The following are related key terms used in the AMDA Dementia Clinical Practice Guideline (CPG): Cognition refers to activities related to organizing memory, sensation, and thinking. Behavior refers to an individual’s observable actions. Mental status refers to an individual’s overall level of alertness, activation, and responsiveness to the outside world. As defined, clinicians know that the core of caring for patients with dementia would be to: support function, provide a protective environment, and ensure an optimum level of quality of life. The AMDA CPG on dementia supports these goals. The steps are designed to: identify patients at risk for new and progressive dementia, manage the symptoms, consequences, and complications of dementia, minimize preventable functional decline, and respond appropriately to the changing needs of patients with dementia.
Dementia, mostly of the Alzheimer’s type, presents many challenges, particularly in care dynamics. At this time, there is no cure for this disease. Alzheimer’s disease is the most common cause of dementia for people older than 65. The risk of getting Alzheimer’s disease doubles every 5 years, and the incidence is still exponentially increasing, so that by the age of 95, nearly one-half of that population will have Alzheimer’s disease.2
The Dementia guideline is best used to manage dementia of a chronic kind. Facility staff may benefit significantly and gain essential direction as you enable this process. Identify patients who are at risk for new or progressive dementia, and identify the nature and causes of dementia in different patients. Establish that the patient has dementia and the underlying cause. Each patient will be different and therefore specifics of not only the cause but the presentation of symptoms and effects on the quality of life of the patient will define the management and treatment. Often presentation of symptoms will tell you if it is a new development or evidence of progression and decline. Make appropriate environmental modifications to maximize patient dignity, comfort, and safety. Modifying the environment is essential for patient safety, with the goal to reduce the risk of injuries from falling or wandering. Environmental modifications are general in nature. Protective endeavors by staff need to be patient-centric, that is, specific to the patient’s risk factors. Often because of a lack of training, staff lose focus on the specific causes of patient’s risk factors and rely on the general environmental modifications for patient safety. Your direction may significantly enable staff to recognize patient-specific risk factors if they have a substantial knowledge base of how to recognize the behavior dynamics for a particular patient.
If clearly identified, managing disability assists in maintaining dignity and minimizing decline. Medication management, management of system deficits, rehabilitation services, and restorative programs may be appropriate. Recreational services could support cultural and social needs. Complications are minimized when appropriate interventions are selected. Manage and treat acute changes and new symptoms. Find opportunity to look for anything that may have induced the change, complication, or deterioration.
Dementia can only stabilize or progress. Progression may be slow or rapid, dependent on the cause of the dementia. Rapid changes are more easily recognized than slow changes. Acute conditions such as an infection may trigger rapid deterioration. It is important for the facility staff to be trained to recognize these changes and how it affects the needs of the patient. Staff need to be taught to bring all changes to the practitioners’ attention. For the most part, care plans need to be updated more often than what the federal guidelines basic expectations reflect (e.g., every 90 days) with this disease state.
Physicians and other health care practitioners play an important leadership role on the interdisciplinary team and should be involved in all facets of managing and treating the patient with dementia. Staffing shortages and high turnover present challenges. Facility staff may have some basic fundamental knowledge on managing dementia but may need a push in the application of these fundamentals. Staff rely on the practitioner for guidance on management and treatment of the disease.
“Recognition” means identifying the presence of a risk or condition. “Assessment” means clarifying the nature and causes of a condition or situation and identifying its impact on the individual. “Treatment” means selecting and providing appropriate interventions for that individual. “Monitoring” means reviewing the course of a condition or situation as the basis for deciding to continue, change, or stop interventions. Now let’s discuss the steps in the CPG.
Review available information about the patient’s recent or past physical, functional, cognitive, and behavioral status. Look for previous diagnoses that may indicate the presence of dementia. (We will look at that on table 1 from the AMDA CPG on the next slide.) Check current medical orders for medications that can alter cognitive function (e.g., psychotropics, sedatives, hypnotics, cardiac antiarrhythmics, and medications with significant anticholinergic properties). If the patient has recently been treated for an acute medical or psychiatric illness, carefully review all available transfer information, including recent hospital discharge summaries. Also review other pertinent information, including information obtained from speaking with the patient, family, or other caregivers. How the facility staff will evaluate new admissions for dementia as well as picking up new onsets of dementia should be established and standardized. The resident assessment instrument RAI) process suggests that by the 24th hour, facility and practitioners must have identified initial care concerns of patients and have interventions initiated. Provide teaching and coaching as needed. Communicate to staff your specific expectations. Recommend tools, and share your expectations of what type of information you want gathered that is significant to the patient’s care goals.
