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California%20Guideline%20for%20Alzheimer

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Concurrent medical conditions. Medications. Behavior symptoms and mood. Living arrangements ... Medical Record Checklist. List of Reversible Medical Conditions ... – PowerPoint PPT presentation

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Title: California%20Guideline%20for%20Alzheimer


1
2008 California Guideline for Alzheimers
Disease Management Debra Cherry, PhD
Alzheimers Association, California Southland
2
Presenter Disclosures
  • The following financial relationships with
    commercial interests relevant to this
    presentation existed during the past 12 months
  • Grants to the Alzheimers Association, California
    Southland Chapter
  • Forest Laboratories
  • Pfizer/Eisai
  • Janssen Pharmaceuticals
  • Novartis
  • Elan

3
Objectives
  • Describe the process utilized to update the
    California Guideline for AD Management
  • Review the Guidelines recommendations
  • Apply the recommendations to patients and
    caregivers
  • Use the Guideline to implement a quality
    improvement project

4
What is a clinical guideline?
  • A document with the aim or guiding medical
    decisions and practice regarding
  • Diagnosis
  • Management
  • Treatment
  • Briefly identifies, summarized and evaluates best
    evidence and most current data. Includes
    consensus statements from experts.

5
History of California AD Management Guideline
  • 1995 California Workgroup on Guideline for
    Alzheimers Disease Management formed
  • 1998 Publication of the first Guideline
  • 2002 Guideline updated published in The
    American Family Physician
  • 2008 Third update completed.

6
Composition of the California Workgroup
  • Representatives from throughout the State
  • Healthcare providers
  • Consumers
  • Academicians
  • Professional and volunteer organizations

7
Purpose of the Guideline
  • Represents core care recommendations for AD
    management which are
  • Based on scientific evidence
  • Supplemented by expert consensus
  • General guide to post-diagnostic care
  • Intended for Primary Care Practitioners
    including
  • Physicians
  • Nurse Practitioners/Nurses
  • Physician Assistants
  • Also defines a role for
  • Social Workers
  • Care Managers

8
Mrs. R. L.
Mrs. R. L. is a retired librarian who visits her
physician for a routine follow-up for her
osteoarthritis, GERD, and glaucoma. She has
enjoyed her 3 years of retirement, but reports
that recently her husband has been worried about
her memory. Mrs. L. states that she had started
writing reminder notes, which dont always
help. She admits to reading less than she used
to she also drives less because traffic is such
a problem.
9
Mrs. R. L.
Mr. L. reports that his wife often returns from
grocery shopping having forgotten to pick up
several things that she intended to buy. At
other times she will wander through the house,
looking in drawers or closets for items that she
had put away for safe-keeping. Although they
used to go out to dinner at least once a week,
they now go much less frequently because Mrs. L.
states that I just never know what to order, and
its not as much fun as it used to be.
10
Dementia Warning Signs
Task Example
Memory decline Forgetfulness
Difficulty performing familiar tasks Bill paying, shopping
Disorientation Getting lost in familiar places
Impaired judgment Inviting strangers into the home
Impaired abstract thinking, problem-solving Driving skills
11
Dementia Warning Signs
Task Example
Misplacing things Losing valuable items in the home
Mood or behavior change New-onset irritability, unusual habits or activities
Personality change Withdrawn, increased socialization
Problems with language Word finding difficulties
12
What signs and symptoms are present in Mrs. R. L.
that suggest that she may have a dementia?
13
Guideline for AD Management
  • Assessment
  • Treatment
  • Patient Family Education Support
  • Legal Considerations

14
Assessment
  • Cognitive status
  • Daily function
  • Concurrent medical conditions
  • Medications
  • Behavior symptoms and mood
  • Living arrangements
  • Support system

15
Assessing Cognition
Test Items/Score Domains
Folstein Mini-Mental Status Exam 19 items 30 points Multi-dimensional
Mini-Cog 2 items 5 points 3-item recall Clock drawing
Blessed Orientation-Concentration-Memory 6 items 28 points Orientation, concentration, recall
Cognitive Assessment Screening Instrument 25 items 100 points Multi-dimensional
16
Assessment Function Activities of Daily Living
(ADL)
  • Self-feeding
  • Dressing
  • Ambulation
  • Toileting
  • Bathing
  • Transfer from bed to toilet
  • Continence
  • Grooming
  • Communication

17
Assessment Function Instrumental ADL (IADL)
  • Writing
  • Reading
  • Cooking
  • Cleaning
  • Shopping
  • Doing laundry
  • Climbing stairs
  • Using telephone
  • Managing medication
  • Managing money
  • Ability to perform outside work
  • Ability to travel (public transportation)

18
Assessment Concurrent Conditions
  • Chronic disease
  • Ability to manage
  • Acute Conditions
  • Delirium
  • Infection/UTI/Influenza

19
Assessment Medications Cognition
  • Anticholinergics
  • Benzodiazepines
  • Sleep aids
  • Antipsychotics
  • Narcotics
  • Muscle relaxants
  • NSAIDs
  • Anti-arrhythmics
  • Antihypertensives
  • Cimetidine
  • Corticosteroids
  • Hypoglycemic agents

20
Assessment Behavior Mood
  • Agitation
  • Restlessness
  • Irritability
  • Aggression
  • Psychosis
  • Delusions
  • Paranoia
  • Hallucinations
  • Depression
  • Withdrawal
  • Sleep disturbances
  • Appetite changes
  • Apathy
  • Loss if interest

