Download Document

2008
California Guideline
for Alzheimer’s
Disease
Management
Debra Cherry, PhD
Alzheimer’s Association,
California Southland
Brad Williams, PharmD, CGP
USC School of Pharmacy
Objectives
• Describe the process utilized to update the
California Guideline for AD Management
• Review the Guideline’s recommendations
• Apply the recommendations to patients and
caregivers
• Use the Guideline to implement a quality
improvement project
History of California AD
Management Guideline
•
•
•
•
1995: California Workgroup on Guideline for
Alzheimer’s Disease Management formed
1998 Publication of the first Guideline
2002 Guideline updated & published in The
American Family Physician
2008 Third update completed.
Composition of the California
Workgroup
Representatives from throughout the State:
• Healthcare providers
• Consumers
• Academicians
• Professional and volunteer organizations
Purpose of the Guideline
Represents core care recommendations
for AD management which are:
• Based on scientific evidence
• Supplemented by expert consensus
• General guide to post-diagnostic
care
• Intended for Primary Care
Practitioners including:
– Physicians
•Also defines a role for:
– Nurse Practitioners/Nurses
–Social Workers
– Physician Assistants
–Care Managers
Mrs. R. L.
Mrs. R. L. is a retired librarian who visits her physician
for a routine follow-up for her osteoarthritis, GERD,
and glaucoma. She has enjoyed her 3 years of
retirement, but reports that recently her husband has
been worried about her memory. Mrs. L. states that she
had started writing reminder notes, “which don’t
always help.” She admits to reading less than she used
to; she also drives less because “traffic is such a
problem.”
Mrs. R. L.
Mr. L. reports that his wife often returns from grocery
shopping having forgotten to pick up several things that she
intended to buy. At other times she will wander through the
house, looking in drawers or closets for items that she had
put away for safe-keeping. Although they used to go out to
dinner at least once a week, they now go much less
frequently because Mrs. L. states that “I just never know
what to order, and it’s not as much fun as it used to be.”
Dementia Warning Signs
Task
Example
Memory decline
Forgetfulness
Difficulty performing familiar
tasks
Bill paying, shopping
Disorientation
Getting lost in familiar places
Impaired judgment
Inviting strangers into the home
Impaired abstract thinking,
problem-solving
Driving skills
Dementia Warning Signs
Task
Example
Misplacing things
Losing valuable items in the home
Mood or behavior
change
New-onset irritability, unusual habits or
activities
Personality change
Withdrawn, increased socialization
Problems with language
Word finding difficulties
What signs and symptoms are present
in Mrs. R. L. that suggest that she may
have a dementia?
Guideline for AD Management
•
•
•
•
Assessment
Treatment
Patient & Family Education & Support
Legal Considerations
Assessment
•
•
•
•
•
•
•
Cognitive status
Daily function
Concurrent medical conditions
Medications
Behavior symptoms and mood
Living arrangements
Support system
Assessing Cognition
Test
Items/Score
Domains
Folstein Mini-Mental Status
Exam
19 items
30 points
Multi-dimensional
Mini-Cog
2 items
5 points
3-item recall
Clock drawing
Blessed OrientationConcentration-Memory
6 items
28 points
Orientation, concentration,
recall
Cognitive Assessment
Screening Instrument
25 items
100 points
Multi-dimensional
Assessment: Function
Activities of Daily Living (ADL)
•
•
•
•
Self-feeding
Dressing
Ambulation
Toileting
• Bathing
• Transfer from bed to
toilet
• Continence
• Grooming
• Communication
Assessment: Function
Instrumental ADL (IADL)
•
•
•
•
•
•
Writing
Reading
Cooking
Cleaning
Shopping
Doing laundry
•
•
•
•
•
Climbing stairs
Using telephone
Managing medication
Managing money
Ability to perform outside
work
• Ability to travel (public
transportation)
Assessment: Concurrent
Conditions
• Chronic disease
– Ability to manage
• Acute Conditions
– Delirium
– Infection/UTI/Influenza
Assessment: Medications &
Cognition
•
•
•
•
•
•
Anticholinergics
Benzodiazepines
Sleep aids
Antipsychotics
Narcotics
Muscle relaxants
•
•
•
•
•
•
NSAIDs
Anti-arrhythmics
Antihypertensives
Cimetidine
Corticosteroids
Hypoglycemic agents
Assessment: Behavior & Mood
• Agitation
– Restlessness
– Irritability
– Aggression
• Psychosis
– Delusions
– Paranoia
– Hallucinations
• Depression
– Withdrawal
– Sleep disturbances
– Appetite changes
• Apathy
– Loss if interest
Assessment: Living Arrangements
• Declining ability for self-care
– Patient autonomy vs. need for care
• Safety issues
– Rugs, appliances
– Driving
• Abuse and neglect
– Dependence
– Caregiver stress
Assessment: Support System
• Family’s ability to care for patient
• Community supports
– Alzheimer’s Association
– Caregiver Resource Center
– Religious or other groups
• Community resources – day care, in-home care
• Health care resources
• Advance directives
Mrs. R has come to the USC Alzheimer’s
Disease Center and been thoroughly assessed.