Table 1 from the AMDA CPG suggests diagnoses that indicate the presence of dementia. Look for any of these diagnoses in recent or past history. It is prudent to review all records available at transfer. But this is not without its challenges. The most common problems are: availability of these records (sometimes not available at all – home setting, respite, etc.); whether records that came with the patient are legible.
Nurses, nursing assistants, social workers, therapists, and practitioners should observe the patient&apos;s current physical, functional, and psychosocial status. Function may be assessed with one of several instruments: MDS/RAI – ADL sections Barthel Index FAQ-Functional Activities Questionnaire Cognition may be assessed using: MMSE-Mini-Mental State Examination Clock drawing test Blessed Orientation-Memory-Concentration test The Cornell Scale for Depression in Dementia may help to detect clinically significant depression in patients who have significant cognitive impairment. Dementia is typically a chronic condition, with gradual progression of symptoms such as memory loss, inability to follow directions, and inability to recognize familiar objects or use them correctly. Patients with dementia may display worse symptoms at different times but unlike patients with delirium they usually do not have altered levels of consciousness or significant day-to-day fluctuations in their function and thinking. Recent, abrupt changes in function, level of consciousness, and behaviors in patients with dementia almost always result from other acute conditions.
Certain conditions may predispose patients to dementia. Alcohol abuse Brain tumors Cerebrovascular disease Chronic subdural hematoma Creutzfeldt-Jacob disease Heavy-metal exposure HIV infection Hypothyroidism (untreated) Lyme disease Neurosyphilis Normal-pressure hydrocephalus Parkinson’s disease Pick’s disease Vitamin B12 deficiency It may also be helpful to identify patients who are at risk for progression of dementia as a result of acute conditions or medication use. The practitioner should promptly identify and manage patients with these risk factors: Host-Related Factors Infections Significant pain or trauma Urinary retention Nutritional deficiencies (including vitamin B12 deficiency) Stroke or seizure Myocardial infarction Dehydration New or unstable arrhythmias Depression Hypo- or hyperthyroidism Iatrogenic or Nosocomial Factors Drug toxicity or adverse drug reactions Recent admission to the facility Recent hospitalization Transfer to a new environment Recent surgery under general anesthesia
Document findings related to the patient’s physical, functional, and psychosocial status in the appropriate location in the medical record. The quality, rather than the quantity, of documentation is most important. Document information that will enable useful conclusions to be drawn and appropriate interventions initiated, in a manner that communicates effectively to other members of the interdisciplinary team. Common agreement of the dementia problem, supporting evidences as well as the possible care goals should be established. At this point, each discipline should have interim plans for care now.
The period immediately after admission to a long term care facility is often critical in patients with dementia. Frequently, patients with dementia are admitted without adequate documentation of prior work-up, diagnosis, or management plans. Relevant information may be unavailable or incomplete, and the reasons for existing care may be poorly understood. Immediate assessment is necessary to ensure that patients with dementia are identified promptly and appropriate interim care plans implemented. It is important, therefore, to make every effort to complete the following steps as soon as possible after admission.
The practitioner must decide if a work-up is likely to be medically useful, that is, whether testing and examination is likely to better define the patient’s status or the cause of his or her symptoms or impairments and help to guide management. If necessary, the practitioner should then consult with the patient (to the extent feasible), the patient’s family, and other interdisciplinary team members to determine if a work-up is appropriate, that is, whether the information gained is likely to result in or change interventions that may improve the patient’s quality of life. It is important to document the medical necessity of the work-up and its scope or the reasons for limiting its scope. The facility bioethics committee (if available) may provide a forum for assessing factors relevant to determining the desirability of a work-up and may recommend an appropriate course of action.
The primary aim of a diagnostic work-up in patients with dementia is identification of potentially treatable conditions. All or part of this work-up may not be indicated if the patient has a terminal or end-stage condition, if it would not change the patient’s management, if the patient or substitute decision-maker has refused treatment, or if the burden of the work-up is greater than the benefit of treatment.4
You will need to decide if these tests, which all will require a transfer from the facility, are medically appropriate and necessary.
