New “Common Sense” Guidebook Emphasizes Sound Clinical Judgment and Team-Oriented Care for Dementia Patients

In a new handbook titled The Common Sense Guide to Dementia for Clinicians and Caregivers, authors Anne M. Lipton, MD, PhD, and Cindy D. Marshall, MD, assert that a heightened clinical understanding of dementia is needed by all stakeholders in a patient’s care, including physicians, nurses, and family caregivers. Annals of Long-Term Care: Clinical Care and Aging had the opportunity to interview Lipton about the contents of the book and its value as a go-to resource for healthcare professionals providing long-term care to older patients with Alzheimer’s and dementia.
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According to the 2013 Alzheimer’s Disease Facts and Figures report, one in three older adults dies with Alzheimer’s disease or another dementia. In 2012, the 5 million Americans who have Alzheimer’s or dementia were cared for by more than 15 million caregivers, representing an estimated 17.5 billion hours of care valued at $216 billion. Statistics project that the number of Americans with dementia is expected to rise—perhaps even triple—by 2050 in the absence of treatment to prevent, slow, or stop the disease. In a new handbook titled The Common Sense Guide to Dementia for Clinicians and Caregivers, authors Anne M. Lipton, MD, PhD, and Cindy D. Marshall, MD, assert that a heightened clinical understanding of dementia is needed by all stakeholders in a patient’s care, including physicians, nurses, and family caregivers. Annals of Long-Term Care: Clinical Care and Aging^® (ALTC) had the opportunity to interview Lipton about the contents of the book and its value as a go-to resource for healthcare professionals providing long-term care to older patients with Alzheimer’s and dementia.

ALTC: How is the book structured, and how is it intended to be used?

Lipton: Since we know that time is of the essence in caregiving, we formatted the book so that readers can find and absorb what they need in a hurry and read the rest at their leisure. The guide is a practical and accessible reference book for family and clinical caregivers, including physicians, many of whom may work with numerous patients with dementia but are not specialists in this area of care. The chapters are indexed for easy identification of topics, which include dementia screening and prevention, caregiver burden, dementia medication, mood and behavioral issues, legal and financial matters, end-of-life care, and much more. Each chapter includes Common Sense Rules, which highlight the important take-home messages throughout the text.

In one of the first chapters of the book, you and Dr. Marshall write, “Not only laypeople, but many medical professionals, continue to hold a mistaken and outmoded viewpoint that nothing can be done for dementia.” What are some of the common misconceptions about dementia care, and how does your book aim to correct them?

The first chapter starts by defining all the terms. For example, the terms Alzheimer’s disease and dementia are not interchangeable. A specific dementia diagnosis should be sought to optimize treatment and management because most types of dementia can be treated in some way. Ignoring dementia may not only delay treatment, but may also put off important planning measures from being put into place—or prevent them altogether, if a patient progresses too far, losing the ability to make legal, financial, or medical decisions. Another example we have encountered is the belief by a number of caregivers that they should correct and/or test a patient with dementia, when these tactics are typically not helpful and may incite anger in a patient. Support, reassurance, and/or entering the patient’s world usually work much better. Several chapters discuss these and other strategies in depth.

Medication administration is another area in which there are frequent misunderstandings or mistakes being made. What are some of the most important common sense rules that long-term care providers should remember when giving medication to residents with dementia?

Geriatric practitioners have probably heard and practiced the admonition “start low and go slow,” but it is equally important to “keep going” to achieve a therapeutic dose of a given neuropsychiatric medication. Regular review of medications is important to help avoid unnecessary continuation, duplication, and interactions. Individual prescribers may be careful to avoid a “drug cascade,” but patients with dementia often have multiple prescribers. Hospitalizations or transfers to different points of care may increase the potential for medication mistakes due to transcription and other errors.

Just as neuropsychiatric medications should be initiated gradually, they should be tapered off similarly. Sometimes dementia medications are abruptly stopped due to lack of perceived improvement around the time of a move to long-term care. As we discuss in the book, such medications should usually not be stopped abruptly or changed during times of transition. It might make more sense to gradually taper a medication a few weeks after a move or at least not until a patient appears to have adjusted to the new environment.

Unfortunately, dementia medications are not expected to result in dramatic improvements in a patient’s behavior, cognition, or function. Such expectations are unrealistic and should not guide treatment. Instead, dementia medications should be carefully assessed as to whether they may be effecting modest symptomatic improvements, slowing decline, and/or maintaining cognition, behavior, and function.

The Common Sense Guide to Dementia for Clinicians and Caregivers was published in September 2012 by Springer.