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guidelines for Alzheimer's disease management

Assessment: 1) conduct & document an assessment of: a) basic & instrumental activities of daily living (ADL) b) cognitive status 1] mini mental status examination (MMSE); Montreal cognitive assessment 2] neuropsychologic battery for dementia evaluation c) other medical conditions d) behavioral problems e) psychotic symptoms f) depression (see screening for depression, Geriatric depression scal) 2) reassessment should occur every 6 months, or more frequently if indicated 3) identify the primary caregiver & assess adequacy of family & other support systems 4) assess the patient's decision-making capacity & whether a surrogate has been identified 5) assess the patient's & family's culture, values, primary language & decision-making process [1] Management: 1) develop & implement an ongoing treatment plan with defined goals; include a) appropriate use of pharmaceutical agents (see pharmaceutical agents for treatment of AD) b) referral to appropriate structured activities - exercise improves outcomes (see exercise & Alzheimer's disease) - recreation & adult day care services c) appropriate treatment of medical conditions d) Mediterranean diet reduces mortality & may help maintain global cognitive function [4] 2) treat behavioral problems & mood disorders using: a) non pharmacologic approaches 1] environmental modification - music therapy may be of benefit [14] 2] task simplification 3] appropriate services b) referral to social services or support organizations for patients who wander - Alzheimer's Association Safe Return Program c) medications if clinically indicated [1] 3) tailored lighting can help improve sleep & mood [12] 4) adequate sleep may preserve cognition in preclinical & early symptomatic AD [13] 5) no benefit of cognitive training in patients with mild-moderate AD or vascular dementia [9] 6) a single trial of cognitive rehabilitation shows promise [9] 7) in-home occupational therapy does not slow functional decline [11] 9) see early intervention for Alzheimer's disease 10) see pharmaceutical agents for treatment of AD 11) see drugs to avoid in patients with dementia Patient & Caregiver education & support:* 1) caregiver support may delay institutionalization of AD patients (1.5 years) without increasing caregiver burden [7,8] 2) discuss the diagnosis & progression of AD with the patient & the family in a manner consistent with their values, preferences & the patient's abilities 3) refer to support organizations for educational materials on: a) community resources b) support groups c) legal & financial issues d) respite care e) future care needs & options 4) support organizations include: a) Alzheimer's Association b) Caregiver Resource Centers c) local social service department 5) discuss the patient's need to make advance directives & to identify surrogates for medical & legal decision making Reporting requirements: 1) driving: report the diagnosis of Alzheimer's disease to the health department in accordance with California State Law (sections 2500 & 2572 of title 17, California Code of Regulations) 2) abuse: monitor evidence of abuse & report all instance of abuse to Adult Protective Services or police department, as required by law Clinical trials: - Ornish Intensive Lifestyle changes improved cognition in patients with mild cognitive impairment or early dementia [15]

Related

Alzheimer's Association Caregiver Resource Center dementia & driving drugs to avoid in patients with dementia exercise & Alzheimer's disease investigational therapies for treatment of Alzheimer's disease pharmaceutical agents for treatment of Alzheimer's disease (Alzheimer's agent) prevention of Alzheimer's disease/dementia

