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National Focus on Dementia Care Combines Medication

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National Focus on Dementia Care Combines Medication VOLUME 6, NUMBER 1 • WINTER/SPRING 2013 PUBLISHED BY THE FLORIDA COASTAL GERIATRIC RESOURCES, EDUCATION, AND TRAINING CENTER (GREAT GEC) In the United States, dementia affects over 5 million persons, and the prevalence of dementia is projected to increase to over 16 NATIONAL FOCUS ON million by the first half of the 21 st century as the boomers age. De - mentia is defined as a chronic acquired decline in memory and at DEMENTIA CARE COMBINES least one other area of cognitive function such as language, visuo- spatial, or executive function. Although dementia is a well-recog - nized chronic condition, it is important to be aware that it is not a MEDICATION WITH uniform disease entity. Alzheimer’s is one cause (and the most common) of dementia and INCREASED MONITORING affects 60 to 70 percent of adults with dementia. Other causes of dementia include vascular dementia, Lewy Body dementia, and fron - By Naushira Pandya, M.D., CMD totemporal dementia, which are collectively responsible for 15 to 30 GREAT GEC Project Director and Professor and Chair of the Department of Geriatrics percent of cases. In addition, there are those causes of dementia that may be completely reversible if detected and treated in a timely manner. These include drug toxicity, metabolic disorders such as electrolyte disorders, thyroid disease, subdural hematoma, and nor - mal pressure hydrocephalus. This devastating condition can lead to significant medical and psy - chosocial problems for both patients and families. It increases care - giver burden as well as financial and psychological distress for families and leads to a gradual inexorable decline in cognition and ex - ecutive function in affected individuals. As dementia progresses from mild to the moderate and severe stages, patients become more dis - oriented, get lost in familiar places, and require assistance with meal preparation, shopping and banking, and dressing and grooming. Although these tasks require much time and care coordination on the part of caregivers and families, the most distressing aspects are behavioral and mood disorders that can develop into frankly psy - chotic symptoms with delusions and hallucinations. Individuals may become aggressive toward caregivers, agitated, restless, anxious, or depressed. They may develop delusions (such as spousal infi - delity, belongings being stolen, food poisoned) or auditory or visual hallucinations, the latter being more common and affecting about 11 percent of patients. Agitation or aggression is seen in 80 percent of Alzheimer’s dis - ease patients and is a common precipitating cause for nursing-home placement. An acute infection, delirium, pain, or medication-related problem, and environmental changes can also contribute to agitation and aggression, as can unmet needs. Patients may be hungry, thirsty, bored, depressed, upset by noise level, or be cared for by unfamiliar or inexperienced caregivers. Most experts agree that these behaviors are a result of frustrated attempts by individuals to communicate, and their failure to do so results in frustration and acting out. In the clinical arena, it has become increasingly common to treat the behavioral symptoms of dementia with antipsychotic medications such as haloperidol, or atypical antipsychotics such as risperidone, olanzapine, and quetiapine, although antipsychotics have not been Continued on the next page... ALSO IN THIS ISSUE: Grants • Education • News • Nutrition • Disease Management • Events Dementia...continued from page 1 approved by the Food and Drug Administration (FDA) to treat dementia. In The CMS has prepared a training manual called Hand in Hand , which 2005 and 2008, the FDA issued the strongest possible warnings called will be sent to each facility. This initiative requires current and future in - black box warnings , stating that patients administered antipsychotics were creases in interprofessional collaboration between practitioners, family 1.6 to 1.7 times more likely to die than those who took a placebo. This risk members, clinical pharmacists, nurses, nursing assistants, and therapists appears to be greater in individuals with existing cardiovascular conditions as well as mental health professionals. Current regulations require that the and risks. medication regimen is reviewed each month by a consultant pharmacist in Nearly 40 percent of patients with dementia who reside in nursing homes order to assess the appropriate use of each medication and in particular receive antipsychotics. A report issued in May 2011 by the Office of In - whether there is a bona-fide indication for each psychotropic medication spector General of the Department of Health and Human Services (DHHS) (including