Title: Dementia Clinical Practice Guideline
1Dementia Clinical Practice Guideline
-
- For Medical Directors, Attending Physicians and
Advanced Practitioners
2Dementia
- - 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.
3Dementia
- 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
4Dementia
- Expectations of guideline implementation
- Identify dementia, new or progressive
- Assess for underlying cause
- Facilitate Environmental modifications dignity
and safety
5Dementia
- Expectations of guideline implementation
- Manage or minimize disability
- Prevent complications and decline
- Manage symptoms, consequences and complications
6Dementia
- 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.
7Dementia
- 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
8Applying the Care Process
- There are four steps to the care process
- Recognition
- Assessment (root cause analysis)
- Treatment
- Monitoring
9Recognition
- 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?
10Diagnoses 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
11Neurological Impairments or Behaviors That May
Suggest Underlying Dementia3
12Recognition
- 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
13Recognition-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
14Recognition
- Documentation
- Interdisciplinary team (IDT)
- Care decisions
- and planning
15Assessment
- 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)
16Assessment
- 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
17Elements 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
18Radiological 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)
19Purposes 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
20Assessment
- 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
21Diagnostic 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
22Assessment
- 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
23Assessment
- Step 6. Identify the patients strengths and
deficits. - Assess patients capabilities
- Describe behaviors by specific characteristics
- Manage other conditions
- Always review the patients medications
24Assessment
- 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
25Assessment
- 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
26Examples 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
27Treatment
- 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.
28Treatment
- Step 10. Optimize function and quality of life
and capitalize on remaining strengths. - Consider using complementary and alternative
therapies - Prevent excess disability
29Environmental 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
30Environmental 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
31Treatment
- 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
32Treatment
- 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
33Treatment
- Step 11. Address socially unacceptable or
disruptive behaviors - Management based on careful evaluation
- Define target symptoms
- Unless behavior a danger, use non-pharmacological
interventions
34Treatment
- 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
35A 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
36Treatment
- 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
37Treatment
- 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
38Treatment
- 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
39A 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
40Treatment
- 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
41Monitoring
- 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
42Monitoring
- 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
43Summary
- 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