She has been determined to have a diagnosis
of Alzheimer’s disease. What next?
Treatment: Develop a Treatment Plan
•
•
•
•
•
Improve cognitive function
Increase level of function
Delay disease progression
Manage behavior disturbances
Ease caregiver burden
Treatment: Improve Cognitive
Function
• Cholinergic manipulation
– Cholinesterase inhibitors
• All agents block acetylcholinesterase activity
• Rivastigmine also blocks butyrylcholinesterase
• Galantamine stimulates cholinergic receptors
• NMDA antagonist
– Reduces glutamate activity
– Regulates calcium entry into cells
Donepezil (Aricept®)
• Approved for all
stages of AD
• Availability
– 5 & 10 mg tablets
– 5 & 10 mg ODT
– 1 mg/mL solution
• Dosing
– 5 mg is therapeutic
– May increase to 10 mg
after 4-6 weeks
• May be given without
regard to food
• CYP1A2 substrate
Galantamine (Razadyne®)
• Approved for mild,
moderate AD
• Availability
– 4, 8, 12 mg tablets
– 8, 16, 24 mg ER capsules
– 4 mg/mL solution
• Will be first ChEI to go
generic
• Dosing
– Initial daily dose of 8 mg is not
therapeutic
– Dose escalation is 8 mg/day in
4-6 week intervals
– Maximum is 24 mg/day
• Give with meals
• Elimination
– 50% renal
– 2D6/3A4 substrate
Rivastigmine (Exelon®)
• Approved for mild,
moderate AD
• Availability
– 1.5, 3, 4.5, 6 mg
capsules
– 4.6, 9.5 mg/24 hr
transdermal patch
– 2 mg/mL solution
• Dosing
– Initial dose of 1.5 mg twice daily is
not therapeutic
– Dose escalation is 1.5 mg twice daily
in 4-6 week intervals
– Maximum is 12 mg/day
– Initial patch dose of 4.6 mg/24 hours
is therapeutic
• Must give with meals
• Renal excretion
Principles for ChEI Use
• Initial treatment upon
diagnosis or 6-months
duration of AD
symptoms
• Evaluate for ADR
after 2-4 weeks
• Evaluate for
effectiveness every 6
months
– Switch if poor
tolerance, or continued
decline
• Discontinue prior to
surgery
Counseling Points
• Effects on cognition are very mild
– May stabilize or slow decline for 6-12 months
• May improve independence, self-care
• Gastrointestinal effects are prominent
• May slow heart rate
The Evidence Suggests…
Conclusion Because of flawed methods and
small clinical benefits, the scientific basis
for recommendations of cholinesterase
inhibitors for the treatment of Alzheimer’s
disease is questionable.
-Kaduszkiewicz, et al., BMJ 2005;331:321-327
Memantine (Namenda®)
• Approved for use in
moderate, severe AD
– Monotherapy
– With ChEI
• Availability
– 5 & 10 mg tablets
– 10 mg/5 mL solution
• Dosing
– 5 mg/day for 1 week
– Increase by 5 mg/day in
weekly intervals to 10 mg
twice daily
– 10 mg/day maximum with
renal impairment
• May be taken without
regard to meals
• Renal elimination as
unchanged drug
Memantine Adverse Effects
• > 5% incidence in clinical trials
– Agitation (less than for placebo)
– Diarrhea
– Insomnia
• 5% incidence
– Dizziness
– Headache
– Hallucinations
Memantine
• Effects in moderate AD
– Slower decline in overall function and in loss of
activities of daily living
– No significant effect on cognition
• Systematic reviews have reported small to
no clinically relevant effect
TREATMENT
Recommendations (cont.)
•
•
Treat behavioral symptoms and mood disorders using:
– Non-pharmacologic approaches, such as environmental
modification, task simplification, appropriate activities, etc.
IF non-pharmacological approaches prove unsuccessful, THEN
use medications, targeted to specific behaviors, if clinically
indicated. Note that side effects may be serious and significant.
