ALZHEIMERS DISEASE AND RELATED DEMENTIASLEHMAN COLLEGENUR 409
Definition of DementiaRefers to the loss of memory, reasoning, judgment, and language that it interferes with everyday life.Changes may occur gradually or quickly
CognitionCognition is the act or process of thinking, perceiving, and learning.Cognitive activities that become impaired in dementia include:Decision-makingJudgmentMemorySpatial orientationThinking, ReasoningVerbal communication
A client with dementia may undergo behavioral and personality changes as well, depending on the area(s) of the brain affected.
Alzheimers Disease (AD)Most common form of dementia among persons aged 65 and olderIntellectual deterioration severe enough to interfere with occupational or social performance.Decline in two or more areas of cognition:Memory, language, calculation, visuospatial perception, judgment, abstraction, or personalityAD constitutes about 50% or all dementias
Multi-infarct disease is the second most common cause of irreversible dementiaTypes of infarct diseaseBlood clots blocking small blood vessles in the brain and destroy brain tissueLewy body dementia is similar to Alzheimers disease but may progress more rapidlyLewy bodies are abnormal brain cellsPicks disease another form of dementia
Brain is quickly injured from hypoxia, reduced blood flow or drugs:Alzheimers diseaseMulti-infarct dementiaAlcoholic dementiaHuntingtons choreaAIDs related dementiaToxic or traumatic brain injuryMalignant disease
Alzheimers DiseaseEtiology and risk factorsCause of Alzheimers disease unknownIncreasing age is a risk factor Genetic factors involvement of five chromosomesClinical situations associated with AD include:Elevated homocysteinInflammationStrokeOxidative damage from free radicals
PathophysiologyAlzheimers disease disrupts:Communication, metabolism, repair of neuronsPresence of beta-amyloid plaques, which are proteins that are dense and insoluble deposits around the brain. Neurofibrillary tangles which is an irreversible change in the tracts of healthy neurons, which then begin to degenerate leading to memory failure, personality changes, and problems with activities of daily living.
Acetylcholine is also decreased in clients with ADGross changes in the brain of persons with AD include:Enlarged ventricles, hippocampal shrinkage, generalized atrophy, shrunken gyriA decline in cholinergic neurons in the basal nucleus leads to loss of choline acetyltransferase in the neocortex and hippocampusAlso involves neurotransmitter changes. The decline in cholinergic neurons in the basal nucleus leads to loss of choline acetyltransferase in the neocortex and hippocampus.
Clinical ManifestationsImpairment of decision-making beginning insidiously and progressing.Preclinical Alzheimers DiseaseHippocampusresponsible for short and long-term memoryMild Alzheimers DiseaseMemory disturbancePoor judgment and problem-solving skillsCareless in work habits and household choresMay become confused and get lostMay become irritable, suspicious, agitated or apathetic
Moderate Alzheimers DiseaseMay demonstrate language disturbance, characterized by impaired word-findingMotor disturbance apraxiadifficulty in using everyday objects: toothbrush, comb, razorHyperorality: put things in the mouthWorsening irritability and depression, psychosis, incontinence may occurSevere Alzheimers DiseaseInability to recognize familiar facesVoluntary movement is minimal
Clinical ManifestationsAD characterized by relentless impairment of decision-making that generally begins insidiously and usually progresses slowlyOnset of AD typically occurs in late middle age, 65 years or older; some familial cases can occur in ages 40s50s
Classification of Alzheimers DiseasePreclinical Alzheimers DiseaseBegins near the Hippocampus Affected regions begin to shrink leading to memory lossMild Alzheimers DiseaseMemory disturbance, confused and disoriented at times. Clients begin to get lost. Routine activities take longerPerson may become irritable, suspicious, indifferent, moody, agitated, apathetic
Moderate Alzheimers DiseaseClient may demonstrate language disturbance, impaired word findingApraxiadifficulty in motor activitiesdoing everyday activities. Resulting in safety issues. Hyperorality, depression and irritability may worsen. Wandering at night is common.Severe Alzheimers DiseasePlaques and tangles are widespread. Patients do not recognize family or friends. Do not communicate in any way. Voluntary movement is minimal; limbs become rigid with flexor posturing. Urinary and fecal incontinence is frequent. Aspiration and aspiration pneumonia are frequent
