Alzheimer's Disease: Diagnosis and Pathophysiology

Alzheimer's Disease (AD) Demographics

• AD can manifest as early as the 30s, but typically occurs after age 65
• Most individuals with AD survive between 4 and 8 years after diagnosis
• Those diagnosed at younger ages may live up to two decades

Stages of Alzheimer's Disease

• Patients typically spend more time in the moderate stage of AD
• The disease progresses through stages, eventually damaging multiple areas of the brain

Pathophysiology of Alzheimer's Disease

• Younger-onset AD (before age 65) can be familial (inherited) or sporadic (no known cause)
• Familial AD genes tend to develop symptoms in the 30s to 50s
• Sporadic AD is the most common form and is not attributed to genetics
• Late-onset AD (at age 65 or later) accounts for over 90% of AD cases and is usually sporadic

Brain Damage and Abnormalities

• AD destroys neurons and connections in brain areas involved in memory, including the entorhinal cortex and hippocampus
• The disease later affects areas responsible for language, reasoning, and social behavior
• Eventual damage includes neuronal death in the cerebral lobes, producing loss of remote memory
• Two characteristic abnormalities in AD brains are neurofibrillary tangles and amyloid plaques

Cholinergic Hypothesis and Therapy

• Low levels of acetylcholine and decreased function produce memory deficits
• Cholinergic hypothesis led to development of acetylcholinesterase inhibitor drugs
• Cholinergic therapy may slow brain atrophy

Alzheimer's Disease (AD) Demographics

• AD can manifest as early as the 30s, but typically occurs after age 65
• Most individuals with AD survive between 4 and 8 years after diagnosis
• Those diagnosed at younger ages may live up to two decades

Stages of Alzheimer's Disease

• Patients typically spend more time in the moderate stage of AD
• The disease progresses through stages, eventually damaging multiple areas of the brain

Pathophysiology of Alzheimer's Disease

• Younger-onset AD (before age 65) can be familial (inherited) or sporadic (no known cause)
• Familial AD genes tend to develop symptoms in the 30s to 50s
• Sporadic AD is the most common form and is not attributed to genetics
• Late-onset AD (at age 65 or later) accounts for over 90% of AD cases and is usually sporadic

Brain Damage and Abnormalities

• AD destroys neurons and connections in brain areas involved in memory, including the entorhinal cortex and hippocampus
• The disease later affects areas responsible for language, reasoning, and social behavior
• Eventual damage includes neuronal death in the cerebral lobes, producing loss of remote memory
• Two characteristic abnormalities in AD brains are neurofibrillary tangles and amyloid plaques

Cholinergic Hypothesis and Therapy

• Low levels of acetylcholine and decreased function produce memory deficits
• Cholinergic hypothesis led to development of acetylcholinesterase inhibitor drugs
• Cholinergic therapy may slow brain atrophy

Amyloid and Tau Hypotheses

• Amyloid Hypothesis: AD arises from the brain's inability to process amyloid precursor-protein (APP), leading to the presence of beta-amyloid fragments.
• Tau Hypothesis: AD involves abnormal tau proteins that form neurofibrillary tangles.

Recent Research

• Proteins central to AD pathology act as prions, spreading through tissue like an infection.
• AD is triggered by impairment of APP metabolism and progresses through tau pathology, not beta-amyloid.

Risk Factors

• Nonmodifiable risk factors: age, sex, family history, and genetic factors.
• Higher risk in Hispanic and African American individuals, and women.
• Age: most prominent risk factor, with risk doubling every 5 years after 65 and a 50% chance of developing the disease after 85.
• Cardiovascular risk factors: diabetes, midlife obesity, midlife hypertension, and hyperlipidemia.
• Lifestyle risk factors: cigarette smoking, sedentary lifestyle, and repeated TBI trauma.
• Depression: both a symptom and risk factor, with early management potentially preventing cognitive decline.

