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Parallel Session: Dementia diagnosis and treatment

Abstracts and presentations

Care diagnosis: improving the quality of primary care for people with dementia

Jan de Lepeleire, Katholieke Universiteit Leuven, Belgium,
Co-author: Mieke Vermandere

Background: The large majority of people with dementia live at home, alone or with their partner. Availability, coherence and continuity of formal and informal care providers are necessary conditions for qualitative care. Integration and cooperation of family caregivers and volunteers, general practitioners, psychiatrists, neurologists, psychologists, nurses, memory clinics and institutions for elderly care are essential. Besides the diagnosis of dementia, it is extremely important to map the care needs of the patient, and the load and coping capacities of the caregivers. But what other elements should be included in a process of ‘care diagnosis’?

Methods: Performing a Medline-search we found a number of papers in which the authors tried to give a description of care diagnosis. Based on these papers, we selected 26 items which should be included in a care diagnosis. We interviewed relevant stakeholders in dementia care: caregivers, general practitioners, nurses, a geriatric, a neurologist and a psychiatrist. The transcipted data will be analysed a qualitative way to look for key items relevant for a care diagnosis. In a second step, the results will be implemented and evaluated.

Results: We expect the final results of our study in April 2009.

Conclusion: Care diagnosis is a growing field of interest in the domain of dementia care. It is a challenge to describe the necessary elements of care diagnosis. After collecting the data from our interviews, we will present a work document for primary caregivers. The implementation of this document in daily practice and the making of a care plan will be another challenge in dementia care.

Improving the cooperation between general practitioners and community nurses in dementia care

Hendrik van den Bussche, University Medical Centre Hamburg-Eppendorf, Germany,
Co-authors: Annette Ernst, Aenne-Doerte Jahncke-Latteck, Uta Schramm

In Germany, some 75% of patients with dementia live at home, supported and nursed primarily by family caregivers. In addition, GPs and community nurses play an important role in the care, either directly towards the patient or indirectly through supporting the family caregivers. It can be presumed that an optimal communication and cooperation between GPs and nurses would be beneficial for the family caregivers in the sense of burden reduction and thus indirectly for the person with dementia. In Germany, however, this cooperation is far from optimal, as the two professions have almost no contact to define common care objectives and evaluate the effects of their care.

The objective of the study is to develop a toolbox of instruments to improve the cooperation between the two professions and to test the effects of these instruments in a complex intervention evaluated within a randomised controlled trial in Hamburg. The toolbox contains interventions on different levels, e.g. clinical conferences together with the caregivers, measures to increase accessibility, common documentation formats etc.

In the RCT, 30 nursing services working under the umbrella of the Protestant Church and covering the whole territory of the city were allocated at random to the intervention and the control arm. In the intervention arm the complex intervention will be tested over 12 months, whereas in the control group treatment as usual will take place. The project covers some 600 patients and their caregivers. Evaluation will be done by means of attitude questionnaires and case documentation. The project is actively supported by the Department of Nursing of the University of Applied Sciences, the Alzheimer Association, the Association of GPs and the Association of NurseS The project is funded by the Federal Ministry of Health.

The Liaison-Dementia Project

Michael Schuerch, IPAL, Belgium,

The «Intercommunale de Soins spécialisés de Liège» (ISoSL), is divided into three sectors of activity:

  • Sector A - Psychiatric hospital care and associated services.
  • Sector B - Specialized hospital care in geriatrics, psychogeriatrics, palliative care and rehabilitation.
  • Sector C - Residential care and services for the elderly.

Sector B has the largest psychogeriatrics centrer in Belgium, with 141 beds, a day hospital and an outpatient clinic.

The consulting psychogeriatricians and psychologists in the outpatient clinic offer specialised psychogeriatric care and follow up in sector C.

Unfortunately, this «doctors’ appointment» approach isn’t always very effective in treating patients with the behavioral and psychological symptoms of dementia (BPSD).

Simply transporting a resident with severe dementia to the clinic can be a source of difficulty and anxiety for all concerned. Also, the resident isn’t always accompanied by a family member or a professional care giver who can clearly describe the symptoms and difficulties encountered.

Meeting the patient outside of his/her residential context makes it difficult for the clinician to have a realistic and reliable idea of his/her patient’s normal functioning.

The specialist doesn’t visualize his/her patient’s everyday life setting and thus has little recourse but to prescribe medication as best he/she can, often with a small or even deleterious effect.

In order to resolve this frustrating situation for the patient, his/her family, and his/her doctors, the sectors B and C of the ISoSL have recently launched the “Liaison-Dementia” project.

This project consists of two parts:

  1. The creation of specialised psychogeriatric consultations within the sector C, residential units. This visits take place at the request of the residence family doctor with the collaboration and participation of the concerned residential care staff and, if possible, family members.
  2. The creation of a mobile multidisciplinary team experienced in the area of non pharmacological approaches to BPSD. Upon request, members of this team will visit the residential care unit and go work in partnership with the professional caregivers and the family to propose non pharmacological solutions to the specific difficulties encountered with the resident. Progressively, these interventions will permit training of the residential caregivers in the principles and practice of non pharmacological approaches. Interested, capable professional caregivers from the unit also have the possibility of integrating the team, eventually becoming a reference person within the residential care unit. As this process expands, we create the basis of a network of BPSD intervention competency.

