Evaluations We deeply value your feedback, and will utilize it in the ongoing development of our courses and services. www.careandcompliance.com/eval

Dementia Care Update Josh Allen, RN, C-AL

Agenda National trends and statistics The brain Disease overview Research update Care trends and best practices Risk Management

Trends and Statistics

42% of residents living in assisted living have Alzheimer’s disease or another form of dementia Source: National Survey of Residential Care Facilities

Source: National Survey of Residential Care Facilities

More than 5 million Americans are living with the disease. Alzheimer's disease is the sixth leading cause of death in the United States. More than 5 million Americans are living with the disease. 1 in 3 seniors dies with Alzheimer's or another dementia. In 2012, 15.4 million caregivers provided more than 17.5 billion hours of unpaid care valued at $216 billion. Nearly 15% of caregivers for people with Alzheimer's or another dementia are long-distance caregivers. In 2013, Alzheimer's will cost the nation $203 billion. This number is expected to rise to $1.2 trillion by 2050. Source: Alzheimer’s Association, Facts and Figures

www.alz.org

Prevalence An estimated 5.2 million Americans have Alzheimer's disease Approximately 200,000 individuals younger than age 65 have younger-onset Alzheimer's. By 2025, the number of people age 65 and older with Alzheimer's disease is estimated to reach 7.1 million By 2050, the number of people age 65 and older with Alzheimer's disease may nearly triple to a projected 13.8 million Source: Alzheimer’s Association, Facts and Figures

Mortality 6th leading cause of death in the United States overall 5th leading cause of death for those aged 65 and older The only cause of death among the top 10 in America without a way to prevent it, cure it or even slow its progression Deaths from Alzheimer's increased 68 percent between 2000 and 2010, while deaths from other major diseases, including the number one cause of death (heart disease), decreased Source: Alzheimer’s Association, Facts and Figures

Source: Alzheimer’s Association, Facts and Figures

Mortality Ambiguity about the underlying cause of death can make it difficult to determine how many people die from Alzheimer's There are no survivors: if you do not die from Alzheimer's disease, you die with it One in every three seniors dies with Alzheimer's or another dementia Source: Alzheimer’s Association, Facts and Figures

Impact on Caregivers In 2012, 15.4 million family and friends provided 17.5 billion hours of unpaid care Care valued at $216.4 billion 80% of care provided in the community is provided by unpaid caregivers. More than 60 percent of Alzheimer's and dementia caregivers rate the emotional stress of caregiving as high or very high; more than one-third report symptoms of depression Source: Alzheimer’s Association, Facts and Figures

Cost to the Nation In 2013, the direct costs will total an estimated $203 billion Including $142 billion in costs to Medicare and Medicaid Total payments for health care, long-term care and hospice for people with Alzheimer's and other dementias are projected to increase from $203 billion in 2013 to $1.2 trillion in 2050 (in current dollars) Source: Alzheimer’s Association, Facts and Figures

Source: Alzheimer’s Association, Facts and Figures

The Brain

The Brain Cerebrum: remembering, problem solving, thinking, and feeling, also controls movement Cerebellum: controls coordination and balance Brain stem: connects the brain to the spinal cord and controls automatic functions such as breathing, digestion, heart rate and blood pressure

The Cortex Parietal Lobe Frontal Lobe Occipital Lobe Temporal Lobe

Alzheimer’s Disease

Alzheimer’s Disease Source: Alzheimer’s Association

Neurons

Humans: 85 billion Neurons Fruit Fly: 100 thousand neurons Cockroach: One million neurons Mouse: 75 million neurons Cat: One billion neurons Chimpanzee: 7 billion neurons Elephant: 23 billion neurons

Neurons A nerve cell that is the basic building block of the nervous system Specialized to transmit information throughout the body Communicating information in both chemical and electrical forms Sensory neurons carry information from the sensory receptor cells throughout the body to the brain Motor neurons transmit information from the brain to the muscles of the body Interneurons are responsible for communicating information between different neurons in the body

Chemical and Electrical Messages Dendrite Cell body Axon

Synapse The information must be transmitted across the synaptic gap to the next neuron Neurotransmitters Chemical messengers that are released from the axon terminals to cross the synaptic gap and reach the receptor sites of other neurons

Neurotransmitters Acetylcholine: Associated with memory, muscle contractions, and learning. A lack of acetylcholine in the brain is associated with Alzheimer’s disease. Endorphins: Associated with emotions and pain perception. The body releases endorphins in response to fear or trauma. These chemical messengers are similar to opiate drugs such as morphine, but are significantly stronger. Dopamine: Associated with thought and pleasurable feelings. Parkinson’s disease is one illness associated with deficits in dopamine, while schizophrenia is strongly linked to excessive amounts of this chemical messenger.

