National conference of gerontological nurse practitioners

General nurse practitioner care guidelines: Dementia with lewy bodies 

Dementia with Lewy bodies (DLB) is a cortical neurodegenerative disorder in which abnormal structures are found in the brain, mainly in the brainstem and the limbic area. This condition probably is a distinct clinical syndrome that is the second most common cause of dementia after Alzheimer disease (AD). DLB, AD, and Parkinson's disease (PD) affect some of the same areas of the brain, especially the substantia nigra; share some of the same symptoms; and can occur concomitantly. Given these similarities, experts are not certain that the syndrome is distinct. However, many scientists believe it is and that clinical variations occur within the DLB syndrome. Terms used to describe DLB are Lewy body variant of AD, Lewy body dementia, senile dementia-Lewy body type, cortical Lewy body disease, and diffuse Lewy body disease. The latter is a variant that seems to occur in middle-age adults (40 years and older) and results in prominent dementia.

Pharmacologic update: Use of folic acid supplementation to prevent alzheimer disease 

A 2000 study1 in the Journal of Neuroscience described the results of an animal study that adds new knowledge to the possible cause and prevention of Alzheimer disease (AD). In this study, transgenic mice with mutant genes that cause AD in people were randomly assigned to receive a diet either deficient or adequate in folic acid. Mice with low amounts of dietary folic acid had high levels of homocysteine, an amino acid in the blood and brain. Increased levels of homocysteine are believed to damage the DNA of nerve cells in the hippocampus. The mice that received sufficient folic acid could repair this DNA damage. These findings suggest a possible cause-and-effect relationship between folic acid and AD.

Unfortunately, the diagnosis of folate deficiency still presents problems, particularly if hematologic abnormalities are absent. This imprecision relates to the interrelationship between the duration and degree of folate deficiency and other predisposing factors such as genetic make-up. Further research is ongoing to better understand both diagnostic issues and how much folic acid is sufficient. Currently, dosage recommendations for folic acid vary between 0.4 mg/d and 10 mg/d, depending on the severity of the deficiency. Older adults certainly should be encouraged to eat a diet that includes beans; raw, green, leafy vegetables; and foods supplemented with folate.

Putting research into practice: Behavioral and pharmacologic management of dementia 

The management of older adults with dementia must include both behavioral (and other nonpharmacologic interventions) and pharmacologic interventions as appropriate. Several recent studies addressing nonpharmacological interventions are worthy of review.

Beck et al1 tested the impact of several different behavioral interventions, all built on the premise that if an individual's basic psychosocial needs were met, disruptive behavior would decrease. Specifically, residents in long-term care facilities were randomized to one of five interventions. No significant differences emerged for the intervention by time interaction for any disruptive behavior. The participants seemed to experience benefit during the one-on-one interaction, but these effects did not last.

Aromatherapy was another nonpharmacologic intervention tested in a randomized clinical study with older adults with dementia. This study2 included 72 older adults with dementia and associated agitation who were randomly assigned to receive aromatherapy with essential oil of lemon balm. The oil was combined with a base lotion and applied to the residents' faces and arms twice a day. The control group received sunflower oil in the same way. The results indicated that exposure to the oils decreased agitation and improved quality of life. In light of the low risk for side effects from this type of treatment, aromatherapy should be considered for residents in whom pharmacotherapy may not be an option or is not safe.

The current standard of care for pharmacologic management of dementia is a combination of a cholinesterase inhibitor and high-dose vitamin E.3 This standard is based on the results of large-scale, double-blind, placebo-controlled randomized trials. Large-scale placebo-controlled trials of tacrine, donepezil, rivastigmine, and galantamine have demonstrated moderate benefits in patients with mild to moderate dementia.3, 4, 5, 6, 7, 8 Rivastigmine is a dual acetylcholinesterase/butyrylcholinesterase (AChE/BuChE) inhibitor, whereas donepezil and galantamine are acetylcholinesterase-selective inhibitors. Donepezil, rivastigmine, and galantamine are the first-line choices because of their lower side effect profile. Treatment benefits include improved function and behavior.

Table 1 compares the different AChE inhibitors.

Table. 1. Comparison of Acetylcholinesterase Inhibitors

	Characteristic	Donepezil	Rivastigmine	Galantamine
	Safety	Caution in peptic ulcer disease, asthma, and bradycardia	Same	Same
	Tolerability	Insomnia, agitation, leg cramps, GI upset	Agitation, GI upset	GI upset
	Dosing/half-life /metabolism	Daily dosing, 72-hour half-life, liver metabolism	Twice daily, 8-hour half-life, AChE metabolism	Twice daily, 7-hour half-life, liver metabolism
	Behavioral symptom response	Yes	Yes	Yes

Health policy pearls for advance practice nurses who care for geriatric patients 

In July, President Bush signed nursing shortage legislation, the Nurse Reinvestment Act, into law. This important bill includes nurse scholarships in exchange for commitment to work in underserved areas, nurse retention grants, comprehensive geriatric training grants, faculty loan cancellation programs, career ladder grant programs, and public service announcements.

The National Conference for Gerontological Nurse Practitioners (NCGNP) and the 60-plus other nursing and allied health organizations that form the Americans for Nursing Shortage Relief (ANSR) Alliance helped it happen. The ANSR Alliance met regularly to discuss methods to promote the bill and regularly contacted Capitol Hill legislators.

Enactment of this law authorizes the appropriate agencies to establish or expand programs. The second phase of enacting the bill is underway, thus ensuring that funding is appropriated to fully implement all parts and programs. The ANSR Alliance is working with Congress to obtain funds for fiscal year 2003. The budget is tight, but NCGNP and other nursing groups in the coalition will continue to push.

Much of the administrative implementation of the act will be delegated to the Health Resources and Services Administration's Division of Nursing. They have the authority to administer the various nursing scholarship and grant programs that address nursing education. For more information, visit www.bhpr.hrsa.gov/nursing .