Transcript Symptomatic and disease

Treatment Principles
Alzheimer’s Disease (AD)
Treatment goals in AD
Treatment goals
• There is currently no cure for AD.1
• Consequently, alleviating the symptoms of AD, and
delaying symptom progression, are meaningful
therapeutic goals.2
1. Winblad et al. Lancet Neurol 2016;15(5):455–532;
2. Geldmacher et al. J Nutr Health Aging 2006;10(5):417–429
Treatment goals
• There is currently no cure for AD.1
• Consequently, alleviating the symptoms of AD, and
delaying symptom progression, are meaningful
therapeutic goals.2
• Ideally, the patient should be maintained as close as
possible to their cognitive, functional, and behavioral
status at diagnosis, for as long as possible.2
• In mild AD, treatment outcomes should focus on
memory functions.1 In more severe AD, effects on
activities of daily living (ADLs) and psychiatric and
behavioral disturbances are more clinically relevant.1
• Patients and families may find the real-life benefits of
treatment to be the most meaningful, such as the
ability to complete household tasks, to enjoy hobbies,
and to participate in family activities.2
1. Winblad et al. Lancet Neurol 2016;15(5):455–532;
2. Geldmacher et al. J Nutr Health Aging 2006;10(5):417–429
Treatment goals
• There is currently no cure for AD.1
• Consequently, alleviating the symptoms of AD, and
delaying symptom progression, are meaningful
therapeutic goals.2
Treatment expectation versus expected decline in AD2
Global symptom severity
Mild
Untreated
Severe
Time
1. Winblad et al. Lancet Neurol 2016;15(5):455–532;
2. Geldmacher et al. J Nutr Health Aging 2006;10(5):417–429
• AD is a progressive disease, and an untreated
patient will decline over time.2
Treatment goals
• There is currently no cure for AD.1
• Consequently, alleviating the symptoms of AD, and
delaying symptom progression, are meaningful
therapeutic goals.2
Treatment expectation versus expected decline in AD2
Global symptom severity
Mild
Successful
treatment
Untreated
Severe
Time
1. Winblad et al. Lancet Neurol 2016;15(5):455–532;
2. Geldmacher et al. J Nutr Health Aging 2006;10(5):417–429
• AD is a progressive disease, and an untreated
patient will decline over time.2
• A successful treatment will result in a shift of the
curve to the right, representing both short-term
improvement, and long-term slowed progression of
symptoms.2 This would increase the amount of time
that a patient spends in milder stages, relative to
receiving no treatment.2
Treatment goals
• There is currently no cure for AD.1
• Consequently, alleviating the symptoms of AD, and
delaying symptom progression, are meaningful
therapeutic goals.2
Treatment expectation versus expected decline in AD2
Global symptom severity
Mild
Successful
treatment
Untreated
Severe
Time
1. Winblad et al. Lancet Neurol 2016;15(5):455–532;
2. Geldmacher et al. J Nutr Health Aging 2006;10(5):417–429
• AD is a progressive disease, and an untreated
patient will decline over time.2
• A successful treatment will result in a shift of the
curve to the right, representing both short-term
improvement, and long-term slowed progression of
symptoms.2 This would increase the amount of time
that a patient spends in milder stages, relative to
receiving no treatment.2
• The area between the ‘untreated’ and ‘successful
treatment’ curves represents the benefit of the
treatment.2 This benefit is maximized with early
initiation of therapy.2
Treatment goals
• There is currently no cure for AD.1
• Consequently, alleviating the symptoms of AD, and
delaying symptom progression, are meaningful
therapeutic goals.2
Treatment expectation versus expected decline in AD2
Global symptom severity
Mild
Successful
treatment
Untreated
Severe
Time
1. Winblad et al. Lancet Neurol 2016;15(5):455–532;
2. Geldmacher et al. J Nutr Health Aging 2006;10(5):417–429
• AD is a progressive disease, and an untreated
patient will decline over time.2
• A successful treatment will result in a shift of the
curve to the right, representing both short-term
improvement, and long-term slowed progression of
symptoms.2 This would increase the amount of time
that a patient spends in milder stages, relative to
receiving no treatment.2
• The area between the ‘untreated’ and ‘successful
treatment’ curves represents the benefit of the
treatment.2 This benefit is maximized with early
initiation of therapy.2
• At present, AD treatments have not been shown to
prolong life.2 Consequently, the trajectories of treated
and untreated patients will converge in the later
stages of the disease, when treatment no longer
provides measurable benefits.2
Symptomatic and disease-modifying treatments
Treatments for AD can be theoretically classified according to
whether they affect:1
•
the symptoms of the disease
(‘symptomatic treatments’)
•
the underlying pathology of the disease
(‘disease-modifying treatments’).