Disease Overview

CHECK FOR UNDERSTANDING: What is the difference between dementia and Alzheimer’s disease?

Dementia Not a specific disease A general term that describes a wide range of symptoms associated with a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities Alzheimer's disease accounts for 60 to 80 percent of cases Vascular dementia, which occurs after a stroke, is the second most common dementia type Source: Alzheimer’s Association

DEMENTIA Vascular Dementia Alzheimer’s Disease Lewy Body Frontotemporal Parkinson’s Disease Mixed Dementia

Symptoms Symptoms of dementia can vary greatly At least two of the following core mental functions must be significantly impaired to be considered dementia: Memory Communication and language Ability to focus and pay attention Reasoning and judgment Visual perception Source: Alzheimer’s Association

Other Causes of Cognitive Changes Depression Medication side effects Infection Excess use of alcohol Thyroid problems Vitamin deficiencies Source: Alzheimer’s Association

Diagnosis There is no one test to determine if someone has dementia. Medical history Physical examination Laboratory tests Characteristic changes in thinking, day-to-day function and behavior associated with each type Can determine dementia with a high level of certainty Harder to determine the exact type Source: Alzheimer’s Association

Alzheimer’s Disease Symptoms: Difficulty remembering names and recent events Apathy and depression Impaired judgment Disorientation Confusion Behavior changes Difficulty speaking, swallowing and walking Source: Alzheimer’s Association

Alzheimer’s Disease Brain changes: Deposits of the protein fragment beta-amyloid (plaques) that build up between brain cells Twisted strands of the protein tau (tangles) that build up inside cells Evidence of nerve cell damage and death in the brain Source: Alzheimer’s Association

Stages Stage 1 No impairment The person does not experience any memory problems. An interview with a medical professional does not show any evidence of symptoms of dementia. Stage 2 Very mild cognitive decline The person may feel as if he or she is having memory lapses — forgetting familiar words or the location of everyday objects. But no symptoms of dementia can be detected during a medical examination or by friends, family or co-workers. Stage 3 Mild cognitive decline Friends, family or co-workers begin to notice difficulties. During a detailed medical interview, doctors may be able to detect problems in memory or concentration. Source: Alzheimer’s Association

Stages Stage 4 Moderate cognitive decline At this point, a careful medical interview should be able to detect clear-cut symptoms in several areas: forgetfulness of recent events, greater difficulty performing complex tasks, such as planning dinner. Stage 5 Moderately severe cognitive decline Gaps in memory and thinking are noticeable, and individuals begin to need help with day-to-day activities. Stage 6 Severe cognitive decline Memory continues to worsen, personality changes may take place and individuals need extensive help with daily activities. Source: Alzheimer’s Association

Stages Stage 7 Very severe cognitive decline In the final stage of this disease, individuals lose the ability to respond to their environment, to carry on a conversation and, eventually, to control movement.  Source: Alzheimer’s Association

Vascular Dementia Symptoms: Impaired judgment or ability to plan steps needed to complete a task is more likely to be the initial symptom, as opposed to the memory loss often associated with the initial symptoms of Alzheimer's Occurs because of brain injuries such as microscopic bleeding and blood vessel blockage The location of the brain injury determines how the individual's thinking and physical functioning are affected Source: Alzheimer’s Association

Vascular Dementia Brain changes: Brain imaging can often detect blood vessel problems implicated in vascular dementia In the past, evidence for vascular dementia was used to exclude a diagnosis of Alzheimer's disease (and vice versa) That practice is no longer considered consistent with pathologic evidence, which shows that the brain changes of several types of dementia can be present simultaneously Source: Alzheimer’s Association

Dementia with Lewy Bodies Symptoms:  Often have memory loss and thinking problems common in Alzheimer's More likely than people with Alzheimer's to have initial or early symptoms such as sleep disturbances, well-formed visual hallucinations, and muscle rigidity or other parkinsonian movement features Source: Alzheimer’s Association

