The Guideline for Alzheimer’s Disease Management has been updated and is now available through the Alzheimer’s Association at www.alz.org/californiasouthland or www.caalz.org or call (323) 930-6289 or from the California State Department of Public Health, Alzheimer’s Disease Program, at www.cdph.ca.gov/programs/alzheimers.
With the aging of the United States’ population, a doubling in the rate of Alzheimer’s disease is expected within the next 20 years. The increased incidence of this disease coupled with exponential growth in published research on its management creates a challenge for primary care providers. This evidence-based practice guideline provides support for primary care providers who are increasingly encountering complex post-diagnostic management issues of this disease. The guideline’s goal is to inform decisions for the post-diagnostic management of Alzheimer’s disease including periodic assessment of the patient with Alzheimer’s disease, treatment recommendations, support recommendations for the patient and family, and an overview of legal considerations for the practitioner. In addition to primary care providers (family practitioners, internists, physician assistants and nurse practitioners), the Guideline will also be of interest to professionals who provide patient and caregiver education and support, care managers, social workers, Alzheimer’s Association staff, and adult day care providers.
The Guideline was originally published in 1998 with support from the Health Service and Resource Administration of the federal government. It was updated in 2002 with support from the California Department of Health Services. The Guideline is authored by the California Workgroup on Guidelines for Alzheimer’s Disease Management, a statewide coalition of health care providers, representatives of managed care organizations, physician provider groups, academics, state health personnel, care managers, elder law attorneys, and representatives of the Alzheimer’s Association and the Caregiver Resource Centers. The guideline is part of a statewide initiative lead by Department of Public Health, the State’s Alzheimer’s Research Centers of California and the Alzheimer’s Association to improve health care for people with Alzheimer’s disease. Implementation of the guideline is currently under way at a number of health care organizations and health plans throughout California.
Practice Issues in Alzheimer’s Disease Management
Alzheimer’s disease is a progressive, degenerative disease of the brain, and the most common form of dementia in older adults. It is estimated to afflict over 5 million people nationally and nearly half a million in the State of California. The incidence of Alzheimer’s disease doubles every five years after 60 years of age. With the aging of the baby boomers, the rate of this disease will double by 2030 and triple by mid-century. The symptom pattern in Alzheimer’s disease is characterized by a gradual onset of continuing cognitive decline including memory impairment and at least one other cognitive deficit (aphasia, apraxia, disturbance in executive functioning or agnosia) associated with decline in function in normal activities at work or home.
Risk factors for this disease include increasing age, limited education, prior head injury, and genetic predisposition. Recent research has identified potentially modifiable lifestyle activities that may lead to reduced risk for Alzheimer’s disease including aerobic exercise, a diet low in saturated fats, better control of diabetes and hypertension, cognitive stimulation and social engagement.
Alzheimer’s disease is significantly under-diagnosed, under-recognized untreated by health care providers. However, once a clinical diagnosis of Alzheimer’s disease has been made, a treatment strategy should be developed that includes evaluation for medications that may slow cognitive decline, management of co-morbid conditions and challenging behaviors, and referral of the family to supportive and health education services. The use of cholinesterase inhibitors can produce modest improvements in cognitive function and temporarily stabilize or reduce the rate of decline. Three cholinesterase inhibitors currently on the market and approved for used in mild to moderate Alzheimer’s disease include donepezil (AriceptÒ), galantamine (ReminylÒ), and rivastigmine (ExelonÒ). In addition, Namenda (memantine) an NMDA receptor antagonist, has been approved for management of moderate to late stage disease.
Management of co-morbid conditions is essential to minimize unnecessary decline in cognition and function. This includes assessment and treatment of a range of possible conditions that make the symptoms of dementia appear worse. Treatment of depression, urinary tract infections and a host of reversible conditions can restore a person with Alzheimer’s disease to a higher level of function and, in some cases, prevent premature institutionalization.
New data lend strong support for a multi-disciplinary approach to the management of Alzheimer’s disease. There is also new evidence supporting the effectiveness of patient and caregiver education and support in preventing unnecessary disease burden. Interventions now exist for the growing population of independent, very early stage patients with Alzheimer’s disease, as well as for those needing end-of-life care.
See the one-page version of the Guideline for a complete summary of recommendations.
The newly updated Guideline for Alzheimer’s Disease Management sets the standard for post-diagnostic care in the state of California and beyond. This initiative to improve the quality of health care for people with Alzheimer’s disease also includes an educational component for patients and families. An educational booklet and workshop entitled Partnering with Your Doctor are available in English and Spanish through Alzheimer's Association Chapters. For more information, contact your local chapter at (800) 272-3900.
Submitted by:
Debra L. Cherry, PhD
Executive Vice President
Alzheimer’s Association, California Southland
Freddi Segal-Gidan, PA, PhD
Director, Rancho/USC Alzheimer’s Disease Research Center of California (ARCC)
Assistant Clinical Professor, Keck School of Medicine, USC
Neal Kohatsu, MD, MPH
Chief, Cancer Control Branch
California Department of Public Health