During a patient’s initial visit (often during the diagnostic evaluation), you should make an assessment using tests such as the Mini-Mental State Examination (MMSE) or Physical Self-Maintenance Scale (PSMS) to establish baseline cognition and functional ability. You should also ask questions regarding behavioral symptoms, such as agitation, psychosis, anxiety and depression to assess the patient’s response to treatment. You can then compare future assessments to the baseline to track any changes in cognition, function or behavior that may have occurred since a previous visit.
The MMSE and PSMS are often used in clinical settings because they tend to take less time to administer than some of the longer, more involved assessments. The MMSE needs to be completed by a physician or other health care professional. In some cases, the PSMS can be given to the caregiver to complete in the waiting room. Once you choose a particular assessment test, you should repeat the same test during each subsequent visit in order to compare a patient’s current scores to his or her previous scores.
After a diagnosis of Alzheimer’s disease is made and a treatment plan implemented, patients should return for evaluation approximately three months after the start of medication and, subsequently, twice per year. In some cases, patients may need to return more frequently, depending on the medication prescribed. You should administer the MMSE and PSMS, or other assessment, at each visit in order to monitor improvement, stabilization or worsening of cognitive and behavioral symptoms and to better follow the progression of the disease.
Both cognitive and behavioral symptoms of dementia tend to change as the disease progresses, so regular visits can ensure adaptation of treatment strategies to current needs. More frequent visits are often required for patients exhibiting more severe behavioral symptoms, such as depression, agitation, hallucinations, or delirium, who may be taking medications specific to those conditions.
Regular visits are also important in monitoring patients for treatable conditions that may contribute to distress, discomfort and agitation, such as constipation, urinary tract infections and chronic pain.
The patient’s primary caregiver is an invaluable and essential source of information during follow-up visits. Patients will most likely not be reliable in assessing whether an improvement in symptoms has resulted from use of a particular medication. Moreover, since Alzheimer's patients regularly have “good days” and “bad days,” a clinician’s evaluation in one brief visit may not be as valuable or reliable as a caregiver’s report of the patient’s condition over several days or weeks.
Follow-up visits should include a basic physical exam to determine if any decline in physical health has taken place and a detailed interval history obtained from the patient and his or her caregiver. The detailed history should contain information about any extraordinary disruption in the patient’s daily living situation that may have occurred since the last visit, (e.g., moving into a new home, hospitalization, drastic change in routine). It is also helpful to ask the caregiver to bring in or “brown-bag” all medications the patient may be taking at the time of the visit, to determine whether existing symptoms can be attributed to side effects or interactions between prescribed and over-the-counter medication.
When assessing treatment efficacy in patients with Alzheimer’s, it is important to remember that improvement may be minimal and temporary stabilization in cognitive decline is more likely. Typically, less decline is observed in the early stages of the disease, with more rapid degeneration accompanying the later stages. Regardless of treatment, the disease will continue to progress, and you should advise patients and their families to plan ahead for future treatment and care options.
As assessments are being conducted, and a treatment plan determined, explain to the patient and his or her caregiver the limitations of current medications for Alzheimer’s disease. Clarify that existing treatments cannot reverse or stop the progression of Alzheimer’s disease, yet they may be able to help affected individuals maintain their independence for a longer period of time and may even delay the need for professional care and institutionalization.