Dementia with Lewy Bodies Brain changes:  Lewy bodies are abnormal aggregations (or clumps) of the protein alpha-synuclein Alpha-synuclein also aggregates in the brains of people with Parkinson's disease, but the aggregates may appear in a pattern that is different from dementia with Lewy bodies Source: Alzheimer’s Association

Parkinson’s Disease Symptoms: As Parkinson's disease progresses, it often results in a progressive dementia similar to dementia with Lewy bodies or Alzheimer's Problems with movement are a common symptom early in the disease If dementia develops, symptoms are often similar to dementia with Lewy bodies. Source: Alzheimer’s Association

Frontotemporal Dementia Symptoms:  Typical symptoms include changes in personality and behavior and difficulty with language Nerve cells in the front and side regions of the brain are especially affected. Generally develop symptoms at a younger age (at about age 60) and survive for fewer years than those with Alzheimer's Source: Alzheimer’s Association

Other Dementias Creutzfeldt-Jakob disease Normal pressure hydrocephalus Huntington's Disease Wernicke-Korsakoff Syndrome

Depression, Delirium or Dementia?

Delirium An acute confusional state Medical condition that results in confusion and other disruptions in thinking and behavior, including changes in perception, attention, mood and activity level Individuals living with dementia are highly susceptible to delirium Can easily go unrecognized

Onset, Course, Mood Depression Delirium Dementia Onset Weeks to months Hours to days Months to years Mood Low/apathetic Fluctuates Course Chronic; responds to treatment. Acute; responds to treatment Chronic, with deterioration over time Source: American Medical Association

Self-Awareness, ADLs, IADLs Depression Delirium Dementia Self-Awareness Likely to be concerned about memory impairment May be aware of changes in cognition; fluctuates Likely to hide or be unaware of cognitive deficits ADLs May neglect basic self-care May be intact or impaired May be intact early, impaired as disease progresses IADLs May be intact early, impaired before ADLs as disease progresses Source: American Medical Association

Research Updates

Great Info at www.alz.org

Causes Scientists know Alzheimer's disease involves progressive brain cell failure The reason cells fail isn't clear Experts believe that Alzheimer's develops as a complex result of multiple factors rather than any one overriding cause Source: Alzheimer’s Association

Causes Age and Alzheimer’s: Although Alzheimer's is not a normal part of growing older, the greatest risk factor for the disease is increasing age After age 65, the risk of Alzheimer's doubles every five years After age 85, the risk reaches nearly 50 percent Source: Alzheimer’s Association

Causes Family History and Alzheimer’s: Research has shown that those who have a parent, brother, sister or child with Alzheimer's are more likely to develop the disease The risk increases if more than one family member has the illness Either heredity (genetics) or environmental factors or both may play a role Source: Alzheimer’s Association

VIDEO: THE ROLE OF GENETICS IN ALZHEIMER’S Watch This Video VIDEO: THE ROLE OF GENETICS IN ALZHEIMER’S Instructors: Click on the link to the movie to begin. The movie will open in Media player. Double click on the playing video to make it full-screen. When movie is complete, hit escape. Then, close Media player to return to PowerPoint. Source: Alzheimer’s Association

Genes Linked to Alzheimer’s Amyloid precursor protein (APP), discovered in 1987, is the first gene with mutations found to cause an inherited form of Alzheimer's. Presenilin-1 (PS-1), identified in 1992, is the second gene with mutations found to cause inherited Alzheimer's. Variations in this gene are the most common cause of inherited Alzheimer's. Presenilin-2 ( PS-2), discovered 1993, is the third gene with mutations found to cause inherited Alzheimer's. Apolipoprotein E-e4 (APOE4), discovered in 1993, is the first gene variation found to increase risk of Alzheimer's and remains the risk gene with the greatest known impact. Having this mutation, however, does not mean that a person will develop the disease. Source: Alzheimer’s Association

Treatments Drug Name Brand Name Approved For FDA Approved donepezil Aricept All stages 1996 galantamine Razadyne Mild to moderate 2001 memantine Namenda Moderate to severe 2003 rivastigmine Exelon 2000 tacrine Cognex 1993 Source: Alzheimer’s Association

