● Abstraction assessment requires the identification of similarities between words. ● Orientation assessment includes date, month, year, day, place, and city. The MoCA is readily available (MoCA: Montreal Cognitive Assessment, 2018), and it is becoming more widely used in clinics and research, likely due to relatively recent copyright limitations on the MMSE that have made its use more restricted over the past several years. The suggested cutoff score of ≥ 26 out of a total possible score of 30 delineates normal cognitive function from possible MCI or dementia (Nasreddine et al., 2005). Positive screens for dementia using rapid assessment tools such as the MMSE, Mini-Cog Assessment, or MoCA are suggestive of the need for further testing and do not constitute a diagnosis of dementia or neurocognitive disorder. Once diagnosed with dementia, there are different staging tools that can be used to determine an individual’s cognitive and/or functional level. The Global Deterioration Scale (GDS; Reisberg, Ferris, de Leon, & Crook, 1982) or the Brief Cognitive Rating Scale (BCRS; Reisberg & Ferris, 1988) may be used to classify the stage of dementia based on a prescribed set of clinical characteristics. Both of these tools are based on Reisberg’s Pharmacology Despite recent encouraging progress with respect to understanding the pathology of AD, there is no cure and no effective treatment for the disease. There are some medications approved for management of AD symptoms; but pharmacological management has proven to be disappointing. The goals of maintaining cognitive functioning, slowing functional decline, and effectively managing disabling symptoms have been elusive. Currently, the U.S. Food and Drug Administration (FDA) has approved five medications for the treatment of AD symptoms. The medications represent two different families of drugs with different mechanisms of action. Three of the approved medications are acetylcholinesterase inhibitors (also called cholinesterase inhibitors ), which stop or slow the action of acetylcholinesterase, an enzyme that breaks down acetylcholine (ACh). ACh is critical for the normal functioning of neurons within the hippocampus and cerebral cortex, is neuroprotective, and has been identified as deficient in individuals with AD. The approved medications are donepezil (Aricept), rivastigmine (Exelon), and galantamine (Reminyl). Medication is prescribed upon diagnosis of the disease and has been demonstrated to be modestly effective in slowing functional and cognitive decline over a course of approximately 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, 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
seven-stage model described earlier and are clinically friendly for use. The Clinical Dementia Rating (CDR; Morris, 1993) scale is widely used as a staging tool in research but the time required for administration prohibits its use clinically. The CDR is a tool that utilizes information from both the caregiver and patient to determine the level of impairment in memory and orientation, judgment and problem solving, and functioning in self-care, home, and community activities. Scores range from 0 (no impairment) to 3 (severe impairment). Many factors complicate the diagnosis of AD. The disease may go unrecognized because of the common assumption that changes in memory and other cognitive symptoms are part of the normal aging process. The hallmark diagnostic criterion for dementia is that memory, cognitive, or language impairment are significant enough to interfere with daily life functions. In some cases, people may experience MCI, problems with memory, language, or another mental function severe enough to be noticeable to other people and to show up on tests, but not serious enough to interfere with daily life. Studies have demonstrated that 22% to 33% of individuals diagnosed with MCI go on to develop dementia over the ensuing 3 to 5 years (Britt et al., 2011; Kaduszkiewicz et al., 2014).
MEDICAL MANAGEMENT OF ALZHEIMER’S DISEASE
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 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.
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