Senior's Toolkit
Dementia assessment tool Notes Instructions
Dementia is a progressive neurodegenerative disease of variable etiologies. There are many diagnostic tools but the most familiar are the MMSE and MOCA. The MMSE can be used to diagnose Alzheimer's disease and the MOCA is more sensitive for the non Alzheimer's type diseases. Once dementia is diagnosed there is no need to continue doing the MMSE or MOCA, the best way to follow the progress is using a functional scale. The easiest and probably best tool to use is the Global Deterioration Scale but one can also use other tools like tbe iADL and ADL scales. In any patient with cognitive impairement it is important to do a mood screen assessment as treatment of depression can be benificial for the patient. The advantage of the Geriatric depression scale (short or long) over the PHQ9 is that the GDS is a yes/no answer as compared to the choice of 4 answers for the PHQ9. Clicking on anything highlighted in blue in this tool will generally open or close something. Tool dates in orange indicate more than a year has past since the test. Labs that are small and in italics also indicate more than a year has past since the test. Hover over the result to see the date it was done. Darker resources indicate that they have been printed in the past. The CT and MRI lines allow free text to be entered that will be saved and will be there when the tool is opened again. eg CT Head Dec 2018 Normal If you want the direct tool score update feature to work you should NOT change the name of the Senior Care Toolkit unless you make the same adjustment in the xGlobal Deterioration Scale and Refresh Seniors Toolkit eforma. Close
Instructions to load Senior Care Toolkit A) Delete the following eForms if they are in your system: 1) Global deterioration scale 2) Geriatric depression scale 3I Geriatric depression scale- short B) Load the following eForms: IMPORTANT: Do not change the names unless you know how to alter the code for the linking 1) 9-Senior Care Toolkit 2) Global deterioration scale 3) xGlobal deterioration scale 4) Geriatric depression scale 5I Geriatric depression scale- short 6) Refresh Senior Care Toolkit 7) ADL 8) iADL 9) First Link Referral C) Test the links: Open the Senior Care Toolkit Click on Dementia assessment tool Click on Tools links next to 1,3,4 Click on the individual tool links to see that the eForm is in your system. Click on the MOST link Scroll down to the eForm section and click on all of those links Make a note of the missing links and then load the missing eForms D) Create the measurements: You will need to create some of the following measurements ADL ADL ADL 0-100 IADL iADL iADL 0-30 FRAI Frailty Score Frailty Score 0-10 GDS Depression scale GDS 0-30 GDSS Depression scale GDS short 0-20 GLDS Functional scale Global Deterioration Scale 0-10 MOST MOST MOST no validation 3MS 3MS 3MS 0-100 MMSE MMSE MMSE 0-30 MOCA MOCA MOCA 0-30 GAD7 GAD7 GAD7 0-30 PHQ9 PHQ9 PHQ9 0-30 Close
Working diagnosis: Global Deterioration Scale Medication alerts:
Close 1) Mood Tools GDS(short) PHQ GAD GDS 1. During the past two weeks, have you often been bothered by little interest or pleasure in doing things? 2. During the past two weeks, have you often been bothered by feeling down, depressed or hopeless? 3. Neither of the above is true. 2) Pattern Tool Close
Alzheimers Mixed Vascular DLB PDD Frontotemporal NPH Other
Acute onset and fluctuating course
Gradual cognitive decline-memory,language,visiospacial
Acute onset,stepwise decline- may be in relation to CVA/TIA Focal neurological findings including gait disturbance presumed secondary to cerebrovascular disease
Early behaviour issues and personality changes Family history of Frontotemporal Dementia
Fluctuating cognition from day to day Evidence of visual hallucinations Parkinsonian features Unexplained falls and episodes of loss of conciousness
Parkinsonian features present for more than 1 year before cognitive decline
Rapidly progressive decline Early abnormal gait without evidence of cerebrovascular disease Early presentation with urinary urgency or incontinence 3) Cognitive assessment Tools MMSE MOCA 3MS 4) Functional assessment Tools Global Deterioration Scale iADL ADL Frailty score 5) Advanced directives MOST
Close Lab results eGFR: Na: K: Ca: Alb: TSH: A1C: Hb: WCC: PLT: VB12: ANA: HIV: Imaging CT MRI
Lab/imaging Refresh tool results
Resource Links             Click to show potential resources
Cancer      Dementia      Depression      Falls      General      Home Support      Recreation      Social      Transport
Handouts                     Click once to select for printing and double click to view
Resources                     Click once to select for printing and double click to view
eForms                         Click to view
Physician resources      Click once to select for printing and double click to view
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Cholinesterase Inhibitors
Indications Contraindications Side Effects Medications Monitoring

• Alzheimer's disease < 80yr
• Alzheimer's disease > 80yrs and healthy with behavioural problems.
• Maybe Vascular dementia
• Maybe Dementia with Lewy Bodies.
• Not useful in FrontoTemporal dementia.