The current treatments for AD are symptomatic;
disease-modifying treatments are not yet available.2
1. Kennedy. Primary Psychiatry. 2013;
2. Winblad et al. Lancet Neurol 2016;15(5):455–532;
3. Adapted from: Van Dam & De Deyn. Nat Rev Drug Discov 2006;5(11):956–970
Symptomatic and disease-modifying treatments
Treatments for AD can be theoretically classified according to
whether they affect:1
•
the symptoms of the disease
(‘symptomatic treatments’)
•
the underlying pathology of the disease
(‘disease-modifying treatments’).
The current treatments for AD are symptomatic;
disease-modifying treatments are not yet available.2
As shown on the previous screen, AD is a progressive disease, and
an untreated patient will decline over time.
1. Kennedy. Primary Psychiatry. 2013;
2. Winblad et al. Lancet Neurol 2016;15(5):455–532;
3. Adapted from: Van Dam & De Deyn. Nat Rev Drug Discov 2006;5(11):956–970
Symptomatic and disease-modifying treatments
Treatments for AD can be theoretically classified according to
whether they affect:1
•
the symptoms of the disease
(‘symptomatic treatments’)
•
the underlying pathology of the disease
(‘disease-modifying treatments’).
The current treatments for AD are symptomatic;
disease-modifying treatments are not yet available.2
A symptomatic treatment can provide an initial benefit,
but the patient will continue to decline.1 The disease pathology will
not be affected, and, if the treatment is withdrawn, the patient will
return to the untreated trajectory.1
1. Kennedy. Primary Psychiatry. 2013;
2. Winblad et al. Lancet Neurol 2016;15(5):455–532;
3. Adapted from: Van Dam & De Deyn. Nat Rev Drug Discov 2006;5(11):956–970
Symptomatic and disease-modifying treatments
Treatments for AD can be theoretically classified according to
whether they affect:1
•
the symptoms of the disease
(‘symptomatic treatments’)
•
the underlying pathology of the disease
(‘disease-modifying treatments’).
The current treatments for AD are symptomatic;
disease-modifying treatments are not yet available.2
A disease-modifying treatment would either stop or slow the
progressive decline of the patient.1 Consequently, the patient’s
trajectory of decline would be less steep, diverging at an acute angle
from that of an untreated patient.1 The larger the disease-modifying
effect, the greater this divergence, and the sooner that the benefit of
treatment would be clinically observable.1
Even when disease-modifying treatments become available, they will
not necessarily restore a patient’s function to premorbid levels, and
so symptomatic therapies will still have a role to play.1
1. Kennedy. Primary Psychiatry. 2013;
2. Winblad et al. Lancet Neurol 2016;15(5):455–532;
3. Adapted from: Van Dam & De Deyn. Nat Rev Drug Discov 2006;5(11):956–970
Symptomatic and disease-modifying treatments
Treatments for AD can be theoretically classified according to
whether they affect:1
•
the symptoms of the disease
(‘symptomatic treatments’)
•
the underlying pathology of the disease
(‘disease-modifying treatments’).
The current treatments for AD are symptomatic;
disease-modifying treatments are not yet available.2
A cure for AD would reverse the disease progress and restore the
patient to their original level of functioning.3
1. Kennedy. Primary Psychiatry. 2013;
2. Winblad et al. Lancet Neurol 2016;15(5):455–532;
3. Adapted from: Van Dam & De Deyn. Nat Rev Drug Discov 2006;5(11):956–970
Key points
• Current treatments for AD are symptomatic; there is no cure, or disease-modifying
treatment, that can affect the underlying pathology of the disease.
• Alleviating the symptoms of AD, and delaying symptom progression, are meaningful
therapeutic goals.
• Even when disease-modifying treatments become available, they will not necessarily
restore a patient’s function to premorbid levels – symptomatic therapies will still have a
role to play.
Current approaches to AD management
Current approaches to AD management
• The management of AD can be categorized into
pharmacological, psychosocial, and caregiving
aspects.