How Alzheimer’s Drugs Work Source: Alzheimer’s Association

How Alzheimer’s Drugs Work Cholinesterase inhibitors Slowing down the disease activity that breaks down a key neurotransmitter Donepezil, galantamine, rivastigmine and tacrine are cholinesterase inhibitors Source: Alzheimer’s Association

How Alzheimer’s Drugs Work Memantine NMDA (N-methyl-D-aspartate) receptor antagonist Works by regulating the activity of glutamate, a chemical messenger involved in learning and memory Protects brain cells against excess glutamate, a chemical messenger released in large amounts by cells damaged by Alzheimer's disease and other neurological disorders Source: Alzheimer’s Association

ADVANCES IN BRAIN DAMAGE Diagnosis VIDEO: ADVANCES IN BRAIN DAMAGE Instructors: Click on the link to the movie to begin. The movie will open in Media player. Double click on the playing video to make it full-screen. When movie is complete, hit escape. Then, close Media player to return to PowerPoint. Source: Alzheimer’s Association

Latest News Brain Atrophy Linked With Cognitive Decline in Diabetes Mediterranean Diet Is Good for the Mind, Research Confirms Alzheimer’s risk raised by high blood sugar, even for those without diabetes Exercise May Be the Best Medicine for Alzheimer‘s Disease

VIDEO: THE BENEFIT OF DIET AND EXERCISE IN ALZHEIMER’S Instructors: Click on the link to the movie to begin. The movie will open in Media player. Double click on the playing video to make it full-screen. When movie is complete, hit escape. Then, close Media player to return to PowerPoint. Source: Alzheimer’s Association

Care Trends and Best Practices

Care Trends and Best Practices Behavior management Communication Wandering and elopement Co-morbidities Changes in condition Tips and tricks…

Behavior Management

Behavior Management Can be one of the most challenging aspects of caring for residents with dementia The key is to have an established management technique Behaviors are not resolved, they are managed. Caregivers will find caring for residents with dementia less stressful if they accept that difficult, and even bizarre behaviors are a normal part of the illness

Top 5 Tips… Try not to take behaviors personally Remain patient and calm Explore pain as a trigger Don't argue or try to convince Accept behaviors as a reality of the disease and try to work through it Source: Alzheimer’s Association

Behavior Management Step 1: Is the behavior a problem? Step 2: What is the problem? Step 3: Who, when and where? Step 4: Why? Step 5: How will you manage the behavior? Step 6: Reassessment

Step 1: Is the Behavior a Problem? A behavior is not a problem unless it negatively affects the resident with the behavior or other residents If a behavior does not negatively affect the resident or other residents, management of the behavior is not necessary

Step 2: What is the Problem? Specifically identify what the problem behavior is

Step 3: Who, When, and Where? Identify with whom the problem behavior occurs, when it occurs, and where it occurs This can identify specific triggers that may be causing the problem behaviors Such as specific times of day, specific residents or staff, or specific places or situations

Step 4: Why? This step can be difficult but attempt to identify why the problem behavior occurs If a specific reason for the behavior cannot be identified, it can be related to a symptom of dementia

This step must be done as a team effort Step 5: How Will You Manage the Behavior? This step must be done as a team effort All members of the staff and caregivers in your community can contribute Remember, problem behaviors in dementia are managed, not resolved

Step 6: Reassessment It is vital that the problem behavior is regularly reassessed Is it getting better? Has it become worse? Should your management solution be changed or updated? Establish a regular time frame for reassessments, such as; every day, every week, etc.

Common Triggers Pain Frustration Demoralizing or infantilizing approach Misunderstanding a request Fatigue Communication barriers Inability to perform a task Inability to express needs Rapid change in the environment

Communication

Communication Be patient and supportive Offer comfort and reassurance Avoid criticizing or correcting Avoid arguing Offer a guess Encourage unspoken communication Limit distractions Focus on feelings, not facts Source: Alzheimer’s Association

Behavior Tips…

Aggression and Anger Try to identify the immediate cause Rule out pain as a source of stress Focus on feelings, not the facts Don't get upset Limit distractions Try a relaxing activity Shift the focus to another activity Decrease level of danger Avoid using restraint or force Source: Alzheimer’s Association