The mobile team and the consulting psychogeriatrician must coordinate closely and are mutually dependant.

The prescription of antipsychotic drugs to people with dementia in care homes

Louise Lakey, Alzheimer’s Society, United Kingdom,

In this presentation I will outline an inquiry run by the first All Party Parliamentary Group on Dementia (APPG) in England into the use of antipsychotic drugs in care homes and the resulting impact on policy. In 2008 the APPG, which is run in partnership with Alzheimer’s Society, conducted an inquiry into the widespread inappropriate prescription of antipsychotic drugs to people with dementia in care homes. The inquiry collected evidence from key stakeholders to inform the development of recommendations for change. The results of the inquiry were disseminated and key decision makers targeted. This work has recently resulted in policy developments in England.

The APPG requested written evidence from a variety of stakeholders including people with dementia, carers, health and social care professionals, care home providers and regulators. The Group also heard oral evidence from key organisations and individuals at the House of Commons. The resulting report ‘Always a last resort’ examined the evidence of the inquiry, which revealed widespread inappropriate prescribing of antipsychotic drugs for people with dementia in care homes. Key recommendations were made to ensure that the drugs were only prescribed to people with dementia when it is appropriate and to ensure that alternatives to the drugs are available and implemented.

The findings were used to urge the government to change its policy on the use of antipsychotic drugs for people with dementia in care homes. This has resulted in a recommendation to reduce the use of antipsychotics in care homes in the National Dementia Strategy for England. The Government has also committed to carrying out a wide-ranging review of the prescription of antipsychotic drugs to people with dementia in all care settings. This will lead to a set of recommendations to resolve this issue.

I will describe the inquiry, the emerging evidence and the resulting recommendations. I will explore the key milestones following the publication of the report that led to a commitment to change within government and which had such an impact on key policy initiatives. I will refer to the future potential for this Group to influence policy for people with dementia and carers.

Cognitive-behavioural, resource-sensitive treatment for early dementia in Alzheimer’s disease (CORDIAL)

Barbara Cramer, Technische Universität München, Germany,
Co-authors: Alexander Kurz, Silvia Egert, Stefan Wagenpfeil, Lutz Frölich, Carolin Knorr, Hermann-Josef Gertz, Angelika Thöne-Otto, Katja Werheid

Background: Alzheimer’s disease can be diagnosed at an early clinical stage, but pharmacological treatment remains unsatisfactory. For patients with mild dementia the loss of previous activities and social bonds, the change of roles within the family, and the prospect of becoming a burden for loved ones are particularly troublesome. Important needs are not met, including preservation of functional ability and maintaining their relationships. Patients’ abilities in terms of learning and adaptive potential are underused.

Methods: The CORDIAL study is a multi-centre, randomised, controlled, single-blind, parallel-group study which evaluates the efficacy of a cognitive-behavioural intervention in 200 patients at the early clinical stage of Alzheimer’s disease. The treatment includes 12 weekly individual sessions of which 6 also involve the patients’ caregivers. The therapy combines interventions which have been demonstrated to improve everyday functioning, quality of life, and mood. It focuses on establishing daily routines, using external memory aids, strengthening personal identity, and enhancing pleasurable activities. Routine medical treatment is used as a comparator. The primary outcome measure is the patients’ functional ability; secondary outcome measures include quality of life, mood, and non-cognitive symptoms. The study is performed at 10 centres including 5 university memory clinics and 5 psychiatrist or neurologist offices. Assessments are performed by independent raters who are blind to the patients’ group assignment. Quality of data is ensured by regular on-site monitoring.

Results: At the time of writing 194 patients have been recruited. The cognitive-behavioural intervention achieves a high social validity and a remarkably low drop-out rate. Information on the intervention and the sampling will be presented and discussed.

Conclusion: A novel cognitive-behavioural intervention for patients with early Alzheimer’s disease is presented which aims at enhancing functional ability and emotional coping. If proven successful cognitive-behavioural therapy might become a regular component of the management of individuals with early dementia.

The 4 Ws of cognitive evaluation in Dementia – why, whom, when and how?

Pasquale Calabrese, University of Basel, Switzerland,

Although new research findings on Alzheimer´s Disease (AD) emerge at a tremendous pace the diagnosis is still based on a clinical workup considering cognitive as well as behavioural disturbances and their influence on everyday activitieS Several longitudinal studies in patients with clinically diagnosed AD have shown that there are some cognitive domains which seem to decline very early in the course of the disease, while other abilities are more robust to neurodegeneration. Moreover, behavioural manifestations also emerge during the disease evolution. Different stages can be recognised: In the mild stage, patients have memory difficulties and also problems in other cognitive functions, but are still relatively independent. In the moderate stage, patients often require assistance with activities of daily living (ADL) and may also require supervision for the safety.

Finally, in the severe stage, patients might become even unable to walk independently and also start to require assistance with eating. If follows, that assessment of a person with Alzheimer´s disease is stage-dependent. These assertions have a significant influence on clinical diagnosis-algorithms as well as on planning and evaluating drug treatments as well as non-pharmacological interventions in dementia. This contribution aims to present some stage specific aspects of dementia diagnosis as well as specific assessment methods, to detect, to track and document dementia evolution as well therapeutic approaches. Potential benefits as well as limitations of cognitive testing as well as some ethical aspects are also discussed.



Last Updated: Wednesday 21 October 2009