21
Assessment Living Arrangements
  • Declining ability for self-care
  • Patient autonomy vs. need for care
  • Safety issues
  • Rugs, appliances
  • Driving
  • Abuse and neglect
  • Dependence
  • Caregiver stress

22
Assessment Support System
  • Familys ability to care for patient
  • Community supports
  • Alzheimers Association
  • Caregiver Resource Center
  • Religious or other groups
  • Community resources day care, in-home care
  • Health care resources
  • Advance directives

23
Mrs. R has come to the Alzheimers Disease Center
and been thoroughly assessed. She has been
determined to have a diagnosis of Alzheimers
disease. What next?
24
Treatment Develop a Treatment Plan
  • Improve cognitive function
  • Increase level of function
  • Delay disease progression
  • Manage behavior disturbances
  • Ease caregiver burden

25
Treatment Improve Cognitive Function
  • Cholinergic manipulation
  • Cholinesterase inhibitors
  • All agents block acetylcholinesterase activity
  • Rivastigmine also blocks butyrylcholinesterase
  • Galantamine stimulates cholinergic receptors
  • NMDA antagonist
  • Reduces glutamate activity
  • Regulates calcium entry into cells

26
Counseling Points
  • Effects on cognition are very mild
  • May stabilize or slow decline
  • May improve independence, self-care
  • Gastrointestinal effects are prominent
  • May slow heart rate

27
TREATMENT Recommendations
  • Treat behavioral symptoms and mood disorders
    using
  • Non-pharmacologic approaches, such as
    environmental modification, task simplification,
    appropriate activities, etc.
  • IF non-pharmacological approaches prove
    unsuccessful, THEN use medications, targeted to
    specific behaviors, if clinically indicated. Note
    that side effects may be serious and significant.

28
Treatment Behavior Symptoms
  • Most difficult for both patients and caregivers
  • Behavior symptoms contribute to
  • Patient distress
  • Caregiver burnout
  • Excess disability
  • Institutionalization

29
Behavioral Symptoms as AD Progresses
Jost BC, Grossberg GT. J Am Geriatr Soc.
1996441078-1081.
30
Mrs. R. L.
Some time has passed and Mr. L. is concerned
about changes in his wifes behavior. She
becomes agitated, especially in the late
afternoon and leaves the house. She says she is
going home and gets more agitated when he reminds
her that she is in her home.
31
Evaluating Behaviors
  • Rapid onset requires search for medical cause
  • Pain, infection, adverse drug effect
  • Identify problem
  • Antecedents - Behaviorial triggers
  • Behaviors Be Specific
  • Consequences

32
Common Causes of Challenging Behaviors
  • Health problems
  • Difficult tasks
  • Confusing environment
  • Communication breakdown
  • Patients perceptions of the situation

33
What may be triggering Mrs. L.s behavior? What
does this behavior mean to her? How should these
symptoms be managed?
34
Mrs. R. L.
Mrs. R. L. has begun a daily exercise program
and late afternoon agitation is now less of an
issue. However, at night she awakens and becomes
agitated. She believes someone is trying to
break into the house. When her husband tries to
reassure her, she gets angry and strikes out at
him.
35
What may be triggering Mrs. L.s behavior? What
does this behavior mean to her? How should these
symptoms be managed?
36
PATIENT and FAMILY EDUCATION SUPPORT Recommendat
ions
  • Integrate medical care with education support
    by connecting patient caregiver to support
    organizations
  • - Alzheimers Association 1-800-272-3900
    www.alz.org
  • - Family Caregiver Alliance 1-800-445-8106
    www.caregiver.org - or your own social
    service department.

37
PATIENT and FAMILY EDUCATION SUPPORT Early
Stages
Pay particular attention to the special needs
of early-stage patients, involving them in care
planning, heeding their opinions and wishes, and
referring them to community resources, including
the Alzheimers Association.
38
PATIENT and FAMILY EDUCATION SUPPORT End of
Life Decisions
Discuss the intensity of care and other
end-of-live care decisions with the Alzheimers
Disease patient and involved family members while
respecting their cultural preferences.
39
LEGAL CONSIDERATIONS Recommendations
  • Include a discussion of the importance of basic
    legal and financial planning as part of the
    treatment plan as soon as possible after the
    diagnosis of AD.
  • Monitor for evidence of and report all suspicions
    of abuse as required by law.
  • Report the diagnosis of AD in accordance with
    local laws.

40
Using the Guideline in a Health Care Setting
Health care organizations are challenged to care
for the growing number of older adults with
chronic health conditions
41
How to use Guidelines for a QI project
  • Set quality goals derived from guideline
  • Train practitioners
  • Add case management
  • Evaluate

42
Implementation Support Tools
  • Provider Tool Kit
  • Medical Record Checklist
  • List of Reversible Medical Conditions
  • Signs/Symptoms of Elder Abuse
  • Mental Status Exam
  • Safe Return / ID Bracelet Program Application
  • Dementia and Driving Reporting Law
  • Prescription Pad

43
QI Projects Using Guidelines
  • Kaiser Permanente Metro L.A.
  • ACCESS Kaiser, Scripps
  • U.C.S.D. Healthcare
  • HealthCare Partners Medical Group
  • SCAN HealthPlan

44
Establishing Partnerships Replication Manual
Based on Alzheimers Association Kaiser
Permanent Metropolitan Los Angeles Dementia Care
Project www.alz.org/california southland Click
on Professional Training then scroll down to
Replication Manual
45
Got Guideline?
2008 California Guideline for Alzheimers Disease
Management Available at www.caalz.org or
contact Amy.Landers_at_alz.org 323-930-6289
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