Diagnostic FindingsDiagnosis made by exclusion (although there are many types of tests under study)r/o known causes: toxic or metabolic abnormalities, drug side effects, cerebrovascular disease, neoplasm, infection.CT scan useful to identify ventricular dilation and sulcal enlargement and cerebral atrophyMRI, PET scans also helpfulLaboratory data to support or dispute other treatable causes: CBC, ESR, BUN, Creatinine, thyroid and liver function studies, calcium, B12, syphillis, HIV
Other DementiasMulti-infarct dementia (MID)Blockage of small cerebral vessles (lacunar)Confusion, memory loss, emotional lability.Occurs more commonly in men than womenOnset ages 60--75
Lewy body dementiaClinical manifestations range from traditional parkinsonianism effects to loss of spontaneous movement (bradykinesia), rigidity, confusion or fluctuating cognition. Visual hallucinations may be one of the first manifestations noted.Other psychiatric symptoms may occur: delusions and depression
Outcome ManagementDiagnosis best made by a multidisciplinary group that can assist the client and familyGoals:Helping maintain mental function Slow the process of deterioration
Outcome Management:Multidisciplinary team to assist client and familyNo cure Helping to maintain function and slowing the process of deterioration
Medical ManagementPharmacotherapyMedications that retain acetylcholine in the neurojunctions such as Tacrine (Cognex), Donepezil (Aricept), Galathamine (Reminyl)Drugs can have small but noticeable effects, depending on the stage of the disease, differences in the way the drugs act in different clientsNone of the medications prevent the progression of the disease
Exelon PatchStart with 4.6 mg for four weeks, then increase to 9.5 mg/24 hours. For moderate to severe Alzheimers may increase to 13.3 mg.
May need to lower dosage for patients with Hepatic disease, or for clients with weight less than 100 pounds.
Change site of patch daily
Side EffectsGastrointestinalNausea, vomiting, diarrhea, anorexia, weight lossSkin Reactionsmay cause mild irritation to dermatitis. Change patch site daily, clean with cool waterNeurologicalMay cause tremor or worsen tremor in Parkinsons clients
Combat oxygen-free radicalsUse of vitamin E and selegiline have been studied. Do support in assisting to delay the later stages of Alzheimers and show some improvements in levels of independenceGinko bilobaMay improve cognitive function fro 612 months; some research does not support this claim
Other medicationsAnti-anxiety, antipsychotics, antidepressantsShould minimize use of these medications
Nursing ManagementComplete history including use of secondary resourcesMini Mental State ExaminationUsual behaviorsImpact on family
Nursing Diagnosis: Impaired Verbal CommunicationOutcomeClients needs will be communicated (early stages); later stages focus on interpretation of clients expressionsInterventionsEarly: speak slowly and simply. Use the patients language. Use calming tone of voice. As disease progresses use of other techniquesNonverbal behavior also importantfrustration, anger, hostility
Decrease environmental stimuliApproach the patient calmlyLimit demands on patinetUse distractionElicit listening behaviorhold hand, maintain physical contactPain assessment and management
Disturbed Thought ProcessOutcomeClient will have appropriate thought processingRetention of informationInterventionsReorient client Allow clients to reminisceUse of repetition
Risk for InjuryOutcomeClients physical and environmental safety will be maintained as evidenced by the absence of physical injury and the existence of a safe living environmentInterventionsSafety in the home: electrical wiring, toxic substances, loose rugs, hot tap water, inadequate lighting, dangerous objects
Self-Care DeficitOutcomesClient will maintain self-care ability as evidenced by completing the tasks they are capable of performing and receiving assistive with ADL they are incapable of performingInterventionsEncourage the client with AD to do as much as possible, as long as it is safe and appropriateGive client plenty of time to complete tasksRemind client that step-by-step process is required
Urge Urinary IncontinenceOutcomesClient will have optimal continence bladder and bowel as evidenced by the client having clean clothing and bedding as much as possible having intactInterventionsToileting scheduleBright signage for the bathroomLimit fluid intake after dinner
Caregiver Role StrainOutcomesFamily will demonstrate decreased role strain as evidenced by voicing their emotional concerns, seeking appropriate assistance, and providing adequate care for the client.InterventionsAllow family members to grieve the loss of the person that they knewProvide formal supports as indicatedRefer to support groupsRespite care, Adult day careNursing