Key Points
- More than 5 million Americans now have Alzheimer’s Disease (AD).
- AD progressively destroys brain cells, causing problems with memory, thinking, and behavior severe enough to affect work, family and social relationships, eventually, the most basic activities of daily living and, finally, death.
- AD is the 7th leading cause of death in the United States, and the 5th leading cause for individuals 65 and older.
- HCPs should be able to provide or recommend a wide variety of services beyond medical management of AD and comorbid conditions, including recommendations regarding psychosocial issues, assistance to families and caregivers, and referral to legal and financial resources in the community.
- Many specialized services are available to help patients and families manage AD.
Assessment
Recommendations
- Conduct and document an assessment, and monitor changes in:
- Daily functioning, including feeding, bathing, dressing, mobility, toileting, continence, and ability to manage finances and medications
- Cognitive status using a reliable and valid instrument
- Comorbid medical conditions which may present with sudden worsening in cognition, function, or as change in behavior
- Behavioral symptoms, psychotic symptoms, and depression
- Medications, both prescription and non-prescription (at every visit)
- Living arrangement, safety, care needs, and abuse and/or neglect. Need for palliative and/or end-of-life care planning
- Reassessment should occur at least every 6 months, and sudden changes in behavior or increase in the rate of decline should trigger an urgent visit to the HCP.
- Identify the primary caregiver and assess the adequacy of family and other support systems, paying particular attention to the caregiver’s own mental and physical health.
- Assess the patient’s decision-making capacity and determine whether a surrogate has been identified.
- Identify the patient’s and family’s culture, values, primary language, literacy level, and decision-making process.
Table 1. Brief Cognitive Assessment Instruments
| Name of Instrument | Number of Items; Time Required Maximum Score | Cognitive Functions Assessed |
|---|---|---|
| Blessed Orientation-Memory-Concentration Test (BOMC) | 6 items; 3 minutes Maximum Score = 28 | Orientation; concentration; short-term verbal recall |
| Cognitive Assessment Screening Instrument (CASI) | 25 items; 15-20 minutes Maximum Score = 100 | Attention; mental manipulation; orientation; long-term memory; short-term memory; language; visual construction; word list fluency; abstraction and judgment |
| MiniCOG | 2 items; 3 minutes Maximum Score = 5 | Visuospatial, executive functioning, short term recall (Note: Includes clock drawing) |
| Mini-Mental State Exam (MMSE) | 19 items; 10 minutes Maximum Score = 30 | Orientation; registration; attention and calculation; short-term verbal recall; naming; repetition; 3-step command; reading; writing; visuospatial |
| Montreal Cognitive Assessment (MoCA) | 12 items; 10 minute Maximum Score = 30 | Visuospatial/executive functioning; naming; attention; repetition; verbal fluency; abstraction; short-term verbal recall; orientation (Note: Includes clock drawing) |
| St. Louis University Mental Status Examination (SLUMS) | 11 items; 7 minutes Maximum Score = 30 | Orientation; verbal recall, calculation, naming, attention, executive function (Note: Includes clock drawing) |
Table 2. Brief Behavioral Assessment Instruments
BEHAVE-AD
- Assessment of 25 behavioral symptoms and a global rating
- Advantage- Includes psychotic symptoms
- Disadvantage- Minimal assessment of disruptive behaviors
Cohen-Mansfield Agitation Inventory (CMAI)
- Rates frequency of 29 agitated behaviors on 7 point scale
- Advantage- Very detailed information about agitation
- Disadvantage- Assesses only agitation
Neuropsychiatric Inventory Questionnaire (NPI-Q)
- Rates frequency, severity of 12 behavioral symptoms as well as caregiver distress associated with symptoms
- Advantage- Several versions; can adapt to setting/time limits; provides information about caregiver stress
- Disadvantage- Long version may be time-consuming to administer
Revised Memory and Behavior Problem Checklist (RMBPC)
- Rates frequency of 24 specific behaviors over past week and degree of distress to caregiver caused by each
- Advantage- Self-administered caregiver-report tool requires less than
10 minutes to complete; allows clinical/empirical assessment of potentially modifiable behavior problems - Disadvantage- Dependent on caregiver’s reading and interpretation (as are all self-report measures)
Ryden Aggression Scale (RAS)
- Assessment of frequency of 25 aggressive behaviors
- Advantage- Very detailed information on aggression
- Disadvantage- Limited to aggressive behavior
Table 3. Functional Assessment Instruments1
Functional Status Questionnaire2
- 34 questions assessing physical,
psychological, social and role functions - Advantage- Self-administered, detailed
- Disadvantage- Limited to patients with mild impairment
Functional Activities Questionnaire
- 10 questions assessing ADL – finances,
meal preparation, shopping, entertainment,
current events, memory for planned events, travel - Advantage- Caregiver-report tool requires less than 10 minutes to complete
- Disadvantage- Dependent on caregiver’s reading and
interpretation (as are all self-report measures)
Physical Self-Maintenance Scale
- 60 questions assessing toilet, bathing,
feeding, dressing, ambulation, shopping, housekeeping, finances, transportation,
medication management - Advantage- Comprehensive caregiver-report tool
- Disadvantage- Time-consuming to complete
Avalable at: http://www.hospitalmedicine.org/geriresource/toolbox/the_functional_activities.htm
Jette AM, Davies AR, et al. The Functional Status Questionnaire: reliability and validity when used in primary care. J Gen Intern Med. 1986;1:143-149.
Figure 1. Alzheimer’s Disease Algorithm