Patients most likely to have dementia manifest impaired mental status and function. If the patient meets the criteria for a diagnosis of dementia (see next slide) proceed through the subsequent steps in the CPG. If the diagnosis of dementia is not made or confirmed, or if a patient with a prior diagnosis of dementia has a recent significant condition change, consider other causes for the patient’s symptoms before concluding either that the patient has dementia or that recent changes are due to dementia.
Adapted from DSM-IV5
Dementia always has a cause, most commonly Alzheimer’s disease or vascular disease; however, a specific cause is not readily detectable in all cases. Determining the cause may help to prevent further deterioration or may establish a prognosis. In some patients, dementia may be so far advanced or function so impaired that additional diagnostic information is not likely to be useful. Consider consultation with a specialist in neuropsychological testing or psychiatric disorders if basic evaluation and testing do not enable adequate assessment of the patient’s conditions, identification of the causes of the patient’s symptoms, or proper management.
Soon after admission or a significant condition change, assess the patient’s capabilities in various domains (e.g., general, medical, emotional, cognitive, behavioral, etc.) using an appropriate assessment instrument. Family members, nursing assistants, and other direct caregivers are important sources of information for this assessment. To ensure objectivity and accuracy as far as possible, choose and consistently use standardized terminology and appropriate evaluation tools. Behaviors may be described by specific characteristics to maximize objectivity and consistency. Problems such as falls or incontinence should not be attributed to dementia until other potentially treatable conditions have been considered. Managing other conditions appropriately often improves a patient’s function and quality of life. No matter what else has been identified as a cause of problematic behavior or altered mental state, always review the patient’s medications. Many medications can cause or contribute to impaired consciousness, increased confusion, and problematic behaviors.
Patients with dementia often have impairments in multiple domains, (e.g., functional, behavioral, social, cognitive etc.). These impairments may affect function and quality of life as much as the patient’s cognitive and behavioral deficits do. Many of these deficits may also be problematic for caregiving staff. For this reason, they should be an important consideration in care planning. Define as accurately and fully as possible the nature, scope, and severity of the patient’s behaviors and cognitive and functional impairments. Before addressing management, determine the significance of the symptoms or impairments to the patient. Socially unacceptable behaviors in patients with dementia don’t always need to be treated with medications and often respond well to nursing interventions. However, an impairment may become disruptive or dangerous to the patient’s function or may cause the patient considerable distress that medication management may become necessary.
Behavioral symptoms in dementia patients often are triggered or exacerbated by physical, organizational, or psychosocial factors. Identifying these triggers enables the use of targeted interventions to prevent or manage the disruptive behavior. The interdisciplinary team should assess how the environment may affect the patient with dementia. It may be helpful to record the events related to a challenging behavior episode. The correct identification of triggers for disruptive behavior requires substantial coordination among interdisciplinary team members. Do not assume that a behavior is triggered by environmental or other non-medical factors until alternative causes have been considered. This is especially important when patients are newly admitted, have recently been hospitalized, or have a significant condition change.
An appropriate, individualized care plan for managing the patient with dementia should include the following categories of approaches: Optimize function and quality of life and capitalize on remaining strengths Address socially unacceptable or disruptive behaviors Manage functional deficits Address pertinent psychosocial and family issues Address ethical issues Manage risks and complications related to dementia, other conditions, or treatments Ensure that all parts of the care plan are consistent and are based on appropriate assessment of the patient. Individual opinions about the management of specific problems or symptoms must be consistent with the broader goals and objectives for the patient’s care.
Patients with dementia often benefit from efforts to optimize their function and quality of life. Such efforts often include activities that target cognitive function (e.g., solving puzzles, engaging in arts and crafts, attending religious services), physical function (e.g., exercising, playing games), and spiritual well-being (e.g., attending religious services). Complementary and alternative therapies may help to optimize function and quality of life in patients with dementia. A patient may display a greater degree of functional deficit than is warranted by his or her impairments. Such “excess disability” may result from unrecognized or inadequately treated medical conditions; adverse medication effects; or emotional, psychological, and environmental factors. Addressing these factors may improve the patient’s function.
The more impaired the individual, the more the environment is likely to affect his or her function and contribute to excess disability. Environmental interventions can help to optimize function and reduce excess disability. This table, which continues on the next slide, suggests possible organizational, physical environment, and psychosocial approaches to environmental adaptation.
