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Dementia Clinical Practice Guideline

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Title: 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
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