Special Report: Alzheimer’s management

One-page Alzheimer’s guidelines streamline care protocol

One-page tool assures no need is overlooked

Physicians receive so many guidelines these days that rather than becoming useful tools to improve patient care, they often collect dust. When the California Workgroup on Guidelines for Alzheimer’s Disease Management, sponsored in part by the Alzheimer’s Association of Los Angeles, set out to develop its "Guidelines for Alzheimer’s Disease Management," it was determined that the document wouldn’t suffer the same fate.

"We knew from the beginning that we wanted to develop a one-page guideline that primary care physicians could keep close at hand," says Debra L. Cherry , PhD, associate executive director of the Alzheimer’s Association of Los Angeles. "We realize that physicians don’t have the resources to meet all the needs of the Alzheimer’s patient. The tool suggests other members of the health care team and the community that are available to help the physician provide the care suggested on the guideline." (See guideline, inserted in this issue.)

"The thing that’s very unique about this guideline is that it brings together in one place all the strategies for comprehensive Alzheimer’s care," notes Elizabeth Heck , LCSW, physician education and outreach manager for the Alzheimer’s Association of Los Angeles. "There are other Alzheimer’s guidelines, including one specifically for psychologists, and one from the government on early recognition and assessment of memory loss. They complement this guideline. They fit inside the framework." (See p. 99 for a case study of an Alzheimer’s program developed by a large managed care organization which includes the new guideline.)

The one-page guideline is organized into four sections. A booklet that clarifies each of the components within the four sections, including suggestions for which member of the health care team is best suited to provide the suggested care or evaluation, accompanies the one-page guideline. The sections are:

I. Assessment. The guideline recommends assessments of daily function, cognitive status, medical conditions, and behavioral problems. "Care managers, social workers, or nurses can perform much of the necessary assessment," notes Cherry. "As we work with managed care organizations and health systems to familiarize them with the new guideline, we emphasize that we expect physicians to work with other professionals to do any assessment or care that is not strictly medical."

II. Treatment. The guideline includes recommendations for using the newest drugs available for management of cognitive decline and behavioral issues. (See recommendations on pharmacological management, inserted in this issue.) It also suggests appropriate activities and therapies to help maintain and enhance daily function. Referrals to community service agencies and support groups are also recommended.

"Alzheimer’s must be addressed on three levels — biological, social, and psychological," notes Cherry. "Any interventions to support the patient and the family must also be on all three levels."

III. Patient and caregiver education and support. "This is clearly where professionals such as care managers play an explicit role," says Cherry. "However, it’s up to care managers and developers of Alzheimer’s programs to educate physicians on that role. Unless others explain the role of care managers and other support professionals, and consumers demand better care, physician behavior won’t change. Care managers can be a tremendous support in making any guideline work."

IV. Reporting requirements. "Reporting laws vary from state to state. There are many considerations such as reporting elder abuse and reporting the necessity for driving restrictions," notes Heck. "Here again, care managers and other support staff can be invaluable in helping physicians keep up with reporting needs — providing the appropriate forms and making sure that the process is followed properly."

Putting them to use

Of course, a guideline is only useful if it is used, note Cherry and Heck. The work group developed an elaborate consumer and provider education plan to disseminate the guideline and encourage providers to use them. The guideline was introduced at a statewide conference held in April. "We invited the medical directors of managed care organizations and community resource organizations around the state," says Cherry. The guideline was introduced to a national audience at the Eighth Annual Alzheimer’s Disease Education Conference in Long Beach, CA, in July.

"We have a two-pronged campaign planned — one for physicians and one for consumers. We want consumers to demand better care. We want them to say, Doctor, that’s not enough. I know there are more treatment options and resources available to help me cope with this disease.’ We hope to force doctors to work with partners, such as care managers and social workers, to meet their patients’ needs," says Cherry.

"We want to target a wide range of people who come in contact with this disease," adds Heck. "We are also developing additional tools to make the process even easier. We’re training physicians and other health care providers on how they can support the recommendations in the guideline. We’re explaining how they are integral to making the process run and move smoothly. We are educating the care manager, the social worker, the nurse, on what their roles can be to help the process." (If your staff come in contact with Alzheimer’s patients and their families, disease-specific training is essential. See suggestions for developing an Alzheimer’s training program on p. 100. Also, see Alzheimer’s warning signs, p. 101.)

For more information, contact the Alzheimer’s Association of Los Angeles, 5900 Wilshire Blvd, Suite 1710, Los Angeles, CA 90036. Telephone: (323) 938-3379. Fax: (323) 938-1036.