Alzheimer’s disease: Management

1. Alzheimer’s Disease

2. Overview

3. Alzheimer's disease A progressive degenerative disorder of the cerebral cortex (especially the frontal lobe) Most common form of dementia 5% of people older than age 65 have a severe form of this disease 12% suffer from mild to moderate dementia

5. Alzheimer's disease Characterized by: Progressive impairment in memory, cognitive function, language, judgment, and ADL Ultimately, patients cannot perform self-care activities and become dependent on caregivers Prognosis: poor

6. Pathophysiology and Etiology

7. Gross pathophysiologic changes: cortical atrophy enlarged ventricles basal ganglia wasting Microscopically: Changes in the proteins of the nerve cells of the cerebral cortex accumulation of neurofibrillary tangles and neuritic plaques (deposits of protein and altered cell structures on the interneuronal junctions) granulovascular degeneration loss of cholinergic nerve cells (important in memory, function, cognition)

11. Biochemically: neurotransmitter systems are impaired Cause: unknown Risk factors: genetics and female gender Viruses, environmental toxins, silent brain infarcts, and previous head injury may also play a role

12. Clinical manifestations

13. Disease onset: subtle and insidious Initially, a gradual decline of cognitive function from a previously higher level Short-term memory impairment is commonly the first characteristic in earliest stages of the disease Forgetful and difficulty learning and retaining new information Difficulty planning meals, managing finances, using a telephone, or driving without getting lost

15. Functional deficits: Language disturbance (word-finding difficulty) Visual-processing difficulty Inability to perform skilled motor activities Poor abstract reasoning and concentration Personality changes: Irritability Suspiciousness Personal neglect of appearance Disorientation to time and space

16. Middle stage: Repetitive actions (perseveration) Nocturnal restlessness Apraxia (impaired ability to perform purposeful activity) Aphasia (inability to speak) Agraphia (inability to write) Signs of frontal lobe dysfunction: Loss of social inhibitions Loss of spontaneity

18. Middle and late stages: Delusions Hallucinations Aggression Wandering behavior Patients in the advanced stage of Alzheimer's disease require total care Urinary and fecal incontinence Emaciation Increased irritability Unresponsiveness or coma

21. complications

22. Increased incidence of functional decline Injury due to lack of insight, hallucinations, confusion, wandering, own violent bahavior Pneumonia and other infections, especially if the patient doesn't get enough exercise Malnutrition and dehydration due to inattention to mealtime and hunger or lack of ability to prepare meals Aspiration

25. Diagnostic evaluation

29. Laboratory tests: complete blood count, sedimentation rate, chemistry panel, thyroid-stimulating hormone, test for syphilis, urinalysis, serum B12, folate level, and test for HIV to rule out infectious or metabolic disorders Commercial assays for cerebrospinal fluid (CSF) tau protein and beta-amyloid Genetic testing In families with a history of Alzheimer's disease, test to confirm AD or to provide information to at-risk family members regarding their likelihood for development of AD

30. management

31. Primary goals of treatment for Alzheimer's disease: To maximize functional abilities and improve quality of life by enhancing mood, cognition, and behavior No curative treatment exists Cholinesterase inhibitors first treatment for cognitive impairment of AD Improve cholinergic neurotransmission to help delay decline in function over time

34. Patients with depressive symptoms should be considered for antidepressant therapy Behavioral disturbances may require pharmacologic treatment anxiolytics, antipsychotics, anticonvulsants Nonpharmacologic treatments used to improve cognition: Environmental manipulation that decreases stimulation Pet therapy Aromatherapy Massage Music therapy Exercise

35. Drug Alert Cholinesterase inhibitors initially aimed at improving memory and cognition seem to have an important impact on the behavioral changes that occur in patients with cognitive impairment improves the apathy, disinhibition, pacing, and hallucinations commonly noted in dementia Be alert for drug interactions with NSAIDs, succinylcholine-type muscle relaxants, cholinergic and anticholinergic agents, drugs that slow the heart, and other drugs that are metabolized by the hepatic CYP2D6 or CYP3A4 pathways

36. Nursing assessment

37. Perform cognitive assessment: orientation, insight, abstract thinking, concentration, memory, verbal ability Assess for changes in behavior and ability to perform ADLs Evaluate nutrition and hydration check weight, skin turgor, meal habits Assess motor ability, strength, muscle tone, flexibility

38. Nursing diagnoses

39. Bathing or hygiene self-care deficit Constipation Disabled family coping Disturbed thought processes Dressing or grooming self-care deficit Feeding self-care deficit Imbalanced nutrition: Less than body requirements Impaired verbal communication Ineffective coping Interrupted family processes Risk for infection Risk for injury Toileting self-care deficit

40. Key outcomes

41. The patient will perform bathing and hygiene needs maintain a regular bowel elimination pattern (Family members will) use support systems and develop adequate coping behaviors remain oriented to time, person, place, and situation to the fullest extent possible perform dressing and grooming needs within the confines of the disease process consume daily calorie requirements

