Mental Health Practice Guidelines
The below guidelines are meant for mental health professionals to use in their clinical practices. Please be aware that there are various authoring organizations. The NGC has summarized these guidelines. Links are provided to the original source within the guideline documents.
Guideline Title
Dementia.
Bibliographic Source(s)
American Medical Directors Association (AMDA). Dementia. Columbia (MD): American Medical Directors Association (AMDA); 2005. 28 p. [20 references]
Guideline Status
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.
FDA Warning/Regulatory Alert
Note from the National Guideline Clearinghouse: This guideline references a drug(s) for which important revised regulatory and/or warning information has been released. On April 12, 2005, the U.S. Food and Drug Administration (FDA) issued a public health advisory to alert health care providers, patients, and patient caregivers to new safety information concerning an unapproved, "off-label" use of certain antipsychotic drugs approved for the treatment of schizophrenia and mania. FDA has determined that the treatment of behavioral disorders in elderly patients with dementia with atypical (second generation) antipsychotic medications is associated with increased mortality. Clinical studies of these drugs in this population have shown a higher death rate associated with their use compared to patients receiving a placebo. See the FDA Web site for more information.
Disease/Condition(s)
Dementia
Guideline Category
DiagnosisEvaluationManagementTreatment
Clinical Specialty
Geriatrics
Intended Users
Advanced Practice NursesAllied Health PersonnelNursesPharmacistsPhysiciansSocial Workers
Guideline Objective(s)
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
Target Population
Elderly individuals and/or residents of long-term care facilities who have, or are suspected of having, dementia
Interventions and Practices Considered
Recognition/Assessment Review patient history Evaluate signs and symptoms Perform diagnostic work-up, if appropriate Determine if patient meets criteria for dementia Identify cause of dementia, if possible Identify patient's strengths and deficits Define the significance of patient's symptoms, impairments, and deficits Identify triggers for disruptive behavior Treatment Prepare interdisciplinary care plan Optimize function and quality of life and capitalize on remaining strengths Consider using complementary & alternative therapies Prevent excess disability Consider medical interventions if appropriate Address socially unacceptable or disruptive behaviors, using both non-pharmacological and pharmacological interventions Manage functional deficits Address pertinent psychosocial and family issues Address related ethical issues Manage risks and complications related to dementia, other conditions, or treatments Monitoring Monitor the patient's progress and adjust management as appropriate
Major Outcomes Considered
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
Methods Used to Collect/Select Evidence
Searches of Electronic Databases
Description of Methods used to Collect/Select the Evidence
Not stated
Number of Source Documents
Not stated
Methods Used to Assess the Quality and Strength of the Evidence
Expert Consensus
Rating Scheme for the Strength of the Evidence
Not applicable
Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence
Not stated
Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations
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.
Rating Scheme for the Strength of the Recommendations
Not applicable
Cost Analysis
A formal cost analysis was not performed and published cost analyses were not reviewed.
Method of Guideline Validation
External Peer ReviewInternal Peer Review
Description of Method of Guideline Validation
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.
Major Recommendations
The algorithm Dementia is to be used in conjunction with the clinical practice guideline. The numbers next to the different components of the algorithm correspond with the steps in the text. Refer to the "Guideline Availability" field for information on obtaining the full text guideline.
Clinical Algorithm(s)
A clinical algorithm is provided for Dementia.
Type of Evidence supporting the Recommendations
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.
Potential Benefits
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
Potential Harms
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
Qualifying Statements
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.
Description of Implementation Strategy
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. 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 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 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 Monitoring Evaluate performance based on relevant indicators and identify areas for improvement Evaluate the predefined performance measures and obtain and provide feedback
Implementation Tools
Clinical AlgorithmTool KitsFor information about availability, see the "Availability of Companion Documents" and "Patient Resources" fields below.
IOM Care Need
Living with Illness
IOM Domain
EffectivenessPatient-centeredness
Bibliographic Source(s)
American Medical Directors Association (AMDA). Dementia. Columbia (MD): American Medical Directors Association (AMDA); 2005. 28 p. [20 references]
Adaptation
Not applicable: The guideline was not adapted from another source.
Date Released
1998 (revised 2005)
Guideline Developer(s)
American Medical Directors Association - Professional Association
Guideline Developer Comment
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
Source(s) of Funding
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.
Guideline Committee
Steering Committee
Composition of Group that Authored the Guideline
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
Financial Disclosures/Conflicts of Interest
Not stated
Guideline Status
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.
Guideline Availability
Electronic copies: None available Print copies: Available from the American Medical Directors Association, 10480 Little Patuxent Pkwy, Suite 760, Columbia, MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com.
Availability of Companion Documents
The following are available: Guideline implementation: clinical practice guidelines. Columbia, MD: American Medical Directors Association, 1998, 28 p. We care: implementing clinical practice guidelines tool kit. Columbia, MD: American Medical Directors Association, 2003. Electronic copies: None available Print copies: Available from the American Medical Directors Association, 10480 Little Patuxent Pkwy, Suite 760, Columbia, MD 21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax (410) 740-4572. Web site: www.amda.com
Patient Resources
None available
NGC STATUS
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.
COPYRIGHT STATEMENT
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.
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