Patients with dementia related to specific causes may benefit from certain medical interventions. For example, medical interventions such as the use of anticoagulants, antihypertensive agents, and lipid-lowering or antiplatelet agents may prevent worsening of symptoms in a patient with multi-infarct dementia. Cholinesterase inhibitors may reduce the rate of decline in cognitive function (notably memory and attention) and may improve behavioral symptoms in patients with mild to moderate dementia. Memantine hydrochloride (an N-methyl-D-aspartate receptor antagonist) is the only medication currently approved by the U.S. Food and Drug Administration to treat patients with moderate to severe dementia of the Alzheimer’s type. This agent may be used alone or in combination with a cholinesterase inhibitor. Behavioral symptoms may be related to an acute medical condition and may respond to appropriately selected medications.
Before initiating drug therapy, ensure that the patient is appropriately assessed. Discuss the goals of therapy with the patient (to the extent feasible) and family. Set realistic expectations based on the patient’s condition and on an understanding of the likely benefits and limitations of current drug therapy for dementia. Be familiar with a medication’s side-effect profile. Monitor the patient closely for adverse drug reactions and obtain pertinent laboratory tests. Observe the patient closely for possible symptom progression or general decline, which could be due to adverse medication effects, progression of dementia, other medical conditions or complications, or a combination of these factors. Periodically assess the patient’s response to any medication to determine whether continued therapy is likely to be beneficial.
The management of socially unacceptable or disruptive behavior should be based on a careful evaluation and description of the behavior. The interdisciplinary team, in conjunction with the practitioner, should define the target symptoms (e.g., self-injury, severe agitation related to delusions) to be addressed and identify care goals. Generally, unless the behavior potentially endangers the patient or others, nonpharmacological interventions should be considered first while efforts are made to identify the causes of the problem.
Patients with dementia invariably have functional deficits. Caregivers need to be aware of these deficits and should be trained to help the patient to compensate for them while also helping to maximize unimpaired function. Focus on maintaining the patient’s dignity and encouraging him or her to use whatever capacities remain. Train staff to help patients with activities of daily living (ADLs) without provoking negative reactions. A restorative nursing program may help to optimize the function of a patient who has impaired cognition and behavior.
Practitioners should help to identify patients who are likely to benefit from such interventions and authorize appropriate evaluations and management. Rehabilitation and nursing staff should be familiar with the impact of impaired cognition and behavior on successful restorative and rehabilitative efforts and should be able to identify patients who are less likely to benefit from the continuation of such efforts. Patients with dementia who need rehabilitative services after an acute illness or injury (e.g., pneumonia or a fractured hip) often take longer to return to their baseline function than patients who are not cognitively impaired. Some may never regain their prior level of functioning. Formal rehabilitation may not be indicated for patients with moderate to severe dementia. In such cases, simple walking exercises can be effective in preventing falls and further functional decline.
Pertinent issues may include personal and family relationships, and other family issues. Work closely with families to help them understand the patient’s situation and the plans for optimizing his or her function. Impaired cognition and socially unacceptable or disruptive behavior often are frightening and confusing to family members, who may not understand the causes and significance of these symptoms. Families may resist some beneficial interventions that they mistakenly believe are dangerous, such as the use of psychoactive medications in situations when these are likely to be helpful. It may be helpful to explain to family members how impairments are defined, causes identified, and management options chosen. Practitioners should help to identify for families the implications of the patient’s underlying condition and reassure them about the appropriateness of the selected management approach. Other members of the interdisciplinary team also play important roles in providing information and support to family members.
Decision-making capacity refers to an individual’s ability to receive, process, deliberate about, and communicate information in order to make choices. It is important to note that patients with dementia may retain partial decision-making capacity in some situations. For example, they may be able to make decisions about daily activities or choices of food or clothing. Patients with mild to moderate dementia may be able to make simple health care decisions if the situation is explained to them in terms they can understand (e.g., the pros and cons of the proposed procedure). A useful screen for decision-making capacity is to see whether a patient can repeat information accurately and show that they understand the consequences of a choice. Facilities should develop policies and procedures for managing issues such as attempted sexual activity between two cognitively impaired patients or between a cognitively impaired patient and a cognitively intact resident.5 6 Input from relevant disciplines, family involvement, and an objective evaluation of decision-making capacity are helpful in handling such situations. Key facility staff should be familiar with relevant federal and state statutes and regulations.7
Obtain and review any advance directives or other specific written or verbal instructions from the patient or family. Decisions about the scope and duration of the patient’s medical treatments should be consistent with these directives. These decisions should be documented in the medical record. Specifically, document the basis for decisions not to treat various situations or conditions. Cause-specific treatments may not be indicated if the patient has a terminal or end-stage condition or if such intervention would not significantly improve the outcome. However, symptomatic treatment may improve comfort and reduce significant distress.