Treatment and Prevention

• SSRIs may slow the conversion from mild cognitive impairment to later stages of AD.
• Certain benzodiazepines (estazolam, quazepam, temazepam, and triazolam) may contribute to cognitive deterioration.
• Antihistamines with anticholinergic properties (chlorpheniramine, diphenhydramine, doxylamine, dimenhydrinate, and meclizine) may accelerate cognitive deterioration.

Amyloid and Tau Hypotheses

• Amyloid Hypothesis: AD arises from the brain's inability to process amyloid precursor-protein (APP), leading to the presence of beta-amyloid fragments.
• Tau Hypothesis: AD involves abnormal tau proteins that form neurofibrillary tangles.

Recent Research

• Proteins central to AD pathology act as prions, spreading through tissue like an infection.
• AD is triggered by impairment of APP metabolism and progresses through tau pathology, not beta-amyloid.

Risk Factors

• Nonmodifiable risk factors: age, sex, family history, and genetic factors.
• Higher risk in Hispanic and African American individuals, and women.
• Age: most prominent risk factor, with risk doubling every 5 years after 65 and a 50% chance of developing the disease after 85.
• Cardiovascular risk factors: diabetes, midlife obesity, midlife hypertension, and hyperlipidemia.
• Lifestyle risk factors: cigarette smoking, sedentary lifestyle, and repeated TBI trauma.
• Depression: both a symptom and risk factor, with early management potentially preventing cognitive decline.

Treatment and Prevention

• SSRIs may slow the conversion from mild cognitive impairment to later stages of AD.
• Certain benzodiazepines (estazolam, quazepam, temazepam, and triazolam) may contribute to cognitive deterioration.
• Antihistamines with anticholinergic properties (chlorpheniramine, diphenhydramine, doxylamine, dimenhydrinate, and meclizine) may accelerate cognitive deterioration.

Prevention Strategies

• Quitting smoking and using safety measures (e.g., seat belts while driving) can reduce the risk of developing Alzheimer's disease.
• Engaging in moderate exercise improves cognitive function.
• Adopting a heart-healthy diet, staying socially active, and seeking treatment for depression can help prevent cognitive decline.

Cognitive Resilience

• Engaging in cognitive activities such as reading, completing puzzles, and learning new information or tasks helps build cognitive resilience and protects against cognitive decline.

Clinical Manifestations of Alzheimer's Disease

• Initial symptoms emerge gradually, with subtle memory loss being the first manifestation.
• Other early signs include difficulty finding words, impaired judgment, disorientation to time and place, frequently misplacing things, decreased initiative, odd behavior, and signs of depression.
• Diurnal changes in cognitive function occur, with patterns of diminished capacity in the evening (sundowning).
• Changes in mood or personality are common as the disease progresses.
• Physical changes occur as the disease progresses.

Prevention Strategies

• Quitting smoking and using safety measures (e.g., seat belts while driving) can reduce the risk of developing Alzheimer's disease.
• Engaging in moderate exercise improves cognitive function.
• Adopting a heart-healthy diet, staying socially active, and seeking treatment for depression can help prevent cognitive decline.

Cognitive Resilience

• Engaging in cognitive activities such as reading, completing puzzles, and learning new information or tasks helps build cognitive resilience and protects against cognitive decline.

Clinical Manifestations of Alzheimer's Disease

• Initial symptoms emerge gradually, with subtle memory loss being the first manifestation.
• Other early signs include difficulty finding words, impaired judgment, disorientation to time and place, frequently misplacing things, decreased initiative, odd behavior, and signs of depression.
• Diurnal changes in cognitive function occur, with patterns of diminished capacity in the evening (sundowning).
• Changes in mood or personality are common as the disease progresses.
• Physical changes occur as the disease progresses.

Diagnosis of Alzheimer's Disease

• No definitive way to diagnose AD except through brain autopsy
• Practitioners rely on differential diagnosis to rