Dementia Clinical Practice Guideline

For Medical Directors, Attending Physicians and Advanced Practitioners

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.

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

Dementia• Expectations of guideline

implementation:– Identify dementia, new or progressive

– Assess for underlying cause

– Facilitate Environmental modifications – dignity and safety

Dementia• Expectations of guideline

implementation:– Manage or minimize disability

– Prevent complications and decline

– Manage symptoms, consequences and complications

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.

Dementia• Practitioner Responsibilities:

– Accurately assess patient’s condition and prognosis

– Identify causes and factors contributing to dementia

– Recommend approaches

– Assists in defining benefits and risks – medical interventions

Applying the Care Process

• There are four steps to the care process– Recognition

– Assessment (root cause analysis)

– Treatment

– Monitoring

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?

Diagnoses That Suggest the Presence of Dementia

• Alzheimer’s 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

Neurological Impairments or Behaviors That May Suggest Underlying Dementia3

Problem Behavioral Consequences

How Caregivers May Misinterpret These Disease Manifestations

Amnesia (loss of memory)

Repeats questions often, misplaces objects

“Frustrating”

“Paranoid”

Apraxia (loss of ability to coordinate learned

movements)

Cannot use utensils, dress, use toilet unassisted

“Won’t eat”“Uncooperative”“Incontinent”

Aphasia (inability to speak or understand)

Cannot follow directions or engage in conversation

“Uncooperative”

“Withdrawn”

Agnosia (inability to recognize what is seen)

Cannot recognize faces, familiar places, or objects

“Frightened, combative”

“Wandering”, “Stealing others’ belongings”

Recognition

• Step 2. Does the patient have current signs and symptoms of dementia?

– Observe patient’s current physical, functional, and psychosocial status

– Assess cognitive status– Function may be assessed with one of several

instruments

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

Recognition

Documentation

–Interdisciplinary team (IDT)

–Care decisions

and planning

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)

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

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

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)

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 patient’s 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

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 patient’s symptoms before making conclusions

Diagnostic Criteria for Dementia

A. The development of multiple cognitive deficits manifested by both1. Memory impairment (impaired ability to learn new information or to

recall previously learned information)2. 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

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

Assessment

• Step 6. Identify the patient’s strengths and deficits.

– Assess patient’s capabilities

– Describe behaviors by specific characteristics

– Manage other conditions

– Always review the patient’s medications

Assessment

• Step 7. Define the significance of the patient’s symptoms, impairments, and deficits. – Often associated with impairments in

multiple domains

– These deficits are problematic

– Determine significance of impairments to the patient

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

Examples of Factors That May Be

Relevant to Disruptive Behaviors • What was the patient doing when the behavior occurred?• What made the patient’s 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

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 patient’s needs change.

Treatment

• Step 10. Optimize function and quality of life and capitalize on remaining strengths.

– Consider using complementary and alternative therapies

– Prevent excess disability

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

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

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

Alzheimer’s dementia• Behavioral symptoms related to an acute

condition may benefit from appropriate medications

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 patient’s response to

treatment

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

Treatment

• Step 12. Manage functional deficits

– Caregivers need to be trained to:

• help the patient to compensate

• maximize unimpaired function

• maintain patient’s dignity

• assist patients with ADLs

• perform restorative nursing

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 patient’s with dementia

• Formal rehabilitation may not be indicated for patients with moderate to severe dementia

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

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

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

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

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

Monitoring

• Step 16. Monitor the patient’s condition and adjust management as appropriate.– Monitor the patient’s progress periodically– Use same methods and criteria used in initial

assessment – Nursing staff should report significant

changes in patient’s condition promptly to practitioner

– Generally, dementia will either stabilize or progress

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

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