17. AD prognosis Optimal case Mini Mental State Examination score 1 2 3 4 5 6 7 8 9 25 ---------------------| Symptoms 20 |----------------------| Diagnosis 15 |-----------------------| Loss of functional independence 10 |--------------------------------| Behavioral problems 5 |-------------------------------------------| 0 Death |------------------------------------------ Nursing home placement Feidman and Gracon, 1996 Years
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23. Hallucinations Delusions Misidentifications ‘ Psychosis’ Adapted from McShane R. Int Psychogeriatr 2000; 12(Suppl 1): 147 –54 Finkel SI et al. Am J Geriatr Psychiatry 1998; 6: 97–100 Alessi C et al. J Am Geriatr Soc 1999; 47: 784–91 Kelompok Gejala BPSD Aggressive resistance Physical aggression Verbal aggression ‘ Aggression’ Withdrawn Lack of interest Amotivation ‘ Apathy’ Sad Tearful Hopeless Low self-esteem Anxiety Guilt ‘ Depression’ ‘ Agitation’ Walking aimlessly Pacing Trailing Restlessness Repetitive actions Dressing/undressing Sleep disturbance
34. The role of the primary care physician in mild to moderate AD * Define all contributory factors and other illnesses * Discuss the diagnosis, and differentiate other types of dementia * Withdraw non-essential drugs that may interfere with cognition * Treat or manage concomitant illness (e.g. depression, hearing loss) Gauthier, Burns and Pettit, 1997
35. The role of the primary care physician in mild to moderate AD (continued) * Discuss the use of symptomatic therapies * Monitor functional ability e.g. driving, safety * Referral to specialist if appropriate * Advise on will-making and advance directives * Refer to local AD association for support * Managing caregivers Gauthier, Burns and Pettit, 1997
36. The role of the primary care in severe AD * Help caregivers discover and optimize the patient's preserved function * Monitor and treat complications * Facilitate caregiver support (respite and day care programs) * Be aware of caregiver burden and stress * Plan institutionalization, if needed * Assist with end-of-life decisions Gauthier, Burns and Pettit, 1997
37. Diagnosing AD in primary care A systematic approach summary CASE-FINDING Symptoms suggesting cognitive impairment MANAGEMENT OF AD *Follow-up *Patient and caregiver counseling *Management and symptomatic treatment *Specialist referral if indicated CLINICAL ASSESSMENT *Clinical history *Physical examination *Laboratory tests *Functional assessment *Cognitive assessment Functional decline and cognitive impairment DIFFERENTIAL DIAGNOSIS *Exclude delirium depression other causes of dementia *Evaluate evidence for AD (neuroimaging) YES AD diagnosis
38. Primary care management of AD follow-up * Cognitive ability * Functional ability * Behavior * General health * Routine health checks
39. Primary care management of AD specialist referral * Inconclusive diagnosis * Atypical presentation * Behavioral/psychiatric symptoms * Second opinion * Family dispute * Caregiver support
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Hinweis der Redaktion
In the optimal case, the course of AD progression can be divided conveniently in to three stages, early, mild to moderate, and severe. In the early stages of the disease, the patient will generally remain symptom-free. As the illness progresses, the extent of cognitive impairment becomes such that patient and caregivers recognize that there is a problem. A progressive and insidious decline in cognition and functional ability marks the mild to moderate stage. Cognitive loss leads to functional decline and behavioral symptoms. The rate of decline varies from patient to patient. During the later severe stages of the illness functional ability is lost completely and institutionalization is inevitable. Although AD is a progressive disease for which there is currently no cure, symptomatic treatments are becoming available that maintain or may improve the patient's functional ability. Despite new symptomatic treatments having not been shown to affect the underlying disease process, the ability to maintain function or cognitive capabilities for longer should be viewed as a viable treatment objective. Expectations, however, should be realistic. Feldman H, Gracon S. Alzheimer's disease: symptomatic drugs under development. In: Gauthier S (ed). Clinical Diagnosis and Management of Alzheimer's Disease. London: Martin Dunitz, 1996:239259. Reproduced by kind permission.
The next two slides examine the role of the primary care physician in mild to moderate AD. AD is probably the most common mental disorder affecting the elderly. In the community, however, perhaps up to half of all sufferers may remain unidentified. The primary care physician (PCP) currently cares for the majority of patients with AD, either at home or in long-term nursing homes. The PCP is in an excellent position to diagnose and manage AD within the community, and can provide the following support (see slides) in the early stages of the disease. Gauthier S, Burns A, Pettit W. In: Alzheimer's Disease in Primary Care. London: Martin Dunitz, 1997. Reproduced by kind permission.
Gauthier S, Burns A, Pettit W. In: Alzheimer's Disease in Primary Care. London: Martin Dunitz, 1997. Reproduced by kind permission.
In the later stages of AD, when the decline in the patient's functional ability is most pronounced, the PCP can help caregivers recognize and optimize the patient's remaining or preserved function. At this stage it is also important to regularly monitor and treat, if appropriate, complications and concomitant illnesses. In severe AD the stress and burden on the caregiver is at its greatest. If available, some form of caregiver support should be arranged, such as respite or day care programs, which are now becoming widely available. Inevitably it will be necessary to plan for institutionalization and assist in end-of-life decisions. Gauthier S, Burns A, Pettit W. In: Alzheimer's Disease in Primary Care. London: Martin Dunitz, 1997. Reproduced by kind permission.
A structured and systematic approach is required to ensure the early diagnosis and management of AD. The diagnostic process includes: Case-finding Clinical assessment Differentiating AD from other causes of dementia Management of AD
Once the diagnosis is certain, scheduled follow-up, initially at short intervals to answer questions, will be required. Continuing, scheduled follow-up visits will be needed, in order to implement a proactive, anticipatory approach that will reduce the impact of the illness on the patient and family. The progressive nature of AD makes follow-up and continuity of care essential. Careful, structured questioning during the follow-up assessments will monitor the progression of the disease, and determine how the caregivers are coping. At each follow-up visit ask about: *Cognitive function: evidence of deterioration since last visit, if any *Functionality, particularly in daily living skills essential for independence, such as driving, shopping, traveling *Behavioral issues, ask about mood and motivation and any difficulties the family has with handling the patient *General health questions, always include nutrition, weight, sleep, mobility/gait, balance problems/falls and any bladder (incontinence) or bowel (constipation) problems *Routine health maintenance (e.g. immunization, cancer checks, etc)
Following the initial diagnosis or after follow-up visits, it may be necessary to refer the patient to a specialist center for further examination. Specialist assessment may be necessary when the: *Patient is obviously having problems with memory and performance but clinical assessment reveals inconclusive evidence of cognitive and functional decline *Presentation, progression or examination is not typical of that expected in AD, making it difficult to make a correct differential diagnosis without specialist evaluation *Behavioral/psychiatric symptoms associated with AD, such as anxiety, depression, delusions, and hallucinations (which are distressing for both the patient and caregivers), do not respond to conventional treatment *Patient or family do not accept the diagnosis and request a second opinion to confirm the decision *Family members are in dispute regarding the management plan for the future care of the patient *Caregiver requires support in providing care for the patient. Referral to respite centers or day care programs can ease the burden and make it easier to cope. In addition, caregivers often suffer from depression and other health problems. Specialist referral may be appropriate in some cases
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