Pharmacological
Psychosocial
Caregiving
• Dementia is a progressive disorder, and a patient’s
treatment must evolve with time to address newly
emerging issues.1
• Furthermore, as the manifestation of dementia varies
considerably from patient to patient, treatment plans
should be individualized.1
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56;
2. APA. Guideline watch. 2014
Current approaches to AD management
• The management of AD can be categorized into
pharmacological, psychosocial, and caregiving
aspects.
Pharmacological
Psychosocial
Caregiving
Pharmacological therapies indicated for the treatment of
AD are:1,2
• acetylcholinesterase inhibitors (AChEIs) – donepezil,
galantamine, and rivastigmine
• memantine.
Other pharmacological therapies used in AD include:1,2
• antipsychotics for psychosis and agitation
• antidepressants for depression
• Dementia is a progressive disorder, and a patient’s
treatment must evolve with time to address newly
emerging issues.1
• sedatives for sleep disturbance.
• Furthermore, as the manifestation of dementia varies
considerably from patient to patient, treatment plans
should be individualized.1
Pharmacological treatments are the topic of Module 5 of
this e-learning, ‘Current pharmacological treatments for
AD’.
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56;
2. APA. Guideline watch. 2014
Current approaches to AD management
• The management of AD can be categorized into
pharmacological, psychosocial, and caregiving
aspects.
Pharmacological
Psychosocial therapies include:1,2
• behavior-oriented approaches
• stimulation-oriented approaches
• emotion-oriented approaches
• cognition-oriented approaches
Psychosocial
• sleep hygiene.
Caregiving
• Dementia is a progressive disorder, and a patient’s
treatment must evolve with time to address newly
emerging issues.1
• Furthermore, as the manifestation of dementia varies
considerably from patient to patient, treatment plans
should be individualized.1
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56;
2. APA. Guideline watch. 2014
These therapies are discussed on the next screen of
this e-learning module.
Current approaches to AD management
• The management of AD can be categorized into
pharmacological, psychosocial, and caregiving
aspects.
Family/caregiver support is a key part of the
management of patients with AD.
Caregiver burden is discussed on Screen 3.16.
Pharmacological
Psychosocial
Caregiving
• Dementia is a progressive disorder, and a patient’s
treatment must evolve with time to address newly
emerging issues.1
• Furthermore, as the manifestation of dementia varies
considerably from patient to patient, treatment plans
should be individualized.1
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56;
2. APA. Guideline watch. 2014
Current approaches to AD management
• The management of AD can be categorized into
pharmacological, psychosocial, and caregiving
aspects.
Pharmacological
Psychosocial
Caregiving
• Dementia is a progressive disorder, and a patient’s
treatment must evolve with time to address newly
emerging issues.1
• Furthermore, as the manifestation of dementia varies
considerably from patient to patient, treatment plans
should be individualized.1
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56;
2. APA. Guideline watch. 2014
• In addition to the emergence of new symptoms of AD
with time, patients may require treatment for
co-occurring psychiatric and medical conditions.1,2
Psychosocial therapies for AD
The purpose of psychosocial therapy is to improve quality of life, and
to maximize patient functioning in the context of existing deficits.1
Several different psychosocial therapies have been developed,
which may be targeted towards the patient,
or their family.1 In general, these psychosocial therapies have not
been studied in randomized, double-blind, controlled trials, and do
not provide lasting effects.1 Nonetheless, certain interventions are
supported by research findings, and have gained clinical
acceptance.1,2
Behavior-oriented approaches
Stimulation-oriented approaches
Emotion-oriented approaches
Cognition-oriented approaches
Sleep hygiene
General psychosocial interventions
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56;
2. APA. Guideline watch. 2014
Appropriate psychosocial therapies for a patient should be selected
based on the availability and cost of the therapy, and the patient’s
characteristics and preferences.1
Psychosocial therapies are generally administered daily or weekly.1
Psychosocial therapies for AD
The purpose of psychosocial therapy is to improve quality of life, and
to maximize patient functioning in the context of existing deficits.1
Several different psychosocial therapies have been developed,
which may be targeted towards the patient,
or their family.1 In general, these psychosocial therapies have not
been studied in randomized, double-blind, controlled trials, and do
not provide lasting effects.1 Nonetheless, certain interventions are
supported by research findings, and have gained clinical
acceptance.1,2
Behavior-oriented approaches
Appropriate psychosocial therapies for a patient should be selected
based on the availability and cost of the therapy, and the patient’s
characteristics and preferences.1
Psychosocial therapies are generally administered daily or weekly.1
•
The aim of behavior-oriented treatments is to identify problem
behaviors and to reduce their frequency, by making changes to
the patient’s environment.1
•
