severe alzheimer s disease in the institutional setting: treatment challenges, behavioral issues, and pharmacologic man

1. Severe Alzheimer�s Disease in the Institutional Setting:

4. Dementia Prevalence in Primaryand Long-Term Care Settings 75% of patients with moderate to severe dementia may go undiagnosed in the primary care setting Almost 50% of residents admitted to long-term care (LTC) facilities have some degree of dementia Up to three quarters of nursing home residents have dementia Key Points Nearly half of all residents in long-term care (LTC) facilities may have some degree of dementia on admission. As many as 75% of patients with moderate to severe dementia may be undiagnosed.Key Points Nearly half of all residents in long-term care (LTC) facilities may have some degree of dementia on admission. As many as 75% of patients with moderate to severe dementia may be undiagnosed.

5. MDS Cognitive PerformanceScale (CPS) Derived from five questions directly from the Minimum Data Set (MDS) Validated as an accurate screening instrument in the skilled facility population in the geriatric literature Positive correlation to the Mini Mental Status Exam (MMSE)

6. Cognitive Performance Scale Comatose [MDS B1] 0 - no, 1 - yes Short Term Memory OK [MDS B2a] 0 - memory okay 1 - memory problem Cognitive Skills for Daily Decision Making [MDS B4] independent modified independence moderately impaired severely impaired

7. Cognitive Performance Scale (CPS) Communication/Hearing Patterns [C4] 0 - understood 1 - usually understood 2 - sometimes understood 3 - rarely/never understood Eating [MDS G1h] 0 - independent 1 - supervision 2 - limited assistance 3 - extensive assistance 4 - total dependence

8. Cognitive Performance Scale (CPS) Scoring System & Correlating Mini Mental Status Exam (MMSE) Score CPS SCORE 0 - Intact 1 - Borderline Intact 2 - Mild Impairment 3 - Moderate Impairment 4 - Moderately Severe Imp. 5 - Severe Impairment 6 - Very Severe Impairment MMSE SCORE (avg.) 24.9 21.9 19.2 15.4 6.9 5.1 0.4

9. Prevalence of Selected CNS Conditionsfrom Admission MDS Files

10. Admission Cognitive Status of All Residentswith Dementia (MDS Diagnosis or CPS > 2)

11. AIT Use in Residents with Admission Dementia (MDS Diagnosis or CPS > 2)

12. Pharmacologic TreatmentSuccess in AD Key Points Benefits of treatment of AD include stabilization and less-than-expected decline, as well as improvement. The overall goals of therapy are to: Maintain patient�s cognitive, functional, and behavioral levels Slow disease progression Sustain functional independence Improve quality of life Consultant pharmacists can help ensure that patients and their families have realistic expectations. Key Points Benefits of treatment of AD include stabilization and less-than-expected decline, as well as improvement. The overall goals of therapy are to: Maintain patient�s cognitive, functional, and behavioral levels Slow disease progression Sustain functional independence Improve quality of life Consultant pharmacists can help ensure that patients and their families have realistic expectations.

13. Functional Loss Over the Course of AD

14. Benefits of Persistent Treatment:Delay in Nursing Home Placement

15. Benefits of Treating Moderate to Severe AD Domains of Efficacy

17. Donepezil Effects on ADLs& Caregiver Burden Feldman et al, JAGS 2003 Community dwelling and ALF AD patients N=290, MMSE range 5-17 Measurements by Disability Assessment for Dementia Scale (DAD) Modified Instrumental Activities of Daily Living Scale (IADL+) Modified Physical Self Maintenance Scale (PSMS+)

18. Caregivers Spent Less TimeAssisting Patients With ADLs

19. Behaviors Are Costly The costs of behavioral management for AD patients is significant Kleinman, et al Behaviors due to dementia, psychosis, agitation/aggression and depression �cost� $5.23 per occurance in intervention and documentation Based on staff mix, frequency, and median US wages (2001), behavioral management �costs� between $75 and $344 PER PATIENT PER MONTH Beeri, et al 30% of the total annual cost of caring for an AD patient is invested in behavioral management

20. Rivastigmine Effects on Behavior Edwards, et al Nursing Home AD patients 26 week open label prospective study, with 26 week open label extension N=173, MMSE range 6-15 Neuropsychiatric Inventory, Nursing Home Version (NPI-NH) 85% of patients receiving therapeutic doses at study end (6-12mg/day)

21. Rivastigmine Effects onBehavior Baseline

22. Rivastigmine Effects on Behavior52 Week Endpoint

23. Rivastigmine Effects on Behavior 15% of patients increased their dose of any psychotropic 11% of those on an antipsychotic 15% of those on an antidepressant 3% of those on an anxiolytic 8% of those on a hypnotic 2% of patients receiving no psychotropic started one

24. Rivastigmine & Behavior: PsychotropicMedication Use in Nursing Home AD Patients

25. Galantamine in Advanced Disease Blesa, et al: Post hoc pooled data study of 4 phase III registration trials 6 month placebo-controlled double blind randomized studies with 6 month open label extensions: consistent study design validates pooling Group 1 (N=72) MMSE<12, galantamine 24mg/day vs placebo. Group 2 (N=165) ADAS-Cog>30, galantamine 24mg/day vs placebo)

26. Galantamine in Advanced Disease

27. Galantamine in Advanced Disease

28. Donepezil in Advanced Disease Winblad, et al: Swedish nursing home AD patients(DSM-IV) 26 week, randomized, double-blind, placebo controlled study N=194, MMSE=1-10 Severe Impairment Battery (SIB) Alzheimer�s Disease Cooperative Study �Activities of Daily Living-severe (ADCS-ADL-sev) Randomized to 5mg/daily x 4 weeks then option to increase to 10mg/daily, vs placebo Mean donepezil dose was 8.2mg/day; 91% reached 10mg/day

29. Winblad, et al: Donepezil group improved on SIB Mean improvement of 5.7 (95% CI 1.5-9.8) p=0.008 Placebo group mean decline of 1.8 Donepezil group declined less on ADCS-ADL-severe Mean of decline of 1.7 (95% CI 0.2-3.2) p=0.03 Placebo group mean decline of 2.9 Donepezil in Advanced Disease

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