anxiolytics, antidepressants, mood stabilizers, and hypnotics) found that 305,000, or 14 percent of the nation’s 2.1 million nursing home followed by recommendations for dose reduction and monitoring. residents, had at least one claim for antipsychotics. In the past 12 years the There is a reporting process for psychotropic medication use in each use of antipsychotics has increased and the DHSS reports that currently facility by the pharmacist to the medical director, administrator, and the di - antipsychotics are used for 24 percent of long-stay residents. rector of nursing. The best practice currently is for facilities to convene Moreover, these medications are costly and require a considerable regular interprofessional psychotropic management meetings to ensure amount of monitoring. Clinical guidelines on dementia, such as those from appropriate use of these medications and to brainstorm in order to iden - the American Medical Directors Association, advise practitioners to ad - tify non-pharmacological interventions whenever possible. dress underlying contributing factors through a “detailed review of the pa - tient’s symptom history and a careful assessment of the circumstances in References which problematic behavior occurs as a basis for both medication treat - Alzheimer’s disease facts and figures 2009. Mebane-Sims, Irma Alzheimer’s ment and non-pharmacological interventions.” Indeed, the body of evi - Association. Alzheimer’s & Dementia , Vol 5(3), May 2009, 234-270. dence regarding the effectiveness of behavioral modifications and non-pharmacological interventions to manage dementia is growing. An - Bassiony MM, Steinberg MS, Warren A, Rosenblatt A, Baker, AS, Lyketsos CG. tipsychotics should only be used if these measures have been tried with - (2000), Delusions and hallucinations in Alzheimer’s disease: prevalence and out success and the patient has true psychosis. clinical correlates . Int. J. Geriat. Psychiatry , 15: 99–107. doi: 10.1002/(SICI)1099-1166(200002)15:2<99::AID-GPS82>3.0.CO;2-5. In May 2012, the Centers for Medicare and Medicaid (CMS) set a goal for reducing the use of antipsychotics in long-term care facilities by 15 Schneider LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic percent by the end of 2012 (overall and not necessarily in each long-term drug treatment for dementia: meta-analysis of randomized placebo-controlled care facility). A collaborative effort is being made by the Partnership to trials. JAMA. 2005;294(15):1934-1943. doi:10.1001/jama.294.15.1934. Improve Dementia Care (comprising industry partners and advocacy groups) to enhance provider and staff education and to develop appro - Gitlin LN, Kales HC, Lyketsos CG. Nonpharmacologic management of behav - priate alternatives to antipsychotics for dementia patients in the nursing- ioral symptoms in dementia. JAMA. 2012;308(19):2020-2029. home setting. doi:10.1001/jama.2012.36918. 2 Both articles written by Cecilia Rokusek, Ed.D., R.D. Assistant Dean, Office of Education, Planning, and Research GREAT GEC Executive Director GEC LEADS THE WAY FOR INTERPROFESSIONAL EDUCATION AND PRACTICE GREAT GEC Receives Supplemental Grant for Over the past four years, interprofessional education and practice have Alzheimer’s Education headlined annual meetings, strategic plans, and curriculum-planning initia - tives for professional organizations and academic institutions throughout the United States, Canada, the European Union, Australia, and New The GREAT GEC has received a $134,906 supplemental two- Zealand. Following the work of the Institute of Medicine and the Interpro - year grant to provide Alzheimer’s disease education to practitioners fessional Education Collaborative, interprofessional education has be - and caregivers. The Professional Education for Alzheimer’s Re - come a part of all health professional education. sources and Leadership (Project PEARL) team will be revising and As we focus our efforts on curriculum development and clinical prac - enhancing existing evidence-based education curricula from tice, we are all presented with the reality that GECs have been leading the Alzheimer’s Community Care, Senior Helpers, and the Johnnie B. way in developing interdisciplinary (now interprofessional) leaders for over Byrd, Sr. Alzheimer’s Center & Research Institute focusing on train - 20 years. GECs are incredible resources for academic programs as pro - ing in Alzheimer’s prevention, diagnosis, and care in medically under - gram planners attempt to make interprofessional education a reality for all served areas to address special needs elderly, particularly Hispanics. the health professions and practice, not only in geriatrics. The curriculum revisions and enhancements will concentrate on two overarching goals that will serve as the umbrella for the objectives The GECs have built a foundation
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