A common ethical issue concerns the patient with dementia who is not consuming enough food or fluids by mouth to maintain weight or adequate nutritional status. Opinions vary as to whether artificial nutrition and hydration are extraordinary medical measures or a part of ordinary care. Substantial functional decline and recurrent or progressive medical illnesses may indicate that a patient who is not eating is unlikely to benefit from artificial nutrition and hydration.8 Sometimes, short-term use of enteral nutrition may help to show whether artificial nutrition and hydration are likely to prevent further physical and functional decline. In recent years, substitute decision-makers have been given substantially more legal authority to withhold or withdraw life-sustaining medical treatments, including artificial nutrition and hydration, on behalf of incapacitated individuals. Whenever possible, include the patient in making such decisions; he or she may be able to express wishes about artificial nutrition and hydration despite having limited decision-making capacity.
Patients with dementia often have complications directly related to their disease (e.g., impaired mobility, urinary incontinence). They may also be at risk for indirect complications such as falls, adverse medication reactions, and aspiration related to tube feeding. The medical treatment of problematic behavior and impaired cognition may also cause complications that resemble an acute illness or a worsening of the underlying condition. Caregivers and the practitioner should anticipate these significant risks and complications and be prepared to address them when they occur. Such plans should address not only medical management (e.g., what to do in case of an abrupt worsening of confusion) but also ethical issues (e.g., when and whether to perform an extensive diagnostic work-up or transfer the patient to a hospital). The onset or worsening of medical illnesses or other problems in patients with dementia often precipitates a series of events, including hospitalization, functional decline, and altered nutritional status, that affect many aspects of the patient’s life and care. Understanding these risks and promptly addressing problems can sometimes prevent hospitalization and its related risks.
Monitor the patient’s progress periodically, using the same methods and criteria used in the initial assessment. Staff should be as objective as possible and should use consistent terminology and designated assessment tools and procedures to make and document their observations of patients with dementia. Nursing staff should report significant changes in the patient’s condition promptly to the practitioner after completing an appropriately detailed nursing assessment. Generally, dementia will either stabilize or progress. Progression may be gradual or rapid. Following an acute condition change, the patient may return partially or completely to his or her baseline state or may decline further.
If the patient’s condition remains stable, continue pertinent interventions. If he or she declines rapidly or progressively, the practitioner, other direct care providers, and possibly a consulting psychiatrist should assess the patient and review the medical record to identify possible reasons for the decline. Periodically, the practitioner should document functional decline that appears to be medically unavoidable (i.e., decline that results from the effects of aging or illness, including the progression of dementia that cannot or should not be treated). The practitioner should periodically review the patient’s condition and risk factors with the nursing staff and the family. As appropriate, review the staging of a patient whose behavior or function changes (improves or declines) significantly from a previous baseline. Periodic attempts, to taper one or more psychoactive medications are sometimes warranted, unless the nature of the condition (e.g., psychotic delusions) or past experience suggest that doing so may result in a return or an exacerbation of the patient’s symptoms.
Dementia – a disorder characterized by progressive decline in multiple areas of cognitive function – causes a range of cognitive, mood, behavioral, and functional impairments. By implementing the steps described in this guideline, long term care facilities can improve their ability to identify patients at risk for new or progressive dementia; manage dementia symptoms, consequences, and complications appropriately; minimize preventable functional decline; and respond appropriately to the changing needs of patients with dementia. These process improvements should help to optimize function and quality of life for many patients with dementia, minimize preventable complications and negative consequences of the condition, and improve resource utilization.
Dementia Clinical Practice Guideline For Medical Directors ...
Clinical Practice Guideline
For Medical Directors,
Attending Physicians and
• - a syndrome
in multiple areas of
deficits in ability self-
care and social and
•“…number of persons in the
industrialized world who are
affected by dementia will increase
from 13.5 million persons in the
year 2000, to 36.7 million in 20501
•Care giving challenges remain
• Expectations of guideline
–Identify dementia, new or
–Assess for underlying cause
modifications – dignity and safety
• Expectations of guideline
–Manage or minimize disability
–Prevent complications and decline
–Manage symptoms, consequences
• Expectations of guideline
– Respond to changing needs of patient
• Patient outcomes should include:
– Maintained or improved function and quality of
life prior to the end of life.
