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SHOULD TREATMENT OF ALZHEIMER’S DISEASE BE LESS AGGRESSIVE IN THE LONG-TERM CARE SETTING?
CHICAGO—Active and aggressive treatment of Alzheimer’s disease should not stop when a patient enters a long-term care facility. Educating nursing staff to recognize the disease and implementing better behavior management may be the key to providing the best care for patients in this setting.
Addressing the 2001 Annual Scientific Meeting of the American Geriatrics Society, Sharon Brangman, MD, emphasized that managing Alzheimer’s disease doesn’t differ that much once a patient is in the nursing home. “We still use the same medications. They still have the same efficacy. And they’re still appropriate,” she said. Alzheimer’s disease “can be successfully managed in the long-term care setting.”
According to Dr. Brangman, Associate Professor of Medicine at the State University of New York Upstate Medical University, “Alzheimer’s disease is underdiagnosed and undertreated in the long-term setting just as much as it is in the office setting.” She said that more than 60% of the patients in nursing homes have the disease and added that behavioral problems and other issues created by the dementia increase both patient discomfort and staff burden. “There are no prescribing guidelines for behavioral problems, so that also creates difficulty for physicians and nursing staff who want to address some of these issues,” she said.
Evaluating and treating the contributory or reversible factors and addressing patient safety issues are very important in the long-term care setting. Dr. Brangman said that staff working in nursing homes may not be familiar with the nuances of treating Alzheimer’s disease patients, and many patient behaviors can be triggered by how staff members approach the patient. “The aide level employee is often the most untrained person, but they’re delivering the most critical care,” she noted.
EFFECTIVE CARE STRATEGIES
An effective care plan for Alzheimer’s disease patients in the nursing home includes both non-pharmacologic and pharmacologic strategies, according to Dr. Brangman. Creating a calming environment for patients, as well as getting them to exercise more and limiting their television viewing, can be very beneficial. “Non-pharmacologic approaches, I don’t think, are used often enough,” said Dr. Brangman. “And again this may have to do with staffing issues and staff education.”
Effective behavior management involves looking at how the patients are being approached by staff, and environmental factors are very important. “We all know that the change of shift in nursing homes is a time of great confusion,” she said. “That’s when a lot of patients begin acting out. There’s so much noise. There are things going on that they can’t quite understand, and they tend to get more agitated. We have to begin to look at the environment. Some innovative facilities are addressing these issues, but I’m afraid that most of them are still using the old institutional setting, which is only exacerbating behavior and memory problems.” She offered that some patients may have a routine of taking their shower or watching a favorite television show at night, so a change in this schedule may be very agitating to them. “What would be the harm of looking at the way we prioritize and deliver care and make sure that we’re giving care that is to benefit the patient and not to be convenient to the staff, especially if those regimens trigger behavior issues?” she asked.
Another problem, according to Dr. Brangman, is that nursing home residents are not active enough, and therefore providing a safe environment for them to move around in is crucial. “I know that many nursing homes are still parking their residents in front of the elevator all day and then putting them to bed at 6:30 PM, and you start to get those calls because they can’t go to sleep,” she said. “They are not doing anything to keep active, and that’s not making them tired. Are they able to wander and walk around? If you have a safe place for them to wander, they can use some of this energy, and that may make them less irritable and agitated.”
Dr. Brangman said that patients in the moderate stage of Alzheimer’s disease respond well to acetylcholinesterase inhibitors. “We see improvements in some behaviors as well as in function and cognition, and these medications work very well with psychotropic management as well as antidepressant therapy,” she said. “There are no contraindications there. So we want to maintain therapy in the advanced stages to help continue the benefits we’ve seen in maintaining cognitive and functional status.” Dr. Brangman added that a recent study involving donepezil and nursing home patients showed “significant improvement” in patients’ global function. Ongoing research may help answer the question as to what benefit donepezil has in treating patients with severe Alzheimer’s disease.
Patients’ other medical problems, including the number and cost of medications, also affect how they are treated for Alzheimer’s disease. “We also know about polypharmacy, and in nursing homes, at least in New York State, there are triggers when somebody is on nine or more medications,” explained Dr. Brangman. “And that happens very frequently, because by the time you start antacids and laxatives and all sorts of other medications, it doesn’t take long for somebody to be on more than nine medications.” She added that depending on the nursing home, there are prospective payment issues. “We have capitation. Cost is a factor. If [patients] are on nine medications, they are probably already over their cap, so do we continue anticholinesterase therapy?”
ASSESSING PATIENT RESPONSE TO TREATMENT
In the nursing home setting, Alzheimer’s disease in patients is likely to be more advanced. Dr. Brangman noted that most families are filled with guilt about placing their loved ones in nursing homes no matter how appropriate and needed it might be, and, therefore, supporting and educating the family is very important. “People tend to have more end-stage disease, and that’s why they’re in a nursing home, because families can’t manage them,” said Dr. Brangman. “Behavioral symptoms are more prevalent, because we know that those are the issues that become increased as the disease progresses.”
Assessing response to therapy for patients with end-stage Alzheimer’s disease has been an ongoing debate. “We may look at symptomatic treatment,” said Dr. Brangman. “Do we see better behaviors? Is the patient more cooperative with activities of daily living? Is the decline less than we would have expected if they had been on no medication at all? Are we seeing improvement? And that does happen in some cases. I think we’ve shown evidence that proves that active and aggressive treatment does benefit the patient,” she concluded.
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—Colby Stong
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