Dementia Clinical Practice Guideline

1
Dementia Clinical Practice Guideline

• For Medical Directors, Attending Physicians and
  Advanced Practitioners

2
Dementia

• - a syndrome characterized by progressive decline
  in multiple areas of cognitive function, which
  eventually produces significant deficits in
  ability self-care and social and occupational
  performance.

3
Dementia

• number of persons in the industrialized world
  who are affected by dementia will increase from
  13.5 million persons in the year 2000, to 36.7
  million in 20501
• Care giving challenges remain

4
Dementia

• Expectations of guideline implementation
• Identify dementia, new or progressive
• Assess for underlying cause
• Facilitate Environmental modifications dignity
  and safety

5
Dementia

• Expectations of guideline implementation
• Manage or minimize disability
• Prevent complications and decline
• Manage symptoms, consequences and complications

6
Dementia

• Expectations of guideline implementation
• Respond to changing needs of patient
• Patient outcomes should include
• Maintained or improved function and quality of
  life prior to the end of life.
• Reduced complications and negative consequences
  of the condition or its management.
• Improved resource utilization.

7
Dementia

• Practitioner Responsibilities
• Accurately assess patients condition and
  prognosis
• Identify causes and factors contributing to
  dementia
• Recommend approaches
• Assists in defining benefits and risks medical
  interventions

8
Applying the Care Process

• There are four steps to the care process
• Recognition
• Assessment (root cause analysis)
• Treatment
• Monitoring

9
Recognition

• Step 1. Does the patient have a history of
  dementia?
• Review of records transfer summary from all
  source (hospital, home, office, another NH, prior
  records)
• History of dementia
• Current symptoms of dementia?

10
Diagnoses That Suggest the Presence of Dementia

• Alzheimers disease
• Drug, alcohol, or anoxic encephalopathy or
  dementia
• Huntington's disease
• Lewy body disease
• Multi-infarct (vascular) dementia

• Normal-pressure hydrocephalus
• Organic brain syndrome
• Parkinson's disease
• Pick's disease
• Progressive supranuclear palsy
• Pseudodementia
• Senile memory loss

11
Neurological Impairments or Behaviors That May
Suggest Underlying Dementia3
12
Recognition

• Step 2. Does the patient have current signs and
  symptoms of dementia?
• Observe patients current physical, functional,
  and psychosocial status
• Assess cognitive status
• Function may be assessed with one of several
  instruments

13
Recognition-Step 2-Continued

• Is the patients at risk for the onset of or
  progression of dementia?
• Certain conditions may predispose patients to
  dementia
• Identify patients who are at risk for progression
  of dementia as a result of
• acute conditions
• medication use

14
Recognition

• Documentation
• Interdisciplinary team (IDT)
• Care decisions
• and planning

15
Assessment

• Period immediately after admission is crucial
• Patients with dementia are often admitted without
  adequate documentation
• Immediate assessment is necessary to ensure
  prompt identification and appropriate plan of
  care (POC)

16
Assessment

• Step 3. Determine if further work-up is necessary
  and appropriate.
• Is a work-up medically appropriate?
• If so, consult with patient and responsible party
  and IDT to determine appropriateness
• Document medical necessity of work-up

17
Elements of Diagnostic Work-up for Patients With
Dementia

• Complete blood count
• Human immunodeficiency virus (HIV) test (if
  atypical sexual history)
• Metabolic screen
• Serum vitamin B12 level
• Syphilis serology
• Thyroid function test

18
Radiological Work-Up

• Computerized tomography or magnetic resonance
  imaging scan of the head
• Evaluate need for CT or MRI based on presence of
  atypical neurological signs and symptoms and time
  of onset (rapid vs. slow)

19
Purposes of a Medical Assessment in Patients With
Dementia

• Defines the causes or contributing medical
  conditions or medications to the dementia, if
  possible
• Identify the relationship between the patients
  medical conditions and his or her functional
  impairment and disabilities
• Identify conditions that can be reversed or
  improved
• Define coexisting conditions and impairments and
  plan management
• Help to identify and address risk factors for
  dementia

20
Assessment

• Step 4. Verify that the patient meets the
  criteria for a diagnosis of dementia.
• Impaired mental status
• Impaired function
• Consider other causes for the patients symptoms
  before making conclusions

21
Diagnostic Criteria for Dementia

• A. The development of multiple cognitive
  deficits manifested by both
• Memory impairment (impaired ability to learn new
  information or to recall previously learned
  information)
• One or more of the following cognitive
  disturbances
• a) Aphasia (language disturbance)
• b) Apraxia (impaired ability to carry out motor
  activities despite intact motor function)
• c) Agnosia (failure to recognize or identify
  objects despite intact sensory function)
• d) Disturbance in executive functioning (i.e.,
  planning, organizing, sequencing, abstracting)
• B. The cognitive deficits in Criteria A1 and
  A2 each cause significant impairment in social or
  occupational functioning and represent a
  significant decline from a previous level of
  functioning

22
Assessment

• Step 5. Identify the cause(s) of dementia.
• Dementia always has a cause
• A specific cause is not readily detectable in all
  cases
• Determining cause may help prevent further
  deterioration

23
Assessment

• Step 6. Identify the patients strengths and
  deficits.
• Assess patients capabilities
• Describe behaviors by specific characteristics
• Manage other conditions
• Always review the patients medications

24
Assessment

• Step 7. Define the significance of the patients
  symptoms, impairments, and deficits.
• Often associated with impairments in multiple
  domains
• These deficits are problematic
• Determine significance of impairments to the
  patient

