Preliminary Care Coordination Plan: Alzheimer’s Disease

The mental health of the elderly has been a health concern for public health since time immemorial. Alzheimer’s disease is one of the neurodegenerative health illnesses that present with cognitive impairment as well as functional and psychological incapacitations. Management of Alzheimer’s disease requires both hospital and community care. Therefore, helpful community resources are essential for holistic care. This is a lifelong condition that requires realistic care goals to improve quality of life and slow progression. This paper aims to develop a care plan for Alzheimer’s, set care goals, and identify handy community resources to improve care outcomes.

Alzheimer’s Disease Care Plan

Alzheimer’s disease has a slow onset and is typically a condition of old age. It usually starts in patients above 65 years old, but about 10% of the cases can occur in younger populations (Kumar et al., 2022). Symptoms of Alzheimer’s disease include but are not limited to progressive memory loss and confusion, language difficulties, loss of writing and reading skills, a reduced span of attention, disorganized and illogical thoughts, inability to learn new skills or cope with new situations, aggression & agitation, anger, and sometimes, depression. Neuronal cell death is the underlying pathogenetic process behind Alzheimer’s disease (AD). Genetics plays a key role in both presenile and senile Alzheimer’s disease. Individualizing the management of every AD patient can promote holistic care.

Physical Needs and Care Plan

AD is an invariably progressive disease with no cure. Physical management aims for symptomatic improvement. Physical management includes physical therapy and psychopharmacotherapy. The FDA had approved three cholinesterase inhibitors (donepezil, galantamine, and rivastigmine) and one Partial N-Methyl D-Aspartate (NMDA) (memantine) (Rosenthal & Burchum, 2020). The choice of pharmacotherapy to use will be determined by patient factors and goals of treatment. Avoidance of polypharmacy should be given priority for AD patients because of the assumption that they already have an underlying cognitive impairment, and in the absence of proper social and family support, compliance to the treatment will be troublesome, thus poor therapeutic achievement. The stage and severity of the patient’s AD are critical in the determination of the choice of drug choice. Moderate to severe AD will require memantine, while donepezil is usable in all stages and severity. Prescription of galantamine and rivastigmine will be appropriate for patients with mild cognitive impairment and dementia stages of AD. Recently the FDA approved aducanumab for AD. Aducanumab slows the progression of the disease through the prevention of amyloid plaque deposition. Prescription of aducanumab will be appropriate for patients with mild to moderate AD symptoms (Cummings, 2021; Olivieri, 2021; Alzheimer’s Association, n.d.). This medication has been marred with controversies and thus not been used widely for Alzheimer’s disease since its approval in 2021

Pneumonia is the most common cause of mortality among patients with AD. Therefore, preventive care is helpful to prevent pneumonia among patients with additional risk factors such as diabetes, immunosuppression, or chemotherapy. Some pieces of clinical evidence have shown that physical exercise therapy can slow down disease progression. However, the late review by the agency for healthcare research and quality has deemed the strengths of this evidence week (Rosenthal & Burchum, 2020). Nevertheless, physical therapy and exercise are still essential for the general health of AD patients

Psychosocial Needs Care Plan

AD progresses with severe neuropsychiatric symptoms despite the physical therapy modalities. Agitation, depression, anxiety, anger, insomnia, and paranoia are some of the neuropsychiatry sequelae of AD (Cummings, 2021; Kumar et al., 2022; Rosenthal & Burchum, 2020). According to Rosenthal and Bochum (2020), these neuropsychiatric symptoms do not ultimately benefit from antipsychotics, mood stabilizers, or antidepressants owing to mortality concerns. Therefore, cholinesterase inhibitors remain the best shot for AD patients that develop these neuropsychiatric symptoms. Some critical psychosocial interventions prevent the progression of this disease and slow down the rate of progression to the aforementioned neuropsychiatric sequelae. These interventions include but are not limited to reminiscence, cognitive stimulation, cognitive training, aromatherapy, occupational therapy, educational support, and other support programs for patients and their families.

Cultural Needs and Care Plan

Culture defines how people think and believe about diseases. The prevalence of AD varies amongst different cultures and races. The culture of a patient with AD will determine how their families provide psychosocial and emotional support. AD patients require cultural support to enable them to cope with the disease. Therefore, religious needs, cultural rituals, and patient caregivers‘ cultural ways of caring for AD patients must be respected. This notwithstanding, patients and their families should also understand the scientific natural history of AD and available management modalities for the disease. Most of the time, the educational levels of the patients are confounded by culture (Rosselli et al., 2022). To address the cultural needs, the health professional needs to offer patient education to both the patient and their families or caregivers. In so doing, holistic care will promote cultural sensitivity and patient-centered care.

Specific Care Goals

AD patients suffer from different symptoms, both physical and mental. The outcome of this affliction is a poor quality of life and dependence on family members or other caregivers for activities of daily living (ADLs). The above-mentioned care needs and interventions are aimed at addressing various dimensions of care. Specific goals of care for AD patients are to improve the patient’s cognitive abilities, slow the progression of the disease, reduce behavioral symptoms, and improve daily functioning. To achieve these goals, good care coordination is essential (Warrick et al., 2018). About 80% of AD patients develop the earlier mentioned neuropsychiatric symptoms later in the disease’s natural history (Rosenthal & Burchum, 2020). Preventing these symptoms would improve the patient’s quality of daily life. These symptoms also cause distress to their caregivers and preventing them should remain a top care priority for positive care outcomes.

Community Resources for Alzheimer’s Disease

Management of AD requires a multidisciplinary approach for positive patient care outcomes (Tang et al., 2019). Mental health specialists, nurses, therapists (occupational, physical, and psychological), and physicians, among other healthcare professionals are required for the complete care of AD patients. Care in the hospital offers different challenges to patient and their families. Therefore, community care remains a better option owing to the chronic nature of the disease. Therefore, community resources are important for patient care. Various community resources can assist in the care of AD patients. Most AD patients qualify for government programs such as Medicare, Medicaid, Social Social Security Disability Income (SSDI) for workers younger than 65, and Supplemental Security Income (SSI) for healthcare insurance (Abramsohn et al., 2019). Therefore, the care professional needs to connect them to these resources for improved access to care. The community also offers other resources such as social support groups such as the Alzheimer’s Association, family and friends networks and groups, dementia support groups, the Family Caregiver Alliance, U.S. Department of Veterans Affairs, Cleveland Clinic’s Healthy Brains, and Alzheimer’s Foundation of America among others (Alzheimer’s Association, n.d.). These groups proved the patient with a sense of belonging and improved their coping with the disease. Laundry services and home care services are also essential for patients daily living in cases where the family caregivers are unavailable.


Alzheimer’s disease is a chronic disease that can be debilitating to patients. These patients require physical, behavioral, psychosocial, as well as cultural care. Interventions aim at slowing progression and improving quality of life. This disease is incurable, but medications as part of physical management can slow progression. Preventing or delaying the onset of neuropsychiatric symptoms is vital as part of care. A wide range of community resources is available for AD patients. These include social support groups, home care services, and health programs.


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