ACT on Alzheimers Disease Curriculum Module VIII Quality

ACT on Alzheimer’s Disease Curriculum Module VIII: Quality Interventions

Quality Interventions • These slides are based on the Module VIII: Quality Interventions text • Please refer to the text for all citations, references and acknowledgments 2

Module VIII: Learning Objectives Upon completion of this module the student should: • Have a basic knowledge of pharmacological and non-pharmacological interventions. • Identify a variety of interventions that can be used with a person who has a diagnosis of Alzheimer’s disease. • Gain insight on how physical, cognitive, and social activities along with diet can be used as positive interventions.

Intervention Goals

Intervention Overview • The treatment for Alzheimer’s disease is symptomatic as there is no cure • All available FDA-approved drugs for Alzheimer’s disease target cognitive and behavioral symptoms • There are many interventions that can improve the quality of and extend life

Intervention Overview • Available interventions for Alzheimer’s disease can be broken down into two categories: – Non-pharmacological interventions – Pharmacological interventions • An intervention checklist has been developed to guide providers on the available nonpharmacological and pharmacological interventions

Non-Pharmacological Interventions

Non-Pharmacological Interventions • There a number of non-pharmacological interventions that have been shown to be effective at improving the quality of life of individuals with Alzheimer’s disease – Counseling, education, support and planning – Stimulation / activity / maximizing function – Safety – Advance care planning – Referral to neurologist or geriatrician for diagnostic uncertainty or behavioral management

Counseling, Education, Support and Planning • Counseling, education, support and planning are critical for sustained management of dementia • Research and clinical practice indicate that counseling, education and support provides the following benefits for care: – Reduces behavioral symptoms – Promotes compliance with treatment plans – Provides a support system – Improves mood – Delays institutionalization

Counseling, Education, Support and Planning • To ensure proper attention to counseling and education, the primary healthcare provider should: – Discuss diagnosis and treatment with patient and family – Encourage individual and caregivers to participate in educational and support groups – Involve individual in care planning decisions – Address caregiver support on an ongoing basis – Connect individual to community resources

Counseling, Education, Support and Planning • A community-based organization can supplement the interventions introduced by the primary care provider • Community-based organizations can provide: counseling, education, support, planning, care management/coordination, physical activity, cognitive stimulation, home and safety services, legal/financial services, advanced care planning and medication management • Connecting to adult day programs is an important service of community organizations

Stimulation/Activity/ Maximize Function • Multiple lifestyle changes may help optimize function in individuals with Alzheimer’s disease – Physical activity – Cognitive activity – Social activity – Healthy diet

Counseling Regarding Safety • There are many counseling options that can improve safety for individuals with Alzheimer’s disease – Legal/financial planning – Driving – Home safety – Medication management – Behavioral issues

Advance Care Planning • It is important for primary care providers to discuss end-of-life treatment goals and options for individuals with dementia and their families earlier in the disease process • End-of-life treatment goals should consider pain management and the goals of individuals via advanced directive

Pharmacological Interventions

Pharmacological Interventions • There a number of categories of pharmacological interventions – Medications for cognitive symptoms – Medications for behavioral and neuropsychiatric symptoms – Contraindicated medications – Vitamins and supplements

Medications for Cognitive Symptoms • Cholinesterase inhibitors are the cornerstone of pharmacotherapy for Alzheimer’s disease • To date, research on these medications is mixed • FDA approved cholinesterase inhibitors include: – Donepezil (Aricept), a selective acetylcholinesterase – Rivastigmine (Exelon), inhibits butyrylcholinesterase – Galantamine, further moderates nicontinic receptor

Medications for Behavioral and Neuropsychiatric Symptoms • 61 -92% of individuals with Alzheimer’s disease will experience neuropsychiatric disturbances which include: irritability, agitation, disinhibition, wandering, delusions, hallucinations, anxiety, depression and sleep disruption

Medications for Behavioral and Neuropsychiatric Symptoms • Approximately 30% of individuals with Alzheimer’s disease suffer from depression. • Treatment with the following is indicated: – Selective serotonin reuptake inhibitor (SSRI) – Serotonin norepinephrine reuptake inhibitor (SNRI)

Medications for Behavioral and Neuropsychiatric Symptoms • During the moderate and late stage of the disease, individuals may have increased symptoms of irritability, agitation and psychosis. There may be modest benefits to an antidepressant prior to starting a neuroleptic • Common neuroleptics include: – Quetiapine (Seroquel) – Risperidone (Risperdal) – Olanzapine (Zyprexa)

Medications for Behavioral and Neuropsychiatric Symptoms • Sleep disturbances occur in 46 -64% of individuals with dementia • Sleep disturbances lead to a wide variety of difficult conditions that can lead to earlier institutionalization • The decision to use a sleep aid is critical and can lead to improved quality of life for both individual and caregiver

Contraindicated Medications • Guidelines have been developed to inform the primary care provider about drugs that may negatively impact cognition or induce delirium • As a general rule, providers should avoid anticholinergics, benzodiazepines, hypnotics, and narcotics in geriatric populations • The Beers Criteria has been developed to guide pharmacological care in populations aged 65 and older

Vitamins and Supplements • There have been many studies that have examined the benefits of the following vitamins and supplements for individuals with Alzheimer’s disease – – – Vitamin E Gingko biloba Estrogen supplementation Omega 3 fatty acids Vitamin B • There is no evidence that vitamins or supplements can help in the treatment or prevention of Alzheimer’s disease

Interventions Summary • In 60 -80% of all Alzheimer’s disease cases, the interventions described in this module will be helpful • A provider may be faced with an atypical disease presentation in which case a referral should be made to a dementia specialist

Organizing Principle of Care • The primary care provider leads a team approach which depends on regular assessments of the individual’s cognitive, behavioral and functional status over time • The organizing principle of care originates with an initial assessment, a care plan and reassessment over time