42. The patient will show no signs of malnutrition effectively communicate needs verbally or through the use of alternative means of communication use support systems and develop adequate coping behaviors (Family members will) discuss the impact of the patient's condition on the family unit remain free from signs and symptoms of infection (Family members will) identify strategies to make the patient's environment as safe as possible perform toileting needs within the confines of the disease process

43. Nursing interventions

45. Establish an effective communication system with the patient and his family to help them adjust to the patient's altered cognitive abilities Provide emotional support to the patient and his family Encourage them to talk about their concerns Listen carefully to them Answer their questions honestly and completely Use a soft tone and a slow, calm manner when speaking to him Because the patient may misperceive his environment,

46. Allow the patient sufficient time to answer your questions his thought processes are slow, impairing his ability to communicate verbally Administer ordered medications to the patient and note their effects If the patient has trouble swallowing, check with a pharmacist to see if tablets can be crushed or capsules can be opened and mixed with a semi-soft food Protect the patient from injury Provide a safe, structured environment Provide rest periods between activities because these patients tire easily

47. Encourage the patient to exercise to help maintain mobility Encourage patient independence allow ample time for the patient to perform tasks Encourage sufficient fluid intake and adequate nutrition Provide assistance with menu selection allow the patient to feed himself as much as he can Provide a well-balanced diet with adequate fiber Avoid stimulants, such as coffee, tea, cola, and chocolate

48. Give the patient semisolid foods if he has dysphagia Insert and care for a nasogastric tube or a gastrostomy tube for feeding as ordered Because the patient may be disoriented or neuromuscular functioning may be impaired, take the patient to the bathroom at least every 2 hours Make sure he knows the location of the bathroom Assist the patient with hygiene and dressing as necessary Many patients with Alzheimer's disease are incapable of performing these tasks

49. Patient teaching

50. Teach the patient's family about the disease Explain that the cause of the disease is unknown Review the signs and symptoms of the disease Be sure to explain that the disease progresses but at an unpredictable rate and that patients eventually suffer complete memory loss and total physical deterioration Review the diagnostic tests that are to be performed and treatment the patient requires Advise family members to provide the patient with exercise Suggest physical activities, such as walking or light housework, that occupy and satisfy the patient

51. Stress the importance of diet Limit the number of foods on the patient's plate so he doesn't have to make decisions If the patient has coordination problems, cut his food and to provide finger foods, such as fruit and sandwiches Suggest using plates with rim guards, easy-grip utensils, and cups with lids and spouts Allow the patient as much independence as possible while ensuring his and others' safety Create a routine for all the patient's activities, which helps them avoid confusion If the patient becomes belligerent, advise family members to remain calm and try to distract him Refer family members to support groups

52. Teaching patient about alzheimer’s disease

53. Counsel family members to expect progressive deterioration in the patient with Alzheimer's disease To help them plan future patient care, discuss the stages of this relentless neurodegenerative disease Bear in mind that family members may refuse to believe that the disease is advancing Be sensitive to their concerns and, if necessary, review the information again when they're more receptive

54. Forgetfulness The patient becomes forgetful, especially of recent events He frequently loses everyday objects such as keys Aware of his loss of function, he may compensate by relinquishing tasks that might reveal his forgetfulness Because his behavior isn't disruptive and may be attributed to stress, fatigue, or normal aging, he usually doesn't consult a physician at this stage

55. Confusion The patient has increasing difficulty at activities that require planning, decision making, and judgment, such as managing personal finances, driving a car, and performing his job He does retain skills such as personal grooming Social withdrawal occurs when the patient feels overwhelmed by a changing environment and his inability to cope with multiple stimuli Travel is difficult and tiring As he becomes aware of his progressive loss of function, he may become severely depressed Safety becomes a concern when the patient forgets to turn off appliances or recognize unsafe situations such as boiling water At this point, the family may need to consider day care or a supervised residential facility

56. Decline in activities of daily living The patient at this stage loses his ability to perform such daily activities as eating or washing without direct supervision Weight loss may occur He withdraws from the family and increasingly depends on the primary caregiver Communication becomes difficult as his understanding of written and spoken language declines Agitation, wandering, pacing, and nighttime awakening are linked to his inability to cope with a multisensory environment He may mistake his mirror image for a real person (pseudohallucination) Caregivers must be constantly vigilant, which may lead to physical and emotional exhaustion They may also be angry and feel a sense of loss.

57. Total deterioration In the final stage of Alzheimer's disease, the patient no longer recognizes himself, his body parts, or other family members He becomes bedridden, and his activity consists of small, purposeless movements Verbal communication stops, although he may scream spontaneously Complications of immobility may include pressure ulcers, urinary tract infections, pneumonia, and contractures

58. Learning activity

59. True or False: Alzheimer’s disease is a memory-related disease that is reversible with medications.

60. FALSE Alzheimer’s disease is a progressive degenerative disorder of the brain that is irreversible The exact cause is unknown; initial stages include recent memory loss and impaired judgment, inability to learn and retain new information, and difficulty finding words; later stages include decreased abilility to care for self, wandering, agitation and hostility, and possibly eventually inability to walk, incontinence, and no intelligible speech Medications may help improve memory in early stages, but there is no cure It is typically diagnosed when other dementia-producing conditions have been ruled out

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