Impact on long-term outcomes, disability and institutionalization, is not clear.
AD2000 Study: Found no significant benefit of donepezil compared with placebo for the two primary endpoints:
Entry to nursing home and progression of disability

Cholinesterase inhibitors produce, on average, small improvements in measures of cognition and ADL
NNT 'improved' on a global assessment scale (CGIC or CIBIC+) = 12
NNT 4-point or greater improvement on ADAS-cog = 10
NNH adverse event = 12
- May slow progression by months, not years
- Not all individuals benefit, but some may 'feel better'
- Many cannot tolerate the side effects and marginal benefits may be outweighed by harms
Frailty
Falls risk
Cardiac conduction adnormalities including atrial fibrillation
CAD and left bundle-branch block
Peptic ulcer disease and other GIT problems
Uncontrolled/severe asthma or severe COPD
Urinary obstruction
Seizure history
Concurrent use of anticholinergic medications
Closed angle glaucoma
Sick sinus syndrome
Poor tolerability: Risk of adverse effect NNH=12
- Gastrointestinal upset
- Increased risk of falling
- Urinary incontinence
- Stimulating, sometimes resulting in agitation or worsening of behaviour
- Cost considerations
- Undesirability of taking one more drug
- Foster unrealistic hopes that may delay dealing with future planning
There is no evidence that one cholinesterase inhibitor is more efficacious than the another

Start with Aricept 2.5-5mg and increase up to 10mg
If GIT upset can try Excelon patch (but it is not covered).
There are various recommendations regarding cardiac monitoring whilst on AChE inhibitors ranging from ECG prior to initiation and with every increase in dose to no ECG and montitoring with pulse checks alone.

Absolute contraindication to acetylcholinesterase inhibitors:
• Second or third-degree heart block in an unpaced patient
• QT prolongation
• Bradycardia of < 50 bpm

Use of acetylcholinesterase inhibitors with caution:
• Left Bundle Branch block
• Patients on concomitant rate limiting drugs such as beta-blockers/amiodarone/digoxin/diltiazem/verapamil may be prescribed acetylcholinesterase inhibitors cautiously if pulse is between 50-60 bpm and asymptomatic
If rate limiting calcium channel blockers or beta-blockers are being used to treat hypertension, alternative anti-hypertensive agents might be considered to facilitate the introduction of acetylcholinesterase inhibitors

Patients fitted with cardiac pacemakers do not need pulse checks as pacemakers safeguard from developing bradycardia
Hull and East Riding Prescribing Committee Recommendations

Monitoring protocol with pulse checks: (Rowland et al pathway)
• If pulse is > 60 bpm and patient is asymptomatic can continue and recheck at each visit.
• If pulse is 50-60 bpm and patient is asymptomatic can continue and recheck in 1 week and if remains asymptomatic can recheck at each visit.
• If pulse is < 50 bpm hold the AChE inhibitor
• If patient is symptomatic (eg syncope or dizziness) hold the AChE inhibitor
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Tricyclic Medications    General    Handout    Taper Rx    Med reduction
  • Possible side effects:

    • Blurred vision, Dry mouth, Constipation, Orthostatic hypotension and increased risk for falls and fractures, Worsening cognitive status

  • Possible issues with taper:

    • Cramping, diarrhea, nausea, sweating, hot or cold flashes, headache, dizziness, flu-like symptoms, fatigue, anxiety, restlessness, trouble sleeping, vivid dreams, tremors, muscle aches, confusion, pounding heart (palpitations), unusual movements, mood changes.

  • Alternative management options:

    • Depression: Counseling, Mirtazepine
    Sleep: Sleep handout
    Chronic pain:
    Frequent headaches:
    Irritable bladder or bowel:

  • Tricyclics:

    • You are taking a class of medication called a Tricyclic Antidepressant. There could be many different reasons that you were started on this other than depression. This includes chronic pain, frequent headaches, fibromyalgia, sleep problems or even bowel or bladder problems.

    Unfortunately as your body gets older, these medications that initially were having good effects on you now start having bad effects and increase your risks for falling and breaking bones such as your hip as well as worsening your memory leading to dementia. Other common side effects include blurred vision, dry mouth, constipation and brief drops in your blood pressure when you stand up, all which get worse with age.

    Often the medication is no longer helping with the initial problem so it makes sense to get you off this medication to better your health, especially as a broken hip or memory changes are common and devastating conditions in your age group.

    If your reason to be on the medication in the first place comes back, we now have safer medications to help manage this.

    We know that people will often experience some non-dangerous symptoms if you come off the medication too quickly, such as increased sweating, headaches, anxiety, trouble sleeping, vivid dreams, diarrhea, muscle aches and changes in mood which although are temporary, are unnecessary and can be prevented by a gradual taper.

