• American Medical Directors Association (AMDA). Dementia. Columbia (MD): American Medical Directors Association (AMDA); 2005. 28 p. [20 references]

This is the current release of the guideline.

This guideline updates a previous version: American Medical Directors Association (AMDA). Dementia. Columbia (MD): American Medical Directors Association (AMDA); 1998. 32 p.

Dementia

Diagnosis
Evaluation
Management
Treatment

Geriatrics

Advanced Practice Nurses
Allied Health Personnel
Nurses
Pharmacists
Physicians
Social Workers

• To offer care providers and practitioners in long-term care facilities a systematic approach to recognizing, assessing, treating, and monitoring patients with dementia, including impaired cognition and problematic behavior
• To help practitioners to provide dementia patients with a systematic assessment and care plan, leading to appropriate management that maximizes functioning and quality of life and minimizes the likelihood of complications and functional decline

Elderly individuals and/or residents of long-term care facilities who have, or are suspected of having, dementia

Recognition/Assessment

1. Review patient history
2. Evaluate signs and symptoms
3. Perform diagnostic work-up, if appropriate
4. Determine if patient meets criteria for dementia
5. Identify cause of dementia, if possible
6. Identify patient's strengths and deficits
7. Define the significance of patient's symptoms, impairments, and deficits
8. Identify triggers for disruptive behavior

Treatment

1. Prepare interdisciplinary care plan
2. Optimize function and quality of life and capitalize on remaining strengths
   • Consider using complementary & alternative therapies
   • Prevent excess disability
   • Consider medical interventions if appropriate
3. Address socially unacceptable or disruptive behaviors, using both non-pharmacological and pharmacological interventions
4. Manage functional deficits
5. Address pertinent psychosocial and family issues
6. Address related ethical issues
7. Manage risks and complications related to dementia, other conditions, or treatments

Monitoring

Monitor the patient's progress and adjust management as appropriate

• Level of functioning:
  • Functional assessment measures such as the Activities of Daily Living (ADL) portion of the Minimum Data Set (MDS), the Barthel Index, or the Functional Activities Questionnaire (FAQ)
  • Cognitive function assessment measures such as the Mini-Mental State Examination (MMSE), the Clock Drawing test, the Blessed Orientation Memory-Concentration Test, or other comparable instruments
• Signs and symptoms of dementia
• Quality of life
• Complications and functional decline

Searches of Electronic Databases

Not stated

Not stated

Expert Consensus

Not applicable

Review

Not stated

Expert Consensus

This guideline was developed by an interdisciplinary workgroup, using a process that combined evidence and consensus-based approaches. The Workgroup included practitioners and others involved in patient care in long-term care facilities. Beginning with a general guideline developed by an agency, association, or organization such as the Agency for Healthcare Research and Quality (AHRQ), pertinent articles and information, and a draft outline, each group worked to make a concise, usable guideline tailored to the long-term care setting. Because scientific research in the long-term care population is limited, many recommendations were based on the expert opinion of practitioners in the field.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

Guideline revisions were completed under the direction of the Clinical Practice Guideline Steering Committee. The committee incorporated information published in peer-reviewed journals after the original guidelines appeared, as well as comments and recommendations not only from experts in the field addressed by the guideline but also from "hands-on" long-term care practitioners and staff.

All American Medical Directors Association (AMDA) clinical practice guidelines undergo external review. The draft guideline is sent to approximately 175+ reviewers. These reviewers include AMDA physician members and independent physicians, specialists, and organizations that are knowledgeable of the guideline topic and the long-term care setting.

The type of evidence supporting the recommendations is not specifically stated.

The guideline was developed by an interdisciplinary workgroup, using a process that combined evidence- and consensus-based approaches. Because scientific research in the long-term care population is limited, many recommendations were based on the expert opinion of practitioners in the field.

