Page 15 - Dementia-Care-Specialist-Toolkit

Alzheimer’s Clinical Care Guideline
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ASSESSMENT Understand (or Know) the Patient

Address the Patient Directly Monitor and Reassess Changes • Comorbid medical conditions, which may
• Confirm, disclose and document the diagnosis in Upon sudden changes or significant decline, and at present with sudden worsening in cognition
the patient record. least annually, conduct and document the following: and function or changes in behavior, and could
• Identify the patient’s culture, values, primary • Ability to manage finances and medications, as complicate management of dementia;
language, literacy level, and decision- well as daily functions, including feeding, bathing, • Emotional, behavioral and/or mood symptoms;
making process. dressing, mobility, toileting and continence; • Medications, both prescription and
• Identify the primary caregiver and assess the • Cognitive status, using a valid and reliable non-prescription, for appropriate use
adequacy of family and other support systems, instrument, e.g., MoCA (Montreal Cognitive and contraindications; and
paying attention to the caregiver’s own mental Assessment), AD8 (Ascertian Dementia 8) or • Adequacy of home environment, including
and physical health. other tool; safety, care needs, and abuse and/or neglect.

CARE PLAN Beneficial Interventions

Disease Management • Consult with or refer to mental health Document Goals of Care
• Discuss the progression and stages of the professionals as needed. • Explore preferred intensity of care to include
disease. • IF non-pharmacological approaches prove palliative care and end-of-life options such as
• Evaluate and manage comorbidities in context of unsuccessful, THEN use medications targeted to hospice.
dementia and prognosis. specific emotions, behaviors or moods, if clinically • Provide information and education on advance
• Consider use of cholinesterase inhibitors, N- indicated. Note, many medications carry an health care directives, Do Not Resuscitate
FDA black box warning and side effects may be
Methyl-D-aspartate antagonist, and other serious, significant or fatal. Orders, Physicians Orders for Life Sustaining
medications, if clinically indicated, to slow Treatment, Durable Power of Attorney and other
cognitive decline. Evaluate Safety Issues documents.
• Promote and refer to social services and • Discuss driving, wandering, firearms, fire hazards, Promote Healthy Living
community support. etc. Recommend medical identification for • Discuss evidence in support of modifiable risk
patients who wander.
Treat Emotional, Behavioral and/or Mood Symptoms factors, e.g., regular physical activity and diet/
• First consider non-pharmacologic approaches nutrition.
such as counseling, environmental modification, Refer to Clinical Studies
task simplification, activities, etc. • If interested, advise patient and family of
opportunities to participate in research.

EDUCATION AND SUPPORT Engage with the Community
For statewide patient and family resources, link to:
Connect with Social and Community Support California Department of Public Health, Alzheimer’s
• Involve the patient directly in care planning, treatment decisions and referrals to community Disease Program (916) 552-9900
resources. cdph.ca.gov/programs/Alzheimers/Pages/default.aspx
• As the disease progresses, suggest appropriate home and community-based programs and Check for local services in your area.
services.
• Link the patient and caregiver to support organizations for culturally appropriate educational
materials and referrals to community and government resources.

IMPORTANT CONSIDERATIONS Time Sensitive Issues
Advance Planning Elder Abuse Eligibility for Benefits
• Discuss the importance of basic legal and • Monitor for evidence of and report all suspicions • Patients diagnosed with early-onset
financial planning as part of the care plan and of abuse (physical, financial, sexual, neglect, Alzheimer’s disease may be eligible for
refer for assistance. isolation, abandonment and/or abduction) to Social Security compassionate allowance.
Adult Protective Services, Long-Term Care • Other benefits may include Department of
Capacity Evaluations Ombudsman or the local police department, as
• Assess the patient’s decision-making capacity required by law. Veterans Affairs or long-term care insurance
coverage under existing policies.
and determine whether a legal surrogate has
been or can be identified. Driving
• Consider literacy, language and culture in • Report the diagnosis of Alzheimer’s disease in
assessing capacity. accordance with California law.

2017, rev. 4 *This guidance may apply to other forms of dementia as well as mild cognitive impairment. California Department of Public Health
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