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Antihistamine Medications    Toggle Patient Handout
  • Possible side effects:

    • •    drowsiness
    •    dry mouth
    •    decreased tear production
    •    urinary retention
    •    blurred vision
    •    constipation
    •    agitation
    •    cognitive changes

  • Taper plan:

    • If used daily for more than 3-4 weeks then reduce dose by 50% every 1 to 2 weeks. You can use a pediatric syrup formulation to do this. Once you are at 25% of the original dose for 1-2 weeks with no rebound symptoms you can stop.

  • Possible issues with taper:

    • Return of symptoms. If this happens consider a trial of a second generation antihistamine at lowest effective dose.

  • Patient handout:

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Benzodiazipine Medications    General    Handout    Benzo Taper    Taper Rx    Med reduction
  • Possible side effects:

    • Drowsiness. Confusion. Dizziness. Trembling. Impaired coordination. Vision problems. Grogginess. Feelings of depression. Worsening cognitive function.

  • Taper plan:

    • If used daily for more than 3-4 weeks. Reduce dose by 25% every week (i.e. week 1-75%, week 2-50%, week 3-25%) and this can be extended or decreased (10% dose reductions) if needed. If intolerable withdrawal symptoms occur (usually 1-3 days after a dose change), go back to the previously tolerated dose until symptoms resolve and plan for a more gradual taper with the patient. Dose reduction may need to slow down as one gets to smaller doses (i.e. 25% of the original dose). Overall, the rate of discontinuation needs to be controlled by the person taking the medication.

  • Possible issues with taper:

    • Rebound insomnia, tremor, anxiety, as well as more serious, rare manifestations including hallucinations, seizures, and delirium

  • Patient handout:

Tapering Prescription Calculator (for medical doctors only)

This tool allows you to create a customized tapering prescription for an individual patient. You select a few simple parameters, the calculator does the work and if you like the results you print it out, sign it and fax it to us toll free - we'll take care of the rest.

Input starting dose for taper (patient's current daily dose)
mg, daily Medication name:

Approximate conversion to Diazepam: mg, daily

Size of taper steps:

Taper speed:






Need help with this tool or want to discuss a particular patient with our pharmacists?
Please call 1-800-727-5048, M-F, 9am -6pm EST



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Overactive bladder medications    Toggle Patient Handout
  • Possible side effects:

    • Dry mouth, dizziness, drowsiness, blurred vision, dry eyes, nausea, vomiting, upset stomach, stomach pain, constipation, diarrhea, headache, unusual taste in mouth, dry/flushed skin, weakness , worsening of memory and cognitive function.

  • Taper plan:

    • If used daily for more than 3-4 weeks. Reduce dose by 50% every 1 to 2 weeks. Once at 25% of the original dose and no withdrawal symptoms have been seen, stop the drug. If any withdrawal symptoms occur, go back to approximately 75% of the previously tolerated dose.

  • Possible issues with taper:

    • Return of symptoms.

  • Patient handout:
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Proton Pump Inhibitors    General    Patient Handout
  • General

    • Proton pump inhibitors (PPIs) reduce the production of acid by blocking the enzyme in the wall of the stomach that produces acid. Proton pump inhibitors are very similar in action and there is no evidence that one is more effective than another. They differ in how they are broken-down by the liver and their drug interactions. The effects of some PPIs may last longer; therefore, they may be taken less frequently.

  • Possible side effects:

    • The most common side effects of proton pump inhibitors are:
       •    Increased the risk of Clostridium difficile infection of the colon.
       •    High doses and long-term use (1 year or longer) may increase the risk of
            osteoporosis-related fractures.
       •    Prolonged use also reduces absorption of vitamin B12 and is associated
            with low levels of magnesium.
       •    Prolonged use is associated with increased risk of heart attacks.
       •    Other side effects include headache, diarrhea, constipation,
            abdominal pain, flatulence, nausea
    Rare serious side effects associate with PPIs include:
       •   Serious allergic reactions, Stevens-Johnson syndrome, toxic epidermal necrolysis,
            reduced kidney function, pancreatitis, reduced liver function, erythema multiforme

    Because of the change in gastric pH, PPIs reduce the absorption and concentration in the blood of ketoconazole and increase the absorption and concentration of digoxin. This may lead to reduced effectiveness of ketoconazole and an increase in digoxin toxicity.

  • Possible issues with stopping:

    • Return of symptoms

  • Patient handout:

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Antipsychotics    General    Patient Handout
  • General

    • Antipsychotics

  • Possible side effects:

    • The most common side effects of antipsychotics are:

  • Possible issues with stopping:

    • Return of symptoms

  • Patient handout:

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Tapering Prescription Calculator (for medical doctors only)

This tool allows you to create a customized tapering prescription for an individual patient. You select a few simple parameters, the calculator does the work and if you like the results you print it out, sign it and fax it to us toll free - we'll take care of the rest.

Input starting dose for taper (patient's current daily dose)
mg, daily

Medication name:

For medications not listed please call us at 1-800-727-5048

Size of taper steps:

Taper speed:






Need help with this tool or want to discuss a particular patient with our pharmacists?
Please call 1-800-727-5048, M-F, 9am -6pm EST