Specific

early intervention for Alzheimer's disease

References

  1. Cummings JL, Frank JC, Cherry D, Kohatsu ND, Kemp B, Hewett L, Mittman B. Guidelines for managing Alzheimer's disease: part I. Assessment. Am Fam Physician. 2002 Jun 1;65(11):2263-72. Review. PMID: 12074525 http://www.aafp.org/afp/20020601/contents.html
  2. Journal Watch 23(22):176-77, 2003 Teri L et al, JAMA 290:2015, 2003 PMID: 14559955
  3. Vickrey BG et al, The effect of a disease management intervention on quality and outcomes of dementia care: A randomized, controlled trial. Ann Intern Med 2006, 145:713 PMID: 17116916 - Belle SH et al, Enhancing the quality of life of dementia caregivers from different ethnic or racial groups: A randomized, controlled trial. Ann Intern Med 2006, 145:727 PMID: 17116917 - Covinsky KE & Johnsron CB Envisioning better approaches for dementia care. Ann Intern Med 2006, 145:780 PMID: 17116923
  4. Scarmeas N et al, Mediterranean diet and Alzheimer's disease mortality. Neurology 2007, 69:1084 PMID: 17846408 - Galvin JE Pass the grain; spare the brain. Neurology 2007, 69:1072 PMID: 17846407 - Scarmeas N et al. Physical activity, diet, and risk of Alzheimer disease. JAMA 2009 Aug 12; 302:627. PMID: 19671904 - Feart C et al. Adherence to a Mediterranean diet, cognitive decline, and risk of dementia. JAMA 2009 Aug 12; 302:638. PMID: 19671905 - Knopman DS. Mediterranean diet and late-life cognitive impairment: A taste of benefit. JAMA 2009 Aug 12; 302:686. PMID: 19671912
  5. APA Work Group on Alzheimer's Disease and other Dementias, Rabins PV, Blacker D, Rovner BW et al American Psychiatric Association practice guideline for the treatment of patients with Alzheimer's disease and other dementias. Second edition. Am J Psychiatry. 2007 Dec;164(12 Suppl):5-56. PMID: 18340692
  6. Olazaran J, Reisberg B, Clare L et al Nonpharmacological therapies in Alzheimer's disease: a systematic review of efficacy. Dement Geriatr Cogn Disord. 2010;30(2):161-78. Review. PMID: 20838046
  7. Geriatric Review Syllabus, 9th edition (GRS9) Medinal-Walpole A, Pacala JT, Porter JF (eds) American Geriatrics Society, 2016
  8. Mittelman MS, Haley WE, Clay OJ, Roth DL. Improving caregiver well-being delays nursing home placement of patients with Alzheimer disease. Neurology. 2006 Nov 14;67(9):1592-9. PMID: 17101889
  9. Bahar-Fuchs A, Clare L, Woods B. Cognitive training and cognitive rehabilitation for persons with mild to moderate dementia of the Alzheimer's or vascular type: a review. Alzheimers Res Ther. 2013 Aug 7;5(4):35. Review. PMID: 23924584 Free PMC Article - Bahar-Fuchs A, Clare L, Woods B. Cognitive training and cognitive rehabilitation for mild to moderate Alzheimer's disease and vascular dementia. Cochrane Database Syst Rev. 2013 Jun 5;(6):CD003260. Review. PMID: 23740535
  10. McLaren AN, Lamantia MA, Callahan CM. Systematic review of non-pharmacologic interventions to delay functional decline in community-dwelling patients with dementia. Aging Ment Health. 2013;17(6):655-66. Review. PMID: 23611141 Free PMC Article
  11. Callahan CM, Boustani MA, Schmid AA et al Targeting Functional Decline in Alzheimer Disease: A Randomized Trial. Ann Intern Med. 2016. Nov 22 PMID: 27893087 http://annals.org/aim/article/2588175/targeting-functional-decline-alzheimer-disease-randomized-trial
  12. Monaco K. Tailored Lighting Improves Alzheimer's Patients Sleep, Mood - Exposure to specific light helped regulate circadian rhythms. MedPage Today. July 25, 2018 https://www.medpagetoday.com/meetingcoverage/aaic/74218 - Figueiro M, et al Tailored lighting intervention to improve sleep, mood and behavior in Alzheimer's Disease patients. Alzheimer's Association International Conference (AAIC) 2018; Abstract #O3-05-02.
  13. Lucey BP, Wisch J, Boerwinkle AH et al Sleep and longitudinal cognitive performance in preclinical and early symptomatic Alzheimer's disease. Brain, Volume 144, Issue 9, September 2021, Pages 2852-2862 PMID: 34668959 PMCID: PMC8536939 (available on 2022-10-20) https://academic.oup.com/brain/article-abstract/144/9/2852/6401973
  14. Clements-Cortes A, Bartel L Sound Stimulation in Patients With Alzheimer Disease Annals of Long-Term Care. 2015 May https://www.hmpgloballearningnetwork.com/site/altc/articles/sound-stimulation-patients-alzheimers-disease
  15. George J Alzheimer's Slowed by Intensive Lifestyle Changes Small trial led by Dean Ornish, MD, shows cognitive improvement. MedPage Today June 11, 2024 https://www.medpagetoday.com/neurology/alzheimersdisease/110596 - Ornish D, Madison C, Kivipelto M et al. Effects of intensive lifestyle changes on the progression of mild cognitive impairment or early dementia due to Alzheimer's disease: a randomized, controlled clinical trial. Alzheimers Res Ther. 2024. Jun 7;16(1):122. PMID: 38849944 PMCID: PMC11157928 Free PMC article. Clinical Trial.
  16. Alzheimer's Association http://www.alzoc.org - Caregiver Resource Centers http://www.caregiver.org