1. 1 大綱 個案報告 Quality Indicators for the Management of Medical Conditions in Nursing Home Residents Treatment and prevention of vascular dementia

2. 2 個案報告 PGY 楊智凱 99.02.22

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4. 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. 5 Past history Hypertension for 3 years Allergy: denied Smoking: 2~3 PPD > 20 years Alcohol: 一杯高粱 /day

6. 6 Neurological Examination Muscle power: R/L = 4/hemiplegia DTR: = ++/+++

7. 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

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16. 16 Quality Indicators for the Management of Medical Conditions in Nursing Home Residents 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. 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. 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. 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. 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

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29. 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. 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. 31 Treatment and prevention of vascular dementia UpToDate® Clinton B Wright, MD, MS Presented by PGY 黃文弘

32. 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. 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. 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. 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. 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. 37 RISK FACTOR MANAGEMENT Statins Antiplatelet agents Homocysteine lowering

38. 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. 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. 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. 41 Treatment duration The course of the disease is not predictable The goal of treatment is primarily to slow cognitive decline

42. 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. 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

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45. 45 Thanks for your attention!!!