– Reduced complications and negative
consequences of the condition or its
– Improved resource utilization.
• Practitioner Responsibilities:
–Accurately assess patient’s condition
–Identify causes and factors contributing
–Assists in defining benefits and risks –
Applying the Care Process
• There are four steps to the care
–Assessment (root cause analysis)
• Step 1. Does the patient have a history
–Review of records – transfer summary
from all source (hospital, home, office,
another NH, prior records)
• History of dementia
• Current symptoms of dementia?
Diagnoses That Suggest the Presence of
• Alzheimer’s disease
• Drug, alcohol, or
• Huntington's disease
• Lewy body disease
• Multi-infarct (vascular)
• Organic brain
• Parkinson's disease
• Pick's disease
• Senile memory loss
Neurological Impairments or Behaviors That
May Suggest Underlying Dementia3
How Caregivers May
Amnesia (loss of
Apraxia (loss of ability
to coordinate learned
Cannot use utensils,
dress, use toilet
Aphasia (inability to
speak or understand)
Cannot follow directions
or engage in
Agnosia (inability to
recognize what is
faces, familiar places,
• Step 2. Does the patient have current
signs and symptoms of dementia?
–Observe patient’s current physical,
functional, and psychosocial status
–Assess cognitive status
– Function may be assessed with one of several
• Is the patients at risk for the onset of or
progression of dementia?
–Certain conditions may predispose
patients to dementia
–Identify patients who are at risk for
progression of dementia as a result of:
• acute conditions
• medication use
• Period immediately after admission is
• Patients with dementia are often
admitted without adequate
• Immediate assessment is necessary
to ensure prompt identification and
appropriate plan of care (POC)
• Step 3. Determine if further work-up is
necessary and appropriate.
–Is a work-up medically appropriate?
–If so, consult with patient and
responsible party and IDT to determine
–Document medical necessity of work-up
Elements of Diagnostic Work-up
for Patients With Dementia
• Complete blood count
• Human immunodeficiency virus (HIV) test
(if atypical sexual history)
• Metabolic screen
• Serum vitamin B12 level
• Syphilis serology
• Thyroid function test
• Computerized tomography or magnetic
resonance imaging scan of the head
• Evaluate need for CT or MRI based on
presence of atypical neurological signs
and symptoms and time of onset (rapid vs.
Purposes of a Medical Assessment in
Patients With Dementia
• Defines the causes or contributing medical
conditions or medications to the dementia, if
• Identify the relationship between the patient’s
medical conditions and his or her functional
impairment and disabilities
• Identify conditions that can be reversed or
• Define coexisting conditions and impairments
and plan management
• Help to identify and address risk factors for
• Step 4. Verify that the patient meets the
criteria for a diagnosis of dementia.
–Impaired mental status
–Consider other causes for the patient’s
symptoms before making conclusions
Diagnostic Criteria for Dementia
A. The development of multiple cognitive deficits manifested
1. Memory impairment (impaired ability to learn new information or to
recall previously learned information)
2. One or more of the following cognitive disturbances:
a) Aphasia (language disturbance)
b) Apraxia (impaired ability to carry out motor activities despite
intact motor function)
c) Agnosia (failure to recognize or identify objects despite intact
d) Disturbance in executive functioning (i.e., planning, organizing,
B. The cognitive deficits in Criteria A1 and A2 each cause
significant impairment in social or occupational functioning
and represent a significant decline from a previous level of
• Step 5. Identify the cause(s) of
–Dementia always has a cause
–A specific cause is not readily
detectable in all cases
–Determining cause may help prevent
• Step 6. Identify the patient’s strengths
–Assess patient’s capabilities
–Describe behaviors by specific
–Manage other conditions
–Always review the patient’s medications
• Step 7. Define the significance of the
patient’s symptoms, impairments, and
–Often associated with impairments in
–These deficits are problematic
–Determine significance of impairments
to the patient
• Step 8. Identify triggers for disruptive
–Behavioral symptoms often triggered
–IDT should assess if environment is
–Make no assumptions until alternate
factors have been considered
Examples of Factors That May Be
Relevant to Disruptive Behaviors
• What was the patient doing when the behavior occurred?
• What made the patient’s behavior better or worse?