Sleep Issues and Sundowning Keep the home well lit in the evening Make a comfortable and safe sleep environment Maintain a schedule Avoid stimulants and big dinners Plan more active days Try to identify triggers Source: Alzheimer’s Association

Wandering Carry out daily activities Identify the most likely times of day that wandering may occur Reassure the person if he or he feels lost, abandoned or disoriented Ensure all basic needs are met Avoid busy places that are confusing and can cause disorientation Place locks out of the line of sight Camouflage doors and door knobs Use devices that signal when a door or window is opened Provide supervision Keep car keys out of sight Source: Alzheimer’s Association

Sexual Behavior Challenges Ensure safety of residents and staff Resident rights Ability to consent Communicate with family Relocate if needed

Co-Morbidities

Swallowing Disorders

Swallowing Disorders Dysphagia: Occurs when there is a problem with any part of the swallowing process. Aspiration: Occurs when liquids or solids are breathed into the respiratory system instead of properly being swallowed into the stomach.

Monitoring for Aspiration Choking on foods, liquids or medication Coughing during or after eating Wet sounding voice Extra effort to chew or swallow “Pocketing” food

Interventions Have resident sit upright when eating. Tilt the resident’s head slightly forward when eating. Ensure the resident remains sitting or standing upright for at least 15-20 minutes after finishing a meal. Minimize distractions in dining area.

Interventions Do not encourage residents to talk until he/she has swallowed his/her food. Cut food into small pieces. Encourage swallowing more than once after each bite or drink. Modified diets if physician ordered. Request a speech therapy evaluation from the physician to evaluate swallowing.

Modified Diets Thick liquids Soft foods Pureed Minced, ground and chopped

Skin Breakdown

Risk Factors Poor nutrition Dehydration Lack of ability to ambulate or move about easily Inability to turn in bed or from side to side in chair Decreased sensation Poor circulation Shearing Loss of bladder and/or bowel control Decreased activity Poor cognitive function

Keeping Skin Healthy Meticulous incontinence care Adequate hydration and nutrition Turn and reposition minimally every 2 hours Hydrate skin with topical application of lotions/creams Utilization of a barrier cream/ointment for incontinence

Falls

Falls More than 1/3 of adults 65 and older fall each year in the US. Men are more likely to die from a fall. However, women are 67% more likely than men to have a nonfatal fall injury. When an older adult falls, the effects go beyond physical injury.

Risk Factors Resident Effects of medications Eyesight problems Hip, leg and foot disorders Disease and illness Environment Elevated Bed Heights Low-seated chairs Poor lighting Slippery floors or non- secured rugs Clutter Poorly maintained ambulatory aides

Fall Risk Assessment Condition of resident Medications History of falls Gait and balance Ambulatory aide assessment Medical history Evaluation by physical therapist

General Strategies Remind resident to request assistance as needed. Ensure all pathways are free from obstacles. Provide adequate lighting. Provide appropriate chairs with arms that are solid and secure.

Fall Risk Reduction Remind resident to request assistance as needed. Ensure all pathways are free from obstacles. Provide adequate lighting. Provide appropriate chairs with arms that are solid and secure. Observe environment for potentially unsafe conditions. Identify residents who are “at risk” for falling and implement specific fall risk reduction strategies for that resident

Responding to a Fall

Changes in Condition

Stop and Watch

Changes in Behavior Physical aggression Physical symptoms, non-aggressive Verbal aggression Verbal symptoms, non-aggressive Social withdrawal Depression Source: www.interact2.net

Mental Status Change New symptoms or signs of increased confusion (e.g. disorientation, change in speech) Decreased level of consciousness Inability to perform usual activities (due to mental status change) New or worsened physical and/or verbal agitation New or worsened delusions or hallucinations Source: www.interact2.net

Communication is Key! Physician Family Licensing agency Your staff

Reducing Off-Label Use of Antipsychotics

Antipsychotics Indicated for persons with mental illness (e.g. schizophrenia, bipolar, etc.) Primarily used to manage psychosis Delusions Hallucinations

Antipsychotics Traditional Haldol Thorazine Mellaril Serentil Atypical Zyprexa Risperdal Seroquel Geodon

Antipsychotics Associated with significant side effects Extrapyramidal effects Tardive dykinesia Hypotension Lethargy