Examples of behavioral interventions are scheduled toileting (to
reduce urinary incontinence), and aggressive-behavior
management training for caregivers.1
•
Behavioral interventions are supported by small
trials and case studies, and are in widespread clinical use.1,2
Stimulation-oriented approaches
Emotion-oriented approaches
Cognition-oriented approaches
Sleep hygiene
General psychosocial interventions
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56;
2. APA. Guideline watch. 2014
Psychosocial therapies for AD
The purpose of psychosocial therapy is to improve quality of life, and
to maximize patient functioning in the context of existing deficits.1
Several different psychosocial therapies have been developed,
which may be targeted towards the patient,
or their family.1 In general, these psychosocial therapies have not
been studied in randomized, double-blind, controlled trials, and do
not provide lasting effects.1 Nonetheless, certain interventions are
supported by research findings, and have gained clinical
acceptance.1,2
Appropriate psychosocial therapies for a patient should be selected
based on the availability and cost of the therapy, and the patient’s
characteristics and preferences.1
Psychosocial therapies are generally administered daily or weekly.1
•
The aim of stimulation-oriented treatments is to activate the
patient’s available cognitive resources.1
•
Examples of stimulation interventions are recreational activities
or therapies (e.g., crafts, games, pets), art therapies (e.g.,
music, dance, art), and exercise.1
•
Stimulation interventions have limited data to support their
efficacy, but should be considered part of the humane care of
patients with dementia.1,2
Behavior-oriented approaches
Stimulation-oriented approaches
Emotion-oriented approaches
Cognition-oriented approaches
Sleep hygiene
General psychosocial interventions
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56;
2. APA. Guideline watch. 2014
Psychosocial therapies for AD
The purpose of psychosocial therapy is to improve quality of life, and
to maximize patient functioning in the context of existing deficits.1
Several different psychosocial therapies have been developed,
which may be targeted towards the patient,
or their family.1 In general, these psychosocial therapies have not
been studied in randomized, double-blind, controlled trials, and do
not provide lasting effects.1 Nonetheless, certain interventions are
supported by research findings, and have gained clinical
acceptance.1,2
Appropriate psychosocial therapies for a patient should be selected
based on the availability and cost of the therapy, and the patient’s
characteristics and preferences.1
Psychosocial therapies are generally administered daily or weekly.1
•
The aims of emotion-oriented treatments are to address issues
of loss, and to improve mood and behavior.1
•
Examples of emotion interventions are reminiscence therapy (in
the context of the patient’s life history), validation therapy, and
supportive psychotherapy.1
•
Emotion interventions have limited data to support their
efficacy.1,2
Behavior-oriented approaches
Stimulation-oriented approaches
Emotion-oriented approaches
Cognition-oriented approaches
Sleep hygiene
General psychosocial interventions
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56;
2. APA. Guideline watch. 2014
Psychosocial therapies for AD
The purpose of psychosocial therapy is to improve quality of life, and
to maximize patient functioning in the context of existing deficits.1
Several different psychosocial therapies have been developed,
which may be targeted towards the patient,
or their family.1 In general, these psychosocial therapies have not
been studied in randomized, double-blind, controlled trials, and do
not provide lasting effects.1 Nonetheless, certain interventions are
supported by research findings, and have gained clinical
acceptance.1,2
Appropriate psychosocial therapies for a patient should be selected
based on the availability and cost of the therapy, and the patient’s
characteristics and preferences.1
Psychosocial therapies are generally administered daily or weekly.1
•
The aim of cognition-oriented treatments is to restore cognitive
deficits, often in a classroom setting.1
•
Examples of cognition interventions are reality orientation,
cognitive retraining, and skills training (focused on specific
cognitive deficits).1
•
Cognition interventions may provide modest and transient
improvements; however, they are associated with adverse
emotional consequences (such as frustration).1,2
Behavior-oriented approaches
Stimulation-oriented approaches
Emotion-oriented approaches
Cognition-oriented approaches
Sleep hygiene
General psychosocial interventions
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56;
2. APA. Guideline watch. 2014
Psychosocial therapies for AD
The purpose of psychosocial therapy is to improve quality of life, and
to maximize patient functioning in the context of existing deficits.1
Several different psychosocial therapies have been developed,
which may be targeted towards the patient,
or their family.1 In general, these psychosocial therapies have not
been studied in randomized, double-blind, controlled trials, and do
not provide lasting effects.1 Nonetheless, certain interventions are
supported by research findings, and have gained clinical
acceptance.1,2
Behavior-oriented approaches
Stimulation-oriented approaches
Emotion-oriented approaches
Cognition-oriented approaches
