Download Slides - ACT on Alzheimer`s

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 are 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 are 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