Annals of Long Term Care

American Society of Consultant Pharmacists 40th Annual Meeting
Anaheim, CA; November 18-20, 2009

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Functional Communication in Alzheimer’s Disease in LTC

Anaheim, CA—Alzheimer’s disease (AD) can profoundly affect communication skills of frail elderly residents in LTC settings. Dr. Richard Stefanacci, Director of the Institute for Geriatric Studies at the Mayes College of Healthcare Business & Policy, University of the Sciences, Philadelphia, PA, and medical director of NewCourtland LIFE, spoke at the American Society of Consultant Pharmacists meeting about the importance of enhancing quality of life (QoL) through improved communication, which in turn benefits residents, their families, and facility staff.

Functional communication assessment is required to be done 14 days after nursing home admission as a result of OBRA ‘87. Further, the new MDS 3.0—now delayed until October 2010—will include a detailed section on cognitive impairment, as well as a requirement for resident interviews. This is in keeping with a focus on outcomes, especially regarding quality of life. The push is toward MDS truly driving the care plan for better outcomes, which provides opportunities for consultant pharmacists to carve out an important niche.

For mild AD, cholinesterase inhibitors are the recommended line of treatment showing efficacy. Unfortunately, in the nursing home, many residents enter the facility not receiving any treatment despite having moderate to severe AD. The speaker emphasized that these patients often benefit from combination therapy. He cited several studies (including Cummings et al, Neurology, 2006; Tariot et al, JAMA, 2004; Reisbert, N Engl J Med, 2003; Arch Neurol, 2006; Winblad et al, J Geriatr Psychiatry, 1999) that showed the efficacy of memantine for treatment of moderate to severe AD, especially in combination with cholinesterase inhibitors. New data on combination therapy with memantine and donepezil show that it improves communication in persons with AD when titrated to therapeutic doses. Tariot et al (JAMA, 2004) looked at persons already receiving the acetylcholinesterase inhibitor (AChEI) donepezil for 2 years who had memantine added to their regimen. The study focused on four areas—cognition, function (ADL, IADL), behavior, and communication—and assessed reading and writing skills. Residents were asked to respond to verbal cueing. Results showed that the combination therapy demonstrated efficacy in ADL, improved behavior, and delayed the onset of behavioral symptoms.

Another study (Hofbauer, presented at the 12th International Conference on Alzheimer’s Disease; July 11-16, 2009; Vienna, Austria) was a 12-week evaluation of function communications and looked at 10 domains: Greeting/Naming, Answering Questions, Writing, Comprehension of Signs and Object-to-Picture Matching, Word Reading and Comprehension, Reminiscing, Following Commands, Pantomime, Gesture, Conversation.

Another measure was to focus on four domains: social communication, communication of basic needs, reading/writing numbers and concepts, and daily planning, which demonstrated improvement in functional communication with memantine over placebo.

Dosing of medication for moderate and severe AD is a significant issue in LTC; many healthcare providers are not titrating up enough, so residents are receiving subtherapeutic doses. Healthcare providers need to start patients on medications such as memantine at 5 mg and go up to 10 mg twice daily for the therapeutic dose. The only individuals for whom it is contraindicated are those with severe renal impairment.

Dr.