-aka Dementia: a syndrome with progressive deterioration in intellectual functioning secondary to structural or functional changes. – Alzheimer’s disease is the most common type of dementia -Alzheimer’s disease is an irreversible form of senile dementia caused by nerve cell deterioration. -Individuals with Alzheimer’s disease experience cognitive deterioration & progressive loss of ability to carry out ADL’s. -The pt experiences a steady decline in physical & mental functioning and usually requires long-term care in a specialized facility in the final stages of the illness. Structural and Chemical changes occur in the brain with Alzheimer’s.
-structural atrophy and brain weight reduction -neurotransmitter abnormalities (acetylcholine, norepinephrine, dopamine, serotonin) Agnosia: failure to recognize or identify familiar objects despite intact sensory function; loss of sensory comprehension Prosopagnosia: inability to recognize oneself & other familiar faces Amnesia: loss of memory caused by brain degeneration Aphasia: language disturbance in understanding and expressing spoken words; inability to speak or understand Apraxia: inability to perform motor activities, despite intact motor function; inability to use objects correctly Anomia: inability to find words.
ETIOLOGY/ CAUSE/ INCIDENCE -exact cause is unknown (age, gender, family history) -more common in women -increased after age 65 (may affect anyone older than 40) -African Americans have increased risk -Hispanics develop earlier than other groups -genetics, chemical imbalances, environmental agents & immunologic changes are other theories. HEALTH PROMOTION – NO proven ways to prevent Alzheimers -current research theories: 1. eating balanced diet 2. eat dark colored fruits & vegetables, soy products, sufficient amts of folate and vitamin B12, C, and E.
3.walking, swimming, regular exercise STAGES OF ALZHEIMERS Early (Mild) or Stage I -1st symptoms up to 4 yrs -independent in ADL’s -no social or employment problems initially -denies presence of symptoms -forgets names; misplaces household items -short-term memory loss; difficulty recalling new information -subtle changes in personality and behavior -loss of initiative; less engaged in social relationships -mild cognitive impairments, problems with judgement -decreased performance, especially when stressed -unable to travel alone to new destinations -decreased sense of smell.
Middle (Moderate) or Stage II -2-3 yrs -impairment of all cognitive functions -problems with handling or unable to handle money & finances -disorientation to time, place, and event -possible depression, agitated -increasingly dependent in ADL’s -visuospatial deficits; difficulty driving, gets lost -speech & language deficits; less talkative, decrease in use of vocabulary, increasingly non-fluent, and eventually aphasic -incontinent -wandering; trouble sleeping LATE (Severe) or Stage III -completely incapacitated; bedridden -totally dependent in ADL’s.
-motor and verbal skills lost -general and focal neurologic deficits -agnosia (loss of facial recognition) COGNITION: refers to the ability of the brain to process, store, retrieve, and use information. -assess pt for deficits in: 1. attention & concentration 2. judgment & perception 3. learning & memory 4. communication & language 5. speed of information procession MMSE (Mini-Mental State Examination: one of the most popular tools nurse or other health care provider can use to assess cognitive status. **One of 1st symptoms of AD is SHORT-TERM MEMORY IMPAIRMENT.
INTERVENTIONS **providing a safe environment is a priority -identify & reinforce retained skills -orient pt to the environment -furnish environment with familiar possessions -acknowledge the pt’s feelings -assist pt & family to manage memory deficits and behavior changes -encourage family to express feelings about caregiving -provide caregiver with support groups -monitor pt’s ADL’s -remind pt to perform self care -help pt maintain independence -avoid activities that tax the memory -allow pt plenty of time to complete activity.
-offer constant encouragement with step to step simple approach -provide pt with mental stimulation with simple games or activities Interventions (con’t) WANDERING: -provide pt with safe environment -prevent unsafe wandering -provide pt with close supervision -close and secure doors -use ID bracelets and electronic surveillance COMMUNICATION: -adapt to the communication level of the pt -use a firm volume & a low-pitched voice to communicate -stand directly in front of the pt and maintain eye contact -call the pt by name and identify yourself; wait for a response -use a calm and reassuring voice.
-demonstrate task if the pt is unable to understand spoken words -speak slowly & clearly, using short words and simple sentences -ask only one question at a time & give one direction at a time -repeat questions if necessary, but do not rephrase IMPAIRED JUDGMENT: -remove throw rugs, toxic substances, and dangerous electrical appliances from the environment. Never leave meds out, take knobs off stove -reduce hot water heater temperature -maintain clear pathway between bed and bathroom at all times ALTERED THOUGHT PROCESS: -call pt by their name -orient the pt frequently -use familiar objects in the room.
-place a calendar and clock in a visible place -maintain familiar routines -allow the pt to reminisce -make tasks simple -allow time for the pt to complete a task -provide positive reinforcement for positive behaviors -promote continence by taking pt to bathroom or giving bedpan or urinal every 2 hrs. ALTERED SLEEP PATTERNS: -allow the pt to wander in a safe place until they become tired -prevent shadows in the room by using indirect light -avoid the use of hypnotics because they cause confusion and aggravate the sundown effect.
Sundown syndrome: awake during the night and sleep during the day -discourage day time naps -keep daily routine with scheduled activities throughout the day -establish bedtime ritual (snack, bathing, toileting, brushing teeth) AGITATION: -assess the precipitant of the agitation -reassure the pt -remove items that can be hazardous when the pt is agitated -approach the pt slowly and calmly from the front, and speak, gesture and move slowly -remove the pt to a less stressful environment; decrease excess stimuli -use touch gently -do not argue with or force the pt MEDICATIONS 1. Donepezil (Aricept): acetylcholinesterase inhibitor used to treat mild to moderate dementia.
Side effects: nausea, diarrhea, slow heart rate (bradycardia) 2. Galantamine (Razadyne): cholinesterase inhibitor used to treat mild to moderate dementia Side effects: N/V/D, anorexia, weight loss ***can cause bronchoconstriction (use with caution in asthma & COPD) 3. Rivastigmine (Exelon): cholinesterase inhibitor used to treat mild to moderate dementia Side effects: N/V/D, abdominal pain, anorexia ***use cautiously with peptic ulcer disease, bradycardia, sick sinus syndrome, urinary obstruction, lung disease (it enhances cholinergic transmission, intensifying symptoms of these disorders) 4.
Tacrine (Cognex): cholinesterase inhibitor used to treat mild to moderate dementia Side effects: ataxia, loss of appetite, N/V/D ***ADVERSE EFFECT- hepatotoxicity (monitor liver studies) 5. Memantine (Namenda): N-methyl-D-aspartate (NMDA) receptor antagonist for treatment of moderate to severe dementia Side effects: dizziness, headache, confusion, constipation Anti-depressants: some pts with AD develop depression and may be treated with anti-depressants. SSRI’s are usually prescribed ( paxil, zoloft ) Psychotropic drugs: considered chemical restraints -used as a last resort for pts with emotional and behavioral health problems.