with memantine (Namzaric) for individuals with moderate to severe AD. None of these medications has any effect on the pathological process of AD. Individuals with AD may be on a variety of other medications to manage symptoms associated with dementia, such as behavioral changes (e.g., agitation, aggression), mood disorders (e.g., depression), sleep disturbance, and/or other psychological (e.g., anxiety) or psychiatric (e.g., hallucinations) conditions. Sometimes considerations related to these medications can impact therapeutic management, so it is important for therapists to understand the implications and potential side effects of these medications, as well as any other medications that individuals with AD may be taking for comorbid conditions. In 2015, the American Geriatric Society updated the Beers Criteria for Potentially Inappropriate Medication Use in Older Adults (American Geriatrics Society, 2015), and this is an excellent resource for rehabilitation professionals to use in support of their assessment of polypharmacy in their older adult clients and patients. domains of care. The framework represents a comprehensive approach to care that may be useful for facilities and individuals offering services to people with AD. The six care domains are represented in Table 3. This conceptual framework is included to remind rehabilitation professionals of the extensive care needs of individuals with AD and their families. Although professional roles may most obviously fall into Domains 1 and 2 (Patient Function and Caregiver Support), the professional responsibility of acting as a resource and advocate for patients or clients may require functioning in any of the domains.
6 months, although study lengths vary (Birks & Grimley Evans, 2015; Birks & Harvey, 2018). Families sometimes expect to see a significant improvement in individuals with AD when they start these medications, but there is often no discernible change upon initiation of treatment. Gastrointestinal complications (diarrhea, nausea, vomiting, and weight loss) are common side effects of cholinesterase inhibitors and sometimes require a change in administration route to dermal patch or discontinuing the medication. A fourth medication approved by the FDA, memantine (Namenda) is prescribed in cases of moderate to severe AD and works by blocking N-methyl-D-aspartate (NMDA), a glutamate receptor. Glutamate is a neurotransmitter that functions in learning and memory but is neurotoxic in excessive amounts. Memantine may be used alone or in combination with cholinesterase inhibitors and has been shown to have a small effect on cognition and behavior in individuals with moderate to severe AD (Kishi et al., 2017; Matsunaga, Kishi, & Iwata, 2015). Common side effects of Namenda include dizziness, confusion, headache, and constipation. The most recent addition to the FDA-approved drugs for AD is a combination of donepezil Care continuum The National Chronic Care Consortium, along with the Alzheimer’s Association, developed tools for the early identification, assessment, and treatment of people with AD and dementia (National Chronic Care Consortium, 2003). Although the consortium is no longer in effect, conceptually, this model remains useful. The tools describe care management of dementia in three phases: initial identification, longitudinal monitoring, and end-of-life stage. In each stage, desired outcomes, assessment procedures, goals, and possible medical and nonmedical interventions are provided for six important
Table 3: Six Care Domains for Persons with Alzheimer’s Disease • Domain 1: Patient function Patient is functioning at maximum level of independence consistent with physical potential and patient and caregiver wishes. • Domain 2: Caregiver support Caregiver (or caregivers) identified and given information and support to best balance his or her caregiver role and personal life in accordance with personal needs and wishes of caregiver. • Domain 3: Medical care Patient receives optimal medical care consistent with accepted standards of care and patient and caregiver preference. • Domain 4: Psychosocial Patient and caregiver understand monitoring parameters to assess mood and behavioral concerns and are satisfied with employed management strategies. • Domain 5: Patient nutrition Patient is in targeted body weight range, and patient and caregiver are satisfied with diet and nutritional status. • Domain 6: Advance directives planning Patient and caregiver understand purposes of advance directives, living will, and durable power of attorney for health care; the patient enacts them according to his or her personal values and needs and, ultimately, the caregiver sees that his or her wishes are followed. Note . Adapted from Chronic Care Networks for Alzheimer’s Disease. (2003). Tools for early identification, assessment, and treatment for people with Alzheimer’s disease and dementia . Retrieved from http://www.alz.org/national/documents/brochure_toolsforidassesstreat.pdf. Reprinted with permission. MOVEMENT DISORDERS ASSOCIATED WITH ALZHEIMER’S DISEASE
Once believed to occur late in the course of the disease, movement disorders, particularly gait changes, are now recognized to occur with MCI and early in the course of dementia (Bridenbaugh & Kressig, 2014). In fact, there is convincing evidence that subtle subclinical gait changes Gait Normal aging brings about predictable gait changes. Older adult gait is not simply a slower version of young adult gait. The following temporal, spatial, and postural changes have been repeatedly evidenced in systematic reviews of gait changes with aging: ● Decreased self-selected gait speed. ● Decreased step and stride length. ● Increased stance time and double-limb support time.
(temporal-spatial parameter changes that are evident on a computerized walkway but not to the naked eye) are predictive of cognitive decline in older adults (Beauchet et al., 2016; Kikkert, Vuillerme, van Campen, Hortobágyi, & Lamoth, 2016; Valkanova & Ebmeier, 2017). ● Increased step width (not a universal finding across studies). ● Increased variability of gait (operationally defined as variability in step or stride time, length, or width). ● Decreased excursion of movement at lower extremity joints. ● Decreased reliance on ankle kinetics and power. ● Less upright posture. (Beauchet et al., 2017; Boyer, Johnson, Banks, Jewell, & Hafer, 2017; Herssens et al., 2018)
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