25
Assessment

• Step 8. Identify triggers for disruptive
  behavior.
• Behavioral symptoms often triggered
• IDT should assess if environment is affecting
  behavior
• Make no assumptions until alternate factors have
  been considered

26
Examples of Factors That May Be Relevant to
Disruptive Behaviors

• What was the patient doing when the behavior
  occurred?
• What made the patients behavior better or worse?
• What was happening just before the behavior
  occurred?
• Was there a change in the environment just before
  the behavior occurred?
• Who was near the individual at the time of the
  incident?
• What was the impact of the behavior on other
  people?
• Did a specific circumstance cause recurrence of
  the behavior

27
Treatment

• Step 9. Prepare an interdisciplinary care plan.
• Define treatment goals that are appropriate for
  the individual patient, taking into account the
  wishes of the patient and/or family
• Incorporate definite, measurable objectives
  derived from those treatment goals and
• Allow for modification as the patients needs
  change.

28
Treatment

• Step 10. Optimize function and quality of life
  and capitalize on remaining strengths.
• Consider using complementary and alternative
  therapies
• Prevent excess disability

29
Environmental Aspects that Can Be Assessed and
Adapted to Optimize Quality of Life for Patients
with Dementia

• Personalize the environment to provide a more
  home-like atmosphere
• Minimize noise
• Provide adequate lighting
• Provide a variety of daily activities (physical,
  spiritual, and cognitive)
• Provide family support and education

30
Environmental Aspects that Can Be Assessed and
Adapted to Optimize Quality of Life for Patients
with Dementia continued

• Provide comfortable seating and mobility devices
• Provide way-finding cues
• Provide relevant staff education and training
• Provide space for both privacy and socialization
• Provide a safe and secure environment for
  patients

31
Treatment

• Step 10 continued
• Consider medical interventions if appropriate
• Medications to prevent worsening of multi-infarct
  dementia
• Cholinesterase inhibitors to reduce the rate of
  decline
• Memantine for moderate to sever Alzheimers
  dementia
• Behavioral symptoms related to an acute condition
  may benefit from appropriate medications

32
Treatment

• Step 10 continued
• Before initiating drugs, ensure patient is
  appropriately assessed
• Discuss the goals of therapy with the patient and
  responsible party (RP)
• Set realistic expectations
• Monitor closely for ADRs
• Observe for symptom progression
• Periodically assess the patients response to
  treatment

33
Treatment

• Step 11. Address socially unacceptable or
  disruptive behaviors
• Management based on careful evaluation
• Define target symptoms
• Unless behavior a danger, use non-pharmacological
  interventions

34
Treatment

• Step 12. Manage functional deficits
• Caregivers need to be trained to
• help the patient to compensate
• maximize unimpaired function
• maintain patients dignity
• assist patients with ADLs
• perform restorative nursing

35
A Word About Rehabilitation

• Practitioners should help to identify patients
  who are likely to benefit
• Rehab. and nursing staff should be familiar with
  the impact of restorative and rehabilitative
  efforts on patients with dementia
• Formal rehabilitation may not be indicated for
  patients with moderate to severe dementia

36
Treatment

• Step 13. Address pertinent psychosocial and
  family issues
• May include personal and family relationships
• Work closely with families/RP to help them
  understand the patient's situation
• Explain to family members/RP how management
  options chosen

37
Treatment

• Step 14. Address ethical issues
• Ethical issues relevant to patients with dementia
  include
• Defining decision-making capacity and identifying
  situations that require substitute
  decision-making,
• Addressing situations related to everyday life
  (e.g., patient preferences, and socially
  questionable behaviors), and
• Discussing possible limitations on medical
  interventions such as hospitalization and CPR

38
Treatment

• Step 14 Continued
• Obtain and review advance directives
• Decisions related to (r/t) scope and duration of
  treatment consistent with directives
• Document these decisions in the medical record

39
A Word About Artificial Nutrition and Hydration

• It is a common ethical issue in patients with
  dementia
• Opinions vary as whether an extraordinary measure
  or routine care
• Substantial decline may indicate that patient is
  not likely to benefit
• Short-term use of enteral nutrition may help to
  show if artificial nutrition and hydration will
  prevent further decline

40
Treatment

• Step 15. Manage risks and complications related
  to dementia, other conditions, or treatments.
• Complication r/t their disease, e.g., impaired
  mobility, urinary incontinence
• At risk for indirect complications, e.g., falls,
  ADRs, aspiration
• Complications of medical treatment for behavior

41
Monitoring

• Step 16. Monitor the patients condition and
  adjust management as appropriate.
• Monitor the patients progress periodically
• Use same methods and criteria used in initial
  assessment
• Nursing staff should report significant changes
  in patients condition promptly to practitioner
• Generally, dementia will either stabilize or
  progress

42
Monitoring

• Step 16 continued
• The practitioner should
• continue pertinent interventions if patient
  remains stable
• assess patient if he/she declines
• document functional decline that appears to be
  medically unavoidable
• review the staging of a patient whose behavior or
  function changes from baseline
• If warranted, periodically attempt to taper one
  or more psychoactive medications

43
Summary

• Dementia causes a range of cognitive, mood,
  behavioral, and functional impairments
• Implementing the steps in the guideline can
• improve ability to identify patients at risk for
  new or progressive dementia
• manage dementia symptoms and respond
  appropriately to the changing needs of patients
  with dementia
• These process improvements should help to
• optimize function and quality of life
• minimize preventable complications
• minimize negative consequences of the condition