Antipsychotics Risk of Death Increased risk of death when used for residents with dementia FDA: 1.6 - 1.7 times increase in death rates Specific causes of death showed that most were due to heart related events or infections (e.g., pneumonia)

Reducing Overuse 1) Work with the physician/prescriber Don’t just ask the doctor for a prescription Ask him/her for alternative solutions to manage the issue Don’t be afraid to advocate for your resident

Reducing Overuse 2) Focus on Resident-Centered Care Use alternative interventions Physical activity Increased engagement Creating calm environments Identifying behavioral triggers Reminiscence therapy

Reducing Overuse 3) Educate your staff Direct care staff, med aides, and nurses Dangers of overuse How to avoid it Address burnout and caregiver stress

Reducing Overuse 4) Track and trend Quality improvement efforts Track and trend usage among your residents Establish realistic goals for reduction NCAL: Reduce off-label use of antipsychotics by 15 percent

NCAL www.ncal.org

Quality Goals Incidence % of residents who have an antipsychotic drug initiated for an off-label use within the first 90 days in your community

# of residents who have been at AL for 90 days or less Quality Goals Incidence # of residents with antipsychotic drug use indicated on medical records over the first 90 days # of residents who have been at AL for 90 days or less

Quality Goals Prevalence % of residents with off-label use of an antipsychotic drug

# of residents (over 90 days) Quality Goals Prevalence # of residents (over 90 days) with antipsychotic drug use indicated on medical records # of residents (over 90 days)

Quality Goals Exclusions: FDA Approved Uses Schizophrenia Bipolar disorder Major depressive disorder Tourette’s disorder Irritability associated with autistic disorder Treatment of resistant depression

ANY QUESTIONS?

Quiz

Question #1 Which of the following is a good intervention for a resident with Dementia? 3-5 medication prescriptions Atkins diet Regular exercise Isolation

Question #1 Which of the following is a good intervention for a resident with Dementia? 3-5 medication prescriptions Atkins diet Regular exercise Isolation

Question #2 A swallowing disorder is NOT considered a co- morbidity when experienced by a person with Dementia. True False

Question #2 A swallowing disorder is NOT considered a co- morbidity when experienced by a person with Dementia. True False

Question #3 High blood pressure increases the risk of Alzheimer’s disease. True False

Question #3 High blood pressure increases the risk of Alzheimer’s disease. True False

Question #4 When redirecting a resident who is wandering, you should never: Attempt change of face Argue with or pull the resident Allow them to wander in a safe area All of the above

Question #4 When redirecting a resident who is wandering, you should never: Attempt change of face Argue with or pull the resident Allow them to wander in a safe area All of the above

Question #5 When conducting a pre-admission appraisal, it is best to: Not allow the resident to answer questions, as they are not a reliable source of information Interview only the resident, as they are the person you will care for Interview both the family members and the resident All of the above

Question #5 When conducting a pre-admission appraisal, it is best to: Not allow the resident to answer questions, as they are not a reliable source of information Interview only the resident, as they are the person you will care for Interview both the family members and the resident All of the above

Question #6 Studies how that a history of diabetes has no impact on the likelihood of developing dementia. True False

Question #6 Studies how that a history of diabetes has no impact on the likelihood of developing dementia. True False

Question #7 Alzheimer’s disease is the ______ leading cause of death in the United States 1st 3rd 5th 6th

Question #7 Alzheimer’s disease is the ______ leading cause of death in the United States 1st 3rd 5th 6th

Question #8 A lack of which of the following neurotransmitters is associated with Alzheimer’s disease? Acetylcholine Endorphins Dopamine Serotonin

Question #8 A lack of which of the following neurotransmitters is associated with Alzheimer’s disease? Acetylcholine Endorphins Dopamine Serotonin

Question #9 The main difference between delirium and dementia is that delirium is a chronic problem that develops slowly over time. True False

Question #9 The main difference between delirium and dementia is that delirium is a chronic problem that develops slowly over time. True False

Question #10 Which of the following are effective methods to reduce off-label use of antipsychotic medications? Work with the physician Educate staff Track and trend All of the above

Question #10 Which of the following are effective methods to reduce off-label use of antipsychotic medications? Work with the physician Educate staff Track and trend All of the above

Evaluation If you have not completed your evaluation please take time to complete when time permits, your feedback is greatly appreciated. www.careandcompliance.com/eval