > 80% of nursing home residents with dementia
• Nearly all patients with dementia will suffer
from mood or behavioral symptoms during
the course of their illness
Ferri et al., 2005; Jeste et al., 2008
112
Adverse Outcomes
•
•
•
•
•
•
Decreased quality of life
Increased hospital length of stay
Increased system-wide costs
Increased caregiver distress, depression, burnout
Independently associated with NH placement
? Increased mortality
Jeste et al., 2008; Finkel et al., 1996
113
114
ACT to the Rescue!
115
Systematic Approach to
Management
•
•
•
•
Step 1:
Step 2:
Step 3:
Step 4:
Define behavior
Categorize target symptom
Identify reversible causes
Use non-drug interventions first to
treat target symptoms
116
Step 1: Define Behavior
• Examples
– Attention seeking behaviors
• Verbal outbursts
– Aggression during cares
– Hitting, pushing, kicking
– Sexual disinhibition
– Restless motor activity, pacing, rocking
– Calling out
117
Step 2: Categorize Target
Symptom
• Psychosis
– Delusions
– Hallucinations
• Mood symptoms
–
–
–
–
Anxiety
Dysphoria
Irritability
Lability
• Aggression
• Spontaneous disinhibition
118
Step 3: Identify Reversible Causes
•
•
•
•
•
•
•
Delirium
Untreated medical illness (e.g., UTI)
Medication side effects, polypharmacy
Environmental triggers
Undiagnosed psychiatric illness
Inexperienced caregivers
Unrealistic expectations
119
Step 3: Identify Reversible Causes
• Common root causes:
–
–
–
–
–
–
Anxiety, fear or uncertainty
Touch or invasion of personal space
Loss of control, lack of choice
Lack of attention to personal needs or wishes
Frustration, grief due to loss of function or ability
Pain or fear of pain
Step 3: Identify Reversible Causes
• Unmet needs
–
–
–
–
–
Boredom
Meaning, purpose
Over/under stimulation
Safety
Environmental stressors
• Caregiver reactions
– Limited knowledge about disease process or
behaviors
121
Step 4: Non-pharmacologic
Interventions
• REMEMBER: behavior is communication
• Think like a behavioral analyst
– Detective work, ask:
•
•
•
•
•
Who (is involved/present)
What (exact description, be specific)
When (time dependent? only in morning? triggers?)
Where (location specific?)
Why (what happens right before, right afterwards? what do
family think is cause?)
– ABC approach (antecedent, behavior, consequence)
122
Step 4: Non-pharmacologic
Interventions
• Activity planning
– Tap into preserved capabilities and previous interests
– Involve repetitive motion
• Communication
– Slow down, offer simple choices
– Help individual find words for self expression
• Simplify Environment
– Remove clutter, minimize stimuli during activity
• Caregiver support
– Self care, minimize confrontation/arguing with loved one
– Identify support network
Gitlin, et al., 2012
123
124
Pharmacological Treatment
•
•
•
•
Antipsychotics
Antidepressants
Mood stabilizers
Cognitive enhancers
125
Antipsychotic Medications in
Dementia
• 1952: First generation antipsychotic: haloperidol
– Extrapyramidal symptoms
– Tardive dyskinesia
• 1989: Second generation antipsychotic: clozapine
– Agranulocytosis
• 1990’s: More second generation antipsychotics
– Risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole
– Less motor side effects, better tolerated
– Utilization of these agents broadens
• THEN in 2005 …
Jeste et al., 2008
126
2005 FDA Box Warning
Elderly patients with dementiarelated psychosis treated with
atypical antipsychotic drugs are
at an increased risk of death
compared to placebo.
127
Bottom Line with Atypical
Antipsychotics
• Modest efficacy in the treatment of psychotic
and neuropsychiatric symptoms
• Increased risk of negative outcomes: DEATH,
STROKE, HIP FRACTURE, FALLS
• Share the decision with healthcare proxies
• Monitor:
– Falls, orthostatic BP, EPS, tardive dyskinesia,
glucose
– Regularly attempt to wean/discontinue
128
Optimizing Medication Therapy
Professional Resources
• AGS Beers Criteria (2012)
• START (Screening Tool to Alert
Doctors to the Right
Treatment)
• STOPP (Screening Tool of
Older Persons’ Potentially
inappropriate Prescriptions)
129
Advanced Care Planning
• Discussion of goals of care, values
• Identification AND engagement of HCPOA
– Honoring Choices
– PREPARE
• Introduce concept of palliative care, educate
about hospice
• Document in EMR, healthcare directive
• Provider Orders for Life Sustaining Treatment
(POLST)
130
Assessing Caregiver/Family Needs
• Be alert for signs of:
– Burnout, depression, neglected self-care, elder
abuse
• Promote:
– Respite services
– Support groups
– Activities to optimize health and well-being
• Refer to one-stop-shop for support:
– Alzheimer’s Association
– Senior Linkage Line
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Patient Engagement:
Research Participation
• Alzheimer’s Association Trial Match
– Free, easy-to-use clinical studies matching
service that connects individuals with
Alzheimer's, caregivers, healthy volunteers and
physicians with current studies.
