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Alzheimer's disease

Description

  • Alzheimer’s disease is an irreversible, progressive brain disease that slowly destroys memory and thinking skills, and eventually even the ability to carry out the simplest tasks. In most people with Alzheimer’s, symptoms first appear after age 60.
  • Alzheimer’s disease is the most common cause of dementia among older people. Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—to such an extent that it interferes with a person’s daily life and activities. Estimates vary, but experts suggest that as many as 5.1 million Americans may have Alzheimer’s.
  • Dementia involves progressive decline in two or more of the following areas of cognition: memory, language, calculation, visual-spatial perception, judgment, abstraction, and behavior.

Causes

The cause of AD is unknown but knowledge about the hereditary links is growing. Patients with Down syndrome eventually develop DAT if they live long enough. There is a higher-than-normal concentration of aluminum in the brain of a person with DAT, but the effect is unknown. A distinct protein, AZ 50, has been identified at autopsy in the brains of DAT patients. This protein has been isolated from neurons that were not yet damaged, suggesting that its presence early in the degenerative process might cause the neuronal damage. The life expectancy of a DAT patient is reduced 30% to 60%.

Characteristics/ Signs and Symptoms

The disease course is divided into four stages, with progressive patterns of cognitive and functional impairments.


Pre-dementia

Stage 1 is characterized by recent memory loss, increased irritability, impaired judgment, loss of interest in life, decline of problem-solving ability, and reduction in abstract thinking. Remote memory and neurological exam remain unchanged from baseline.

Early

Stage 2 lasts 2 to 4 years and reveals a decline in the patient’s ability to manage personal and business affairs, an inability to remember shapes of objects, continued repetition of a meaningless word or phrase (perseveration), wandering or circular speech patterns (circumlocution dysphasia), wandering at night, restlessness, depression, anxiety, and intensification of cognitive and emotional changes of stage 1.

Moderate

Stage 3 is characterized by impaired ability to speak (aphasia), inability to recognize familiar objects (agnosia), inability to use objects properly (apraxia), inattention, distractibility, involuntary emotional outbursts, urinary or fecal incontinence, lint-picking motion, and chewing movements. Progression through stages 2 and 3 varies from 2 to 12 years.

Advanced

Stage 4, which lasts approximately 1 year, reveals a patient with a masklike facial expression, no communication, apathy, withdrawal, eventual immobility, assumed fetal position, no appetite, and emaciation.

Diagnostic Examination

  • Alzheimer's disease is usually diagnosed clinically from the patient history, collateral history from relatives, and clinical observations, based on the presence of characteristic neurological and neuropsychological features and the absence of alternative conditions. 
  • Advanced medical imaging with computed tomography (CT) or magnetic resonance imaging (MRI), and with single photon emission computed tomography (SPECT) or positron emission tomography (PET) can be used to help exclude other cerebral pathology or subtypes of dementia.Moreover, it may predict conversion from prodromal stages (mild cognitive impairment) to Alzheimer's disease.
  • Assessment of intellectual functioning including memory testing can further characterize the state of the disease.Medical organisations have created diagnostic criteria to ease and standardize the diagnostic process for practicing physicians. The diagnosis can be confirmed with very high accuracy post-mortem when brain material is available and can be examined histologically.

Primary Nursing Diagnosis

Self-care deficit related to impaired cognitive and motor function
  • Outcomes. Self-care: Activities of daily living—Bathing, Hygiene, Eating, Toileting; Cognitive ability; Comfort level; Role performance; Social interaction skills; Hope
  • Interventions. Self-care assistance: Bathing and Hygiene; Oral health management; Behavior management; Body
    PET scan of the brain of a person with AD showing a loss of function in the temporal lobe
     image enhancement; Emotional support; Mutual goal setting; Exercise therapy; Discharge planning

Other Nursing Diagnosis

Risk for Injury related to:
  • Unable to recognize / identify hazards in the environment.
  • Disorientation, confusion, impaired decision making.
  • Weakness, the muscles are not coordinated, the presence of seizure activity.

Medical Management

There is no cure for Alzheimer's disease; available treatments offer relatively small symptomatic benefit but remain palliative in nature.
The initial management of the patient begins with education of the family and caregivers regarding the disease, the prognosis, and changes in lifestyle that are necessary as the disease progresses.
Basic collaborative principles include:
  • Keep requests for the patient simple
  • Avoid confrontation and requests that might lead to frustration
  • Remain calm and supportive if the patient becomes upset
  • Maintain a consistent environment
  • Provide frequent cues and reminders to reorient the patient
  • Adjust expectations for the patient as he or she declines in capacity

Pharmacologic Treatment

  • Generally, therapy is focused on symptoms with an attempt to maintain cognition.
  • Donepezil (cholinesterase inhibitor; elevates acetylcholine concentration in cerebral cortex by slowing degradation of acetylcholine released by intact neurons) which improves cognitive symptoms; improves cognitive function in the early stages of the disease only; drug effects diminish as the disease progresses
  • Antidepressants (selective serotonin reuptake inhibitors; increases activity of serotonin in the brain) which treats depression, anxiety, and irritability
  • Other Tests: Supporting tests include computed tomography (CT) scan; magnetic resonance imaging (MRI); positron emission tomography (PET). During the early stages of dementia, CT and MRI may be normal, but in later stages, an MRI may show a decrease in the size of the cerebral cortex or of the area of the brain responsible for memory, particularly the hippocampus. Genetic testing for the ApoE gene is available and the presence of the gene is a risk factor for AD. Genetic tests may be helpful in diagnosis, but further studies are needed to confirm their reliability. 

Nursing Intervention

  1. Establish an effective communication system with the patient and his family to help them adjust to the patient’s altered cognitive abilities.
  2. Provide emotional support to the patient and his family.
  3. Administer ordered medications and note their effects. If the patient has trouble swallowing, crush tablets and open capsules and mix them with a semi soft food.
  4. Protect the patient from injury by providing a safe, structured environment.
  5. Provide rest periods between activities because the patient tires easily.
  6. Encourage the patient to exercise as ordered to help maintain mobility.
  7. Encourage patient independence and allow ample time for him to perform tasks.
  8. Encourage sufficient fluid intake and adequate nutrition.
  9. Take the patient to the bathroom at least every 2 hours and make sure he knows the location of the bathroom.
  10. Assist the patient with hygiene and dressing as necessary.
  11. Frequently check the the patient’s vital signs.
  12. Monitor the patient’s fluid and food intake to detect imbalances.
  13. Inspect the patient’s skin for evidence of trauma, such as bruises or skin breakdown.
  14. Encourage the family to allow the patient as much independence as possible while ensuring safety to the patient and others.


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