Non-pharmacological Approach to the Alzheimer s Disease Patient

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1 Non-pharmacological Approach to the Alzheimer s Disease Patient Dr. DeeDee Hu, PharmD National Council of Certified Dementia Practitioners

2 Objectives Copyright 2009, National Council of Identify pitfalls of many pharmacological therapies Understand the goal of non- pharmacological therapies Understand the various types of NP therapy Assess those patients who may benefit from NP therapy

3 Pharmacological Therapy PROS Proven in clinical trials Target the neurological chemicals that are deficient in AD Easy therapy Once to twice daily Readily available at pharmacies CONS Cost Effect may wear off Medication may not work in all patients Side effects May exacerbate other diseases

4 Non-pharmacological Therapy Interventions that include an activity, environmental design, attitude, or communication directed at the Alzheimer s Disease (AD) patient NonPharmacological Interventions (NPI) Therapy can aid in both behavioral symptoms and memory problems Work together with pharmacological therapy to enhance the quality of life in AD patients

5 Treatment of the Alzheimer s Disease Patient Behavioral Symptoms Pharmacological management Non Pharmacological management Cognitive/ memory loss Pharmacological management Non Pharmacological management

6 Behavioral Symptoms Copyright 2009, National Council of

7 Behavioral Symptoms Copyright 2009, National Council of Often referred to as neuropsychiatric symptoms (NPS) More than half of patients have behavioral symptoms Causes The damage in the brain from AD may also cause the changes in behavior The AD patient is trying to make sense of the world around them, but is reacting in a disorganized way. Negative outcomes of NPS Increased caregiver burnout Increased caregiver turnover Increased morbidity Increased health care costs Increased hospitalizations 1. Alzheimer s Society, Non-pharmacological therapies for the treatment of behavioral symptoms in people with dementia. Jan Ayalon, L, et al. Effectiveness of Nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia. Arch Int Med Nov 2006;166:

8 Behavioral Symptoms Copyright 2009, National Council of Symptoms Restlessness or over-qactivity Depression Irritability, anxiety, or suspicion Aggression (verbal or physical) Hallucinations (seeing or hearing things that aren t there) Delusions (being disturbed by thoughts, and believing things that aren t true) Tendency to shout repeatedly or become noisy Loss of normal inhibitions (e.g. touching their private parts) Wandering 1. Alzheimer s Society, Non-pharmacological therapies for the treatment of behavioral symptoms in people with dementia. Jan 2005

9 Pharmacological management Pharmacological Agents Atypical Antipsychotics Haloperidol (Haldol ) Risperidone (Risperdal ) Olanzapine (Zyprexa ) Ziprasidone (Geodon ) Aripiprazole (Abilify ) Current evidence is not clear to the benefit of these agents in the AD patient Recent evidence has shown an increased risk of death associated with the use of atypical antipsychotics in the dementia patient Therapeutic outcomes of these agents may wear off over time These agents are associated with many potential side effects 3. Schneider LS, et al. Risk of death with atypical antipsychotic drug treatment for dementia: meta-analysis of randomized placebocontrolled trials. JAMA. 2005;294: Wang PS, et al. Risk of death in elderly users of conventional versus atypical antipsychotic medications. N Engl J Med. 2005;352:

10 Nonpharmacological management Communication methods Therapeutic activities Environmental modification Maintaining overall health

11 Communication Methods Communicate within the affected person s frame of reference. Base communication and interaction on what the patient assumes to be reality. Decreases the stress associated with interactions Communication techniques Reality therapy Validation therapy Redirection Memory cueing 5.

12 Communication methods Reality therapy: interact with the affected patient within the realms of their perceived world even if it strays for your reality. Validation therapy: Do not correct or contradict the patient s view on reality; instead, encourage it and validate it. Redirection: Be sensitive when attempting to redirect the the conversation in order to not contradict or deny the patient s sense of reality Memory cueing: Use words and visuals to cue old or recent memories 5.

13 Therapeutic activities Copyright 2009, National Council of Planning structured, individualized activities centered around the patient s interests reduces the behavioral symptoms. Goals Focus on patient s previous interests Cue the patient to old or recent memories Take advantage of the patient s remaining skills Reduce focus on any diminished skills the patient may have Group activities Create friendships Mutual support Spiritual connections Examples of activities Music therapy Gardening Cooking Painting and drawing Singing Pet therapy Walking and light exercise Videotapes of loved ones 6.

14 Environmental modification Include modifications of Lighting Color Noise Furniture placement Goal Help AD patients overcome the loss of their internal mapping abilities Internal mapping abilities help orient people to time and space Create an environment that is specifically designed to support the AD patient s abilities Increased independence More social engagement Increased safety Decreased behavioral symptomd 7.

15 Environmental modifications Example modfications: Low levels of lighting during meals (improves eating habits) Simply furnished spaces with minimal distractions Consistent background noise (musical or nature sounds) Placing objects that cue memories in clear view (photographs, mementoes) Ensuring privacy and personalized space 7.

16 Maintaining Overall health Successfully manage all other diseases states Heart disease Arthritis Diabetes Diet Well balanced, nutrient rich May require supplements in later stages of AD Exercise Increases mobility Maintains independence Improves other disease states Light exercise and walking has been shown to decrease wandering Incorporate into daily routines and scheduled activities 8.

17 Cognitive/memory loss Copyright 2009, National Council of

18 Cognitive/memory loss Copyright 2009, National Council of Characteristics Memory loss -- difficulty remembering recent facts and the inability to acquire new information Causes Alzheimer s Disease (AD) is characterized by a loss of neurons and synapses in various parts of the brain Plaque formation and neurofibrillary tangles Neurological and psychological changes Negative outcomes Increased caregiver burnout Increased caregiver turnover Increased morbidity Increased health care costs Increased hospitalizations

19 Pharmacological Mangement Pharmacological agents Razadyne (galantamine, Reminyl ) Exelon (rivastigmine) Aricept (donepezil) Cognex (tacrine) Namenda (memantine) Agents do not cure Alzheimer s Disease, rather they treat the symptons The effect may wear off over time These agents interact with many other medications These agents are associated with many side effects.

20 Nonpharmacological management Cognitive training Shown to boost daily function in healthy adults Research directed at AD patients is needed Types Memory Reasoning skills Speed of processing Examples Crossword puzzles Computer exercises Reading Word games 9. Wills, S, et al: Long-Term Effects of Cognitive Training on Everyday Functional Outcomes in Older Adults. JAMA, Dec 2006; 296 (23): Shumaker, S, et al. Behavior-Based Interventions to Enhance Cognitive Functioning and Independence in Older Adults (editorial). JAMA. Dec 2006; 296 (23):

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