– http://www.alz.org/research/clinical_trials/find
_clinical_trials_trialmatch.asp
• National Institute of Health (NIH)
– http://clinicaltrials.gov
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HIPAA:
Q&A
• HIPAA (Health Insurance Portability and
Accountability Act)
• Federal law that protects medical information
• Allows only certain people to see information
– Doctors, nurses, therapists and other health care
professionals on the patient’s medical team
– Family caregivers and others directly involved with
a patient’s care (unless the patient says he/she does
not want this information shared with others)
www.nextstepsincare.org, United Hospital Fund, 2002
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HIPAA:
Sharing Patient Information
• If the patient is present and has the capacity to make
health care decisions:
– Health care providers may discuss the patient’s health
information with a family member, friend, or other
person if the patient agrees or, when given the
opportunity, does not object.
• If patient is not present or is incapacitated:
– Health care providers may share the patient’s
information with family, friends or others as long as the
provider determines (based on professional judgment)
that it is in the best interest of the patient.
www.nextstepsincare.org, United Hospital Fund, 2002
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Top 5 Resources for
Patients and Families
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#1 Promoting Wellness &
Function
136
#2 Addressing Behavioral
Challenges
137
#3 Caregiver Support
Alzheimer’s Association
800.272.3900 | www.alz.org/mnnd
One stop shop for:
– Care Consultation
– Support Groups (Memory Club)
– 24/7 Helpline
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#4 In-depth Caregiver Training
Family Memory Care Program
800.272.3900
• 4+ months of 1:1 support, care coordination
• Individual and family meetings
• Dementia-capable trained clinician
139
#5 Medication Review
PharmD Consult
• Medication review, simplification
• Reminder strategies
• Family support, supervision
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ACKNOWLEDGEMENTS
This project is/was supported by funds from the Bureau of Health Professions (BHPr), Health
Resources and Services Administration (HRSA), Department of Health and Human Services (DHHS)
under Grant Number UB4HP19196 to the Minnesota Area Geriatric Education Center (MAGEC) for
$2,192,192 (7/1/2010—6/30/2015). This information or content and conclusions are those of the
author and should not be construed as the official position or policy of, nor should any
endorsements be inferred by the BHPr, HRSA, DHHS or the U.S. Government.
Minnesota Area Geriatric Education Center (MAGEC)
Grant #UB4HP19196
Director: Robert L. Kane, MD
Associate Director: Patricia A. Schommer, MA
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References & Resources
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•
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•
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•
•
2012 Updated AGS Beers
Criteria:http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf
Alzheimer’s Association Family Questionnaire: http://www.alz.org/mnnd/documents/Family_Questionnaire.pdf
Alzheimer’s Association (2009). Know the 10 signs.http://www.alz.org/national/documents/checklist_10signs.pdf
Coach Broyles Playbook on Alzheimer’s: http://www.caregiversunited.com
Honoring Choices Minnesota:http://www.honoringchoices.org
Living Well workbook:http://www.alz.org/documents/mndak/alz_living_well_workbook_2011v2_web.pdf
Medicare Annual Wellness Visit: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-NetworkMLN/MLNMattersArticles/downloads/MM7079.pdf
MiniCog™ http://www.alz.org/documents_custom/minicog.pdf
Montreal Cognitive Assessment (MoCA)http://www.mocatest.org
National Alzheimer’s Project Act: http://aspe.hhs.gov/daltcp/napa/NatlPlan.pdf
Next Step in Care: http://www.nextstepincare.org
Physician Orders for Life Sustaining Treatment (POLST): http://www.polst.org
St. Louis University Mental Status (SLUMS)
examinationhttp://medschool.slu.edu/agingsuccessfully/pdfsurveys/slumsexam_05.pdf
The Alzheimer’s Action Plan:http://www.amazon.com/The-Alzheimers-Action-Plan-Know/dp/0312538715
Understanding Difficult Behaviors:http://www.amazon.com/Understanding-Difficult-Behaviors-suggestionsAlzheimers/dp/0978902009
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