ACT on Alzheimer’s Disease Curriculum

1. ACT on Alzheimer’s Disease Curriculum Module VIII: Quality Interventions

2. Quality Interventions • These slides are based on the Module VIII: Quality Interventions text • Please refer to the text for all citations, references and acknowledgments

3. Learning Objectives Upon completion of this module the student should: • List pharmacological and non-pharmacological interventions. • Summarize the interventions that can be used with a person that has a diagnosis of Alzheimer’s disease. • Gain insight on how physical, cognitive and social activities along with diet can be used as a positive intervention

4. Intervention Goals

5. 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

6. 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

7. Non-Pharmacological Interventions

8. 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

9. 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

10. 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 individuals and caregivers to participate in educational and support groups • Involve individuals in care planning decisions • Address caregiver support on an ongoing basis • Connect individual to community resources

11. Counseling, Education, Support and Planning • A community-based organization can supplement the interventions introduced by the primary care provider • Community-based organizations 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

12. Stimulation/Activity/Max Function • Multiple lifestyle changes may help optimize function in individuals with Alzheimer’s disease • Physical activity • Cognitive activity • Social activity • Healthy diet

13. 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

14. Advanced 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

15. Pharmacological Interventions

16. 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

17. 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

18. 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.

19. 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)

20. 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)

21. 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

22. 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

23. 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

24. 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

25. 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