Treatment: Behavior Symptoms
• Most difficult for both patients and
caregivers
• Behavior symptoms contribute to:
–
–
–
–
Patient distress
Caregiver burnout
Excess disability
Institutionalization
Treatment: Increase level of function
and delay disease progression
•
•
•
•
Behavioral Interventions
Medications
Adult Day Services
Exercise and Recreation
Behavioral Symptoms as
AD Progresses
Prevalence (% of patients)
100
Agitation
80
60
Depression
Irritability
Wandering
Social
Withdrawal
40
Diurnal
Rhythm
Paranoia
Anxiety Mood
Change
0
–40
–30
Hallucinations
Socially Unacceptable
Delusions
20
Suicidal
Ideation
Aggression
Accusatory
Sexually Inappropriate
–20
–10
Months Before Diagnosis
Jost BC, Grossberg GT. J Am Geriatr Soc. 1996;44:1078-1081.
0
10
20
30
Months After Diagnosis
Mrs. R. L.
Some time has passed and Mr. L. is concerned about
changes in his wife’s behavior. She becomes
agitated, especially in the late afternoon and leaves
the house. She says she is going home and gets more
agitated when he reminds her that she is in her home.
Evaluating Behaviors
• Rapid onset requires search for medical
cause
– Pain, infection, adverse drug effect
• Identify problem
a. Behavior triggers
b. Specific Behaviors
c. Consequences
Common Causes of Behaviors
•
•
•
•
•
Health problems
Difficult tasks
Confusing environment
Communication breakdown
Patient’s perceptions of the situation
What may be triggering Mrs. L.’s
behavior?
What does this behavior mean to her?
How should these symptoms be
managed?
Behavior Management Principles
• Non-drug management generally provides better
results
• Assess likelihood that pharmacotherapy will be
beneficial
–
–
–
–
Target medication to specific behavior
Avoid caregiver interpretation of PRN orders
Consider the patient's health status
Consider drug pharmacokinetic and
pharmacodynamic properties
Mrs. R. L.
Mrs. R. L. has begun a daily exercise program
and late afternoon agitation is now less of an
issue. However, at night she awakens and
becomes agitated. She believes someone is
trying to break into the house. When her
husband tries to reassure her, she gets angry and
strikes out at him.
What non-drug strategies are appropriate to
manage Mrs. L.’s current behaviors?
Is drug therapy appropriate, and if so, how should
it be initiated?
PATIENT and FAMILY
EDUCATION & SUPPORT
Recommendations
•
Integrate medical care with education & support by
connecting patient & caregiver to support organizations
- Alzheimer’s Association
1-800-272-3900
www.alz.org
- Family Caregiver Alliance 1-800-445-8106
www.caregiver.org
- or your own social service department.
PATIENT and FAMILY
EDUCATION & SUPPORT
Early Stages
Pay particular attention to the special needs of earlystage patients, involving them in care planning,
heeding their opinions and wishes, and referring them
to community resources, including the Alzheimer’s
Association.
LEGAL CONSIDERATIONS
Recommendations
•
•
•
Include a discussion of the importance of basic
legal and financial planning as part of the
treatment plan as soon as possible after the
diagnosis of AD.
Monitor for evidence of and report all suspicions
of abuse as required by law.
Report the diagnosis of AD in accordance with
local laws.
Using the Guideline in a
Health Care Setting
Health care organizations
are challenged to care
for the growing number
of older adults with
chronic health conditions
How to use Guidelines for a QI
project:
•
•
•
•
Set quality goals derived from guideline
Train practitioners
Add case management
Evaluate
Implementation Support Tools
Provider Tool Kit
•
Medical Record Checklist
•
List of Reversible Medical Conditions
•
Signs/Symptoms of Elder Abuse
•
Mental Status Exam
•
Safe Return / ID Bracelet Program Application
•
Dementia and Driving Reporting Law
•
Prescription Pad
QI Projects Using Guidelines
• Kaiser Permanente – Metro L.A.
• ACCESS – Kaiser, Scripps &
U.C.S.D. Healthcare
• HealthCare Partners Medical Group
• SCAN HealthPlan
Establishing Partnerships
Replication Manual
Based on Alzheimer’s
Association – Kaiser
Permanent
Metropolitan Los
Angeles Dementia
Care Project
www.alz.org/california
southland Click on
Professional Training then
Replication Manual
Got Guideline?
2008 California Guideline for Alzheimer’s Disease
Management
Available at:
www.caalz.org
(you can put your own website information here)
or contact
[email protected]
323-930-6289
(you can put your own contact person here)