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Patient Identification and Initial Strategies

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Title: Patient Identification and Initial Strategies


1
  • Patient Identification and Initial Strategies

2
Alzheimers Disease (AD) More Than Just Memory
Loss
  • AD is a progressive, degenerative disease
    involving
  • Loss of memory and other cognitive functions
  • Decline in ability to perform activities of
    daily living
  • Changes in personality and behavior
  • Increases in resource utilization
  • Eventual nursing home placement

3
Alzheimers Disease Overview
  • Progressive, degenerative brain disease
    characterized by an increasing loss of memory
    other cognitive functions
  • Characterized by changes in activities of daily
    living (ADL), behavior personality, cognition
    including judgment ABCs
  • Most common cause of dementia among people aged
    65 or over

4
Current Prevalence of AD
  • AD is the fourth leading cause of death due to
    disease for people gt 65 years of age in the
    United States1
  • Approximately 4 million people in the United
    States have AD2

1. Murphy SL. Natl Vital Stat Rep.
2000481-106. 2. Evans DA et al. Milbank
Quarterly. 199068267-289.
5
AD Is the Most Prevalent Type of Irreversible
Dementia
VaD, vascular dementia DLB, dementia with Lewy
bodies FTD, frontotemporal dementia. reflects
difficulties diagnosing/reporting dementias
only estimations of prevalencecan be made.
100
80
60
Irreversible dementias ()
40
20
0
AD
VaD
DLB
FTD
Other
Guttman R et al. Arch Fam Med. 19998347-353. McK
eith IG et al. Neurology. 1996471113-1124. Cherr
ier MM et al. J Am Geriatr Soc. 199745579-583.
6
Mortality Due to AD Impact of Age
1,000
10
Rate per 100,000 population
100
1
0.1
0.01
Under45
4554
5564
6574
7584
85
Age (years)
Reprinted with permission from Hoyert DL et al.
Natl Vital Stat Rep. 1999471-104.
7
Cost of AD in the US
  • Annual treatment costs 100 billion
  • 18,408/patient per year for mild AD
  • 30,096/patient per year for moderate AD
  • 36,132/patient per year for severe AD

Leon J et al. Health Aff (Millwood).
199817206-216.
8
Does Treatment Affect the Cost of AD?
  • Savings are small for mild and very severe AD
  • Prevention of even a small decline in cognition
    for patients with moderate AD would save
    3,700 per patient annually
  • Relatively small improvements in patients with
    moderate AD would save 7,100 per patient
    annually

Ernst RL et al. Arch Neurol. 199754687-693.
9
Who Are the Caregivers?
  • The overwhelming majority of patients live at
    home and are cared for by family and friends
  • 77 are women
  • 73 are over 50 years of age
  • 33 are the sole providers
  • 45 are children of the patient
  • 49 are spouses
  • Remainder are close family members or friends

Consumer Health Sciences, LLC. Princeton, NJ
December 1999.
10
Caregiver Burden
  • Caregivers spend from 40100 hours per week with
    the patient
  • 90 are affected emotionally (frustrated,
    drained)
  • 75 report feeling depressed 66 have
    significant depression
  • Half say they do not have time for themselves and
    that the stress affects family relations
  • Many experience a significant loss of income

Coping. Available at http//www.alzheimers.com.
Accessed September 2000.
11
Factors That Create Breaking Pointfor
Caregiver
  • Amount of time spent caring for the patient
  • Loss of identity
  • Patient misidentifications and clinical
    fluctuations
  • Nocturnal deterioration of patient

Annerstedt L et al. Scand J Public Health.
20002823-31.
12
Neuropathological ChangesCharacteristic of AD
AD
Normal
NFT
AP
AP amyloid plaques
NFT neurofibrillary tangles
Courtesy of George Grossberg M.D. St. Louis
University
13
Key Risk Factors for AD
  • Primary risk factors
  • Age
  • Family history
  • Genetic marker such as APOE-4, trisomy 21,
    mutations in presenilin 1,2
  • Cardiovascular risk factors e.g.
    hyperlipidemia/hypertension (the role of statins
    and omega 3 fatty acids)
  • Possible risk factors
  • Head trauma
  • Low level of education
  • Depression
  • Increased zinc?
  • Increased homocysteine (the role of B-vitamins,
    e.g. Folic acid)

14
AD Is Often Misdiagnosed
  • Patient initially diagnosed with AD

Patients first diagnosis other than AD
35
14
14
No 72
9
Yes 28
7
21
Dementia (not AD)
Stroke
Depression
No diagnosis
Normal aging
Other
Source Consumer Health Sciences, LLC.
Alzheimers Caregiver Project. 1999.
15
Treatment Alternatives
  • Symptoms
  • Non-pharmacological
  • Neuroleptics
  • Anti-depressants
  • Anti-convulsants
  • ChEIs
  • NMDA receptor antagonists

16
AD Treatment Algorithm
  • Stage of AD Mild Moderate
    Severe
  • Treatment
  • Options ChEI
    ChEI/ Memantine
    Memantine
  • (alone or in (alone
    or in
  • combination)
    combination)
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