Sleep hygiene
General psychosocial interventions
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56;
2. APA. Guideline watch. 2014
Appropriate psychosocial therapies for a patient should be selected
based on the availability and cost of the therapy, and the patient’s
characteristics and preferences.1
Psychosocial therapies are generally administered daily or weekly.1
•
Many patients with AD suffer from sleep disturbances, which
may be minimized by their participation in daytime activities, and
by improving sleep hygiene (e.g., consistent rising times,
minimizing daytime napping, and daily exercise).1
Psychosocial therapies for AD
The purpose of psychosocial therapy is to improve quality of life, and
to maximize patient functioning in the context of existing deficits.1
Several different psychosocial therapies have been developed,
which may be targeted towards the patient,
or their family.1 In general, these psychosocial therapies have not
been studied in randomized, double-blind, controlled trials, and do
not provide lasting effects.1 Nonetheless, certain interventions are
supported by research findings, and have gained clinical
acceptance.1,2
Behavior-oriented approaches
Stimulation-oriented approaches
Emotion-oriented approaches
Cognition-oriented approaches
Sleep hygiene
General psychosocial interventions
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56;
2. APA. Guideline watch. 2014
Appropriate psychosocial therapies for a patient should be selected
based on the availability and cost of the therapy, and the patient’s
characteristics and preferences.1
Psychosocial therapies are generally administered daily or weekly.1
•
Patients should be periodically monitored for the evolution of
cognitive symptoms and their response to intervention, and for
matters of safety such as suicidality and aggressiveness.1
•
Patients should be advised against driving, due to the increased
risk of traffic accidents.1
•
Patients and their families should be educated about AD, its
treatment, and sources of additional care and support; also,
families should be advised about the need for financial and legal
planning due to the patient’s eventual incapacity.1 A therapeutic
alliance should be established and maintained with the patient
and their family.1
Disease-stage-specific treatment
•
Due to the progressive nature of AD, a patient’s symptoms will
evolve over time.1 Consequently, the treatment of dementia
should be adapted to the stage of the disease.1
Mildly
impaired
patients
Moderately
impaired
patients
Severely
impaired
patients
•
Medications aimed at improving cognition are prescribed based
on disease stage,1 whereas nonpharmacological interventions
and psychiatric medications are used independent of disease
stage, based on the patient’s needs.
•
With nonpharmacological interventions, it is critical to match the
level of demand on the patient with his or her current capacities,
so as not to frustrate or patronize the patient.2
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56; 2. Grossberg & Desai. J Gerontol A Biol Sci Med Sci
2003;58(4):331–353; 3. APA. Guideline watch. 2014; 4. Geldmacher et al. J Nutr Health Aging 2006;10(5):417–429;
5. Schmidt et al. Eur J Neurol 2015;22(6):889–898
Disease-stage-specific treatment
•
Due to the progressive nature of AD, a patient’s symptoms will
evolve over time.1 Consequently, the treatment of dementia
should be adapted to the stage of the disease.1
Mildly
impaired
patients
Moderately
impaired
patients
•
Medications aimed at improving cognition are prescribed based
on disease stage,1 whereas nonpharmacological interventions
and psychiatric medications are used independent of disease
stage, based on the patient’s needs.
•
With nonpharmacological interventions, it is critical to match the
level of demand on the patient with his or her current capacities,
so as not to frustrate or patronize the patient.2
•
Emotion-oriented approaches, such as supportive psychotherapy,
reminiscence therapy, and validation therapy, are especially
valuable in mild AD.2 Patients may also benefit from recreational
activity.1
•
In terms of pharmacotherapy (see Module 5 of this e-learning),
patients with mild AD should be offered a trial of an AChEI.1
AChEIs modestly improve cognition in mild to moderate AD, and
early treatment is associated with slower decline of cognitive
function.3,4
Severely
impaired
patients
•
Depression is common in patients with dementia.1 Regular
counseling or psychological support can help patients to cope
with the diagnosis.1,2 Depression may be treated with cognitive
therapy, or with antidepressants.2,3
•
In mild AD, the use of diaries and recording devices can help
patients to remember events and conversations.2
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56; 2. Grossberg & Desai. J Gerontol A Biol Sci Med Sci
2003;58(4):331–353; 3. APA. Guideline watch. 2014; 4. Geldmacher et al. J Nutr Health Aging 2006;10(5):417–429;
5. Schmidt et al. Eur J Neurol 2015;22(6):889–898
Disease-stage-specific treatment
•
Due to the progressive nature of AD, a patient’s symptoms will
evolve over time.1 Consequently, the treatment of dementia
should be adapted to the stage of the disease.1
Mildly
impaired
patients
Moderately
impaired
patients
•
Medications aimed at improving cognition are prescribed based
on disease stage,1 whereas nonpharmacological interventions
and psychiatric medications are used independent of disease
stage, based on the patient’s needs.
