ACT on Alzheimer’sDisease 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

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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 non-pharmacological 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