1

大綱

個案報告 Quality Indicators for the Management

of Medical Conditions in Nursing HomeResidents

Treatment and prevention of vascular dementia

2

個案報告PGY 楊智凱

99.02.22

3

4

Brief history

51 y/o male C.C.: loss of consciousness on

97.04.23 Right putaminal hemorrhage s/p

craniotomy on 97.04.24 Evacuation for EDH on 97.04.25 Rehabilitation on 97.06.25

5

Past history

Hypertension for 3 years Allergy: denied Smoking: 2~3 PPD > 20 years Alcohol: 一杯高粱 /day

6

Neurological Examination

Muscle power: R/L = 4/hemiplegia DTR: = ++/+++

7

Suspected dementia and adjustment disorder with depressive mood

General tonic-clonic seizure on 97.07.15

吉翔護理之家 : 97.08

8

9

10

11

12

13

14

15

16

Quality Indicators for the Managementof Medical Conditions in Nursing HomeResidents

Debra Saliba, MD, MPH, David Solomon, MD, Laurence Rubenstein, MD, MPH, Roy Young, MD, John Schnelle, PhD,

Carol Roth, RN, MPH, and Neil Wenger, MD, MPH

J Am Med Dir Assoc 2004;5:297–309

99/02/22

PGY 許宏源

17

Background

These nursing home (NH) residents have a significant illness burden, making disease management important but challenging.

Because process-based quality indicators (Qls) explicitly identify steps of care that are associated with better outcomes, they can be used to evaluate the care actually provided to elderly populations

18

These existing QI sets in the community cannot be imported automatically into measures of NH care

NH care involves a continued, ongoing interaction among the resident, her providers, and the care setting

Minimum Data Set (MDS) that is completed at the time of NH admission and regularly thereafter

19

Assessing Care of Vulnerable Elders (ACOVE) study identified 22 conditions as key quality improvement targets

Focus on 11 conditions: depression, diabetes, hearing impairment, heart failure, hypertension, ischemic heart disease, osteoarthritis, osteoporosis, pneumonia, stroke, and vision impairment

20

Methods

A national panel of nursing home experts used a modified-Delphi process to rate the validity (process linked to improved outcomes) and feasibility (of implementation and measurement) of candidate measures

A separate clinical committee reviewed the resulting set of indicators

21

22

23

24

25

26

27

28

29

Discussion

114 quality indicators were identified across the 11 medical conditions

55 indicators (48%) were identical to quality measures for community-dwelling vulnerable elders

A limited number were rated as questionably feasible to implement or measure (6 and 2, respectively)

38 QIs (33%) would not be applied to measures of care quality for persons with advanced dementia or poor prognosis

30

Conclusions

Explicit care processes linked to improved nursing home outcomes for general medical conditions can be identified

These QIs account for the structure of NH care, available information in the MDS, condition prevalence, and the burden of comorbid disease

Nursing home quality measures for medical conditions must account for exclusions related to poor prognosis and advanced dementia.

31

Treatment and prevention of vascular dementia

UpToDate®Clinton B Wright, MD, MS

Presented by PGY 黃文弘

32

INTRODUCTION

Vascular dementia (VaD) is the second most common form of dementia after Alzheimer disease (AD) in most clinical series

Preventative agents and treatments for VaD have at least potential overlap

33

RISK FACTOR MANAGEMENT

Patients with cognitive impairment and clinical or radiologic evidence of cerebrovascular pathology should be screened and treated for vascular risk factors, especially hypertension

34

RISK FACTOR MANAGEMENT

a cohort study of 99 cases followed after a first stroke found that those with recurrent stroke had greater cognitive decline

Srikanth, VK, Quinn, SJ, Donnan, GA, et al.

Long-term cognitive transitions, rates of cognitive change, and predictors of incident dementia in a population-based first-ever stroke cohort.

Stroke 2006; 37:2479

poststroke dementia is associated with higher mortality

Melkas, S, Oksala, NK, Jokinen, H, et al.

Poststroke dementia predicts poor survival in long-term follow-up: influence of prestroke cognitive decline and previous stroke.

J Neurol Neurosurg Psychiatry 2009; 80:865.

35

RISK FACTOR MANAGEMENT

Antihypertensive drugs There is some evidence that blood pressure

lowering reduces the risk of incident dementia and slows cognitive decline

relatively modest reductions of blood pressure (7 to 12/3 to 5 mm Hg) result in reduced rates of incident dementia and/or cognitive decline

Peters, R, Beckett, N, Forette, F, et al.

Incident dementia and blood pressure lowering in the Hypertension in the Very Elderly Trial cognitive function assessment (HYVET-COG): a double-blind, placebo controlled trial.

Lancet Neurol 2008;7:683.

36

RISK FACTOR MANAGEMENT

Diabetes management  A randomized trial comparing two oral

antidiabetic agents in 156 older patients with diabetes found that higher postprandial plasma glucose excursions (less tight diabetes control) were associated with greater declines in cognitive performance

a one percent higher A1C value was significantly associated with poorer cognitive performance

37

RISK FACTOR MANAGEMENT

Statins Antiplatelet agents Homocysteine lowering 

38

RISK FACTOR MANAGEMENT

Healthy lifestyle There is mounting evidence that

certain modifiable health behaviors, (smoking, alcohol use, physical activity, and diet) are associated with cognitive function later in life, underscoring the importance of promoting a healthy lifestyle at all ages

39

DISEASE MODIFYING THERAPY

Acetylcholinesterase inhibitors and memantine (N-Methyl-D-aspartate receptor antagonists ) have been studied in patients with vascular dementia (VaD), although the data are limited

40

DISEASE MODIFYING THERAPY

Calcium channel blockers — Calcium channel blockers are of potential benefit in VaD because of their putative neuroprotective anti-ischemic effects, in addition to blood pressure lowering

41

Treatment duration

The course of the disease is not predictable

The goal of treatment is primarily to slow cognitive decline

42

PROGNOSIS

Recovery of lost cognitive function beyond the initial recovery from a stroke is not likely

poststroke dementia was associated with a reduced survival compared with those who did not develop dementia (five versus nine years)

43

Conclusion

Patients with cognitive impairment and clinical or radiologic evidence of cerebrovascular pathology should be screened and treated for vascular risk factors, especially hypertension

acetylcholinesterase inhibitors and/or meantime  A typical regimen aimed to slow disease

progression in VaD might be donepezil(Aricept) 10 mg/day plus memantine  20 mg/day

44

45

Thanks for your attention!!!