• What was happening just before the behavior occurred?
• Was there a change in the environment just before the
• Who was near the individual at the time of the incident?
• What was the impact of the behavior on other people?
• Did a specific circumstance cause recurrence of the
• Step 9. Prepare an interdisciplinary
– Define treatment goals that are appropriate
for the individual patient, taking into account
the wishes of the patient and/or family;
– Incorporate definite, measurable objectives
derived from those treatment goals; and
– Allow for modification as the patient’s needs
• Step 10. Optimize function and quality
of life and capitalize on remaining
–Consider using complementary and
–Prevent excess disability
Environmental Aspects that Can Be Assessed
and Adapted to Optimize Quality of Life for
Patients with Dementia
• Personalize the environment to provide a
more home-like atmosphere
• Minimize noise
• Provide adequate lighting
• Provide a variety of daily activities
(physical, spiritual, and cognitive)
• Provide family support and education
Environmental Aspects that Can Be Assessed
and Adapted to Optimize Quality of Life for
Patients with Dementia continued
• Provide comfortable seating and mobility
• Provide way-finding cues
• Provide relevant staff education and training
• Provide space for both privacy and socialization
• Provide a safe and secure environment for
• Step 10 continued
–Consider medical interventions if
• Medications to prevent worsening of multi-
• Cholinesterase inhibitors to reduce the rate
• Memantine for moderate to sever
• Behavioral symptoms related to an acute
condition may benefit from appropriate
• Step 10 continued
– Before initiating drugs, ensure patient is
– Discuss the goals of therapy with the patient
and responsible party (RP)
– Set realistic expectations
– Monitor closely for ADRs
– Observe for symptom progression
– Periodically assess the patient’s response to
• Step 11. Address socially unacceptable
or disruptive behaviors
–Management based on careful
–Define target symptoms
–Unless behavior a danger, use non-
• Step 12. Manage functional deficits
–Caregivers need to be trained to:
• help the patient to compensate
• maximize unimpaired function
• maintain patient’s dignity
• assist patients with ADLs
• perform restorative nursing
A Word About Rehabilitation
• Practitioners should help to identify
patients who are likely to benefit
• Rehab. and nursing staff should be
familiar with the impact of restorative and
rehabilitative efforts on patient’s with
• Formal rehabilitation may not be indicated
for patients with moderate to severe
• Step 13. Address pertinent
psychosocial and family issues
–May include personal and family
–Work closely with families/RP to help
them understand the patient's situation
–Explain to family members/RP how
management options chosen
• Step 14. Address ethical issues
–Ethical issues relevant to patients with
• Defining decision-making capacity and
identifying situations that require substitute
• Addressing situations related to everyday
life (e.g., patient preferences, and socially
questionable behaviors), and
• Discussing possible limitations on medical
interventions such as hospitalization and
• Step 14 Continued
–Obtain and review advance directives
–Decisions related to (r/t) scope and
duration of treatment consistent with
–Document these decisions in the
A Word About Artificial Nutrition
• It is a common ethical issue in patients
• Opinions vary as whether an extraordinary
measure or routine care
• Substantial decline may indicate that
patient is not likely to benefit
• Short-term use of enteral nutrition may
help to show if artificial nutrition and
hydration will prevent further decline
• Step 15. Manage risks and
complications related to dementia,
other conditions, or treatments.
–Complication r/t their disease, e.g.,
impaired mobility, urinary incontinence
– At risk for indirect complications, e.g.,
falls, ADRs, aspiration
–Complications of medical treatment for
• Step 16. Monitor the patient’s condition
and adjust management as appropriate.
– Monitor the patient’s progress periodically
– Use same methods and criteria used in initial
– Nursing staff should report significant
changes in patient’s condition promptly to
– Generally, dementia will either stabilize or
• Step 16 continued
–The practitioner should:
• continue pertinent interventions if patient
• assess patient if he/she declines
• document functional decline that appears to
be medically unavoidable
• review the staging of a patient whose
behavior or function changes from baseline
• If warranted, periodically attempt to taper
one or more psychoactive medications
• Dementia causes a range of cognitive, mood,
behavioral, and functional impairments
• Implementing the steps in the guideline can:
– improve ability to identify patients at risk for new or
– manage dementia symptoms and respond
appropriately to the changing needs of patients with
• These process improvements should help to:
– optimize function and quality of life
– minimize preventable complications
– minimize negative consequences of the condition