•
With nonpharmacological interventions, it is critical to match the
level of demand on the patient with his or her current capacities,
so as not to frustrate or patronize the patient.2
•
In terms of pharmacotherapy (see Module 5 of this e-learning), the addition of
memantine to an AChEI may be beneficial in delaying symptom progression
among patients with moderate AD; however, the clinical significance of such
augmentation is slight at best.1,3 Nonetheless, the desirable effects of
combined AChEI and memantine treatment outweigh the undesirable effects
in patients with moderate to severe AD.5
•
Pharmacological and/or nonpharmacological interventions are likely to be
needed as patients begin to experience delusions and hallucinations, and as
they suffer worsening agitation, aggression, and depression.1
Severely
impaired
patients
•
In the moderate stages of dementia, patients may require
supervision to remain safe.1 The patient’s caregiver may begin to
feel more burdened, and respite care (e.g., home health aides, or
day care) may be needed.1
•
Emotion-oriented approaches such as reminiscence therapy and
validation therapy continue to be valuable in the moderate stages
of AD.2 Behavior-oriented approaches are especially helpful for
the treatment of depression in moderate AD.2
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56; 2. Grossberg & Desai. J Gerontol A Biol Sci Med Sci
2003;58(4):331–353; 3. APA. Guideline watch. 2014; 4. Geldmacher et al. J Nutr Health Aging 2006;10(5):417–429;
5. Schmidt et al. Eur J Neurol 2015;22(6):889–898
Disease-stage-specific treatment
•
Due to the progressive nature of AD, a patient’s symptoms will
evolve over time.1 Consequently, the treatment of dementia
should be adapted to the stage of the disease.1
Mildly
impaired
patients
Moderately
impaired
patients
•
Medications aimed at improving cognition are prescribed based
on disease stage,1 whereas nonpharmacological interventions
and psychiatric medications are used independent of disease
stage, based on the patient’s needs.
•
With nonpharmacological interventions, it is critical to match the
level of demand on the patient with his or her current capacities,
so as not to frustrate or patronize the patient.2
Severely
impaired
patients
•
•
In the severe stages of dementia, patients are incapacitated and almost
completely dependent on others for help with basic ADLs, such as
dressing, bathing, and feeding.1
•
As the patient worsens, he or she may need to be transferred to a
nursing home.1,3
•
In terms of pharmacotherapy, memantine is approved for severe AD
(as are certain AChEIs in some regions; see Module 5 of this elearning).1 Additional pharmacotherapy may be needed for psychotic
symptoms and agitation if they cause distress to the patient, or if they
cause significant danger or disruption to caregivers or other nursing
home residents.1 Depression can be difficult to diagnose at this stage of
the disease.1
•
Feeding tube placement, treatment of infection, cardiopulmonary
resuscitation, and intubation must be agreed in advance with the
patient and their family.1 The treatment team should also help the
family to prepare for the patient’s death.1
1. APA. Am J Psychiatry 2007;164(12 Suppl):5–56; 2. Grossberg & Desai. J Gerontol A Biol Sci Med Sci
2003;58(4):331–353; 3. APA. Guideline watch. 2014; 4. Geldmacher et al. J Nutr Health Aging 2006;10(5):417–429;
5. Schmidt et al. Eur J Neurol 2015;22(6):889–898
Key points
• AD is managed through a combination of pharmacological,
psychosocial, and caregiving approaches.
• Pharmacological therapies indicated for the treatment of AD are the
AChEIs and memantine.
• Psychosocial therapies include those targeted at behavior,
stimulation, emotions, cognition, and sleep hygiene. In general,
evidence to support these therapies is limited.
• As the disease advances, patients with AD become increasingly
dependent on caregivers. Consequently, the pressure on caregivers
increases.
• Treatment plans should be individualized, and should evolve as the
disease progresses.