Expected Outcomes from Implementation of this Clinical Practice Guideline

Implementation of this guideline should:

• Identify patients who are at risk for new or progressive dementia
• Identify the nature and causes of dementia in different patients
• Make appropriate environmental modifications to maximize patient dignity, comfort and safety
• Identify and manage potential sources of excess disability
• Minimize preventable complications and functional decline
• Manage dementia symptoms, consequences, and complications effectively and appropriately
• Respond appropriately to the changing needs of patients with dementia

Anticipated care outcomes: As a result of the above, the following patient-related outcomes may be anticipated:

• Maintained or improved function and quality of life prior to the end of life
• Reduced complications and negative consequences of the condition or its management
• Improved resource utilization

• Examples of complications from medical treatment of problematic behavior:
  • Adverse reactions to medication
  • Worsening of disruptive or socially unacceptable behavior
  • Increased lethargy or confusion
  • Cardiac arrhythmias
  • Orthostatic hypotension

• This clinical practice guideline is provided for discussion and educational purposes only and should not be used or in any way relied upon without consultation with and supervision of a qualified physician based on the case history and medical condition of a particular patient. The American Medical Directors Association, its heirs, executors, administrators, successors, and assigns hereby disclaim any and all liability for damages of whatever kind resulting from the use, negligent or otherwise, of this clinical practice guideline.
• The utilization of the American Medical Directors Association's Clinical Practice Guideline does not preclude compliance with State and Federal regulation as well as facility policies and procedures. They are not substitutes for the experience and judgment of clinicians and caregivers. The Clinical Practice Guidelines are not to be considered as standards of care but are developed to enhance the clinician's ability to practice.

The implementation of this clinical practice guideline (CPG) is outlined in four phases. Each phase presents a series of steps, which should be carried out in the process of implementing the practices presented in this guideline. Each phase is summarized below.

1. Recognition
   • Define the area of improvement and determine if there is a CPG available for the defined area. Then evaluate the pertinence and feasibility of implementing the CPG

2. Assessment
   • Define the functions necessary for implementation and then educate and train staff. Assess and document performance and outcome indicators and then develop a system to measure outcomes

3. Implementation
   • Identify and document how each step of the CPG will be carried out and develop an implementation timetable
   • Identify individual responsible for each step of the CPG
   • Identify support systems that impact the direct care
   • Educate and train appropriate individuals in specific CPG implementation and then implement the CPG

4. Monitoring
   • Evaluate performance based on relevant indicators and identify areas for improvement
   • Evaluate the predefined performance measures and obtain and provide feedback

Living with Illness

Effectiveness
Patient-centeredness

• American Medical Directors Association (AMDA). Dementia. Columbia (MD): American Medical Directors Association (AMDA); 2005. 28 p. [20 references]

Not applicable: The guideline was not adapted from another source.

1998 (revised 2005)

American Medical Directors Association - Professional Association

Organizational participants included:

• American Association of Homes and Services for the Aging
• American College of Health Care Administrators
• American Geriatrics Society
• American Health Care Association
• American Society of Consultant Pharmacists
• National Association of Directors of Nursing Administration in Long-Term Care
• National Association of Geriatric Nursing Assistants
• National Conference of Gerontological Nurse Practitioners

Funding was provided by educational grants through Bayer Pharmaceuticals, Eisai, Inc./Pfizer, Eli Lilly & Company, Merck & Company, Novartis Pharmaceuticals, Parke-Davis, and Wyeth-Ayerst Laboratories.

Steering Committee

Committee Members: Marjorie Berleth, MSHA, RNC, FADONA; Susan M. Levy, MD, CMD; Lisa Cantrell, RN, C; Harlan Martin, RPh, CCP, FASCP; Charles Cefalu, MD, MS; Geri Mendelson, RN, CNAA, MEd, NHA; Sherrie Dornberger, RNC, FADONA; Evvie F. Munley; Sandra Fitzler, RN; Jonathan Musher, MD, CMD; Joseph Gruber, RPh, FASCP, CGP; Mary Tellis-Nayak RN, MSN; Larry Lawhorne, MD, CMD; Barbara Resnick, PhD, CRNP; Steven Levenson, MD, CMD; William Simonson, PharmD., FASCP, CGP

Not stated

This is the current release of the guideline.

This guideline updates a previous version: American Medical Directors Association (AMDA). Dementia. Columbia (MD): American Medical Directors Association (AMDA); 1998. 32 p.

None available

This summary was completed by ECRI on July 12, 1999. The information was verified by the American Medical Directors Association as of August 8, 1999. This NGC summary was updated by ECRI on August 26, 2005. This summary was updated by ECRI Institute on July 25, 2008, following the U.S. Food and Drug Administration advisory on Antipsychotics.

This NGC summary is based on the original guideline, which is copyrighted by the American Medical Directors Association (AMDA) and the American Health Care Association. Written permission from AMDA must be obtained to duplicate or disseminate information from the original guideline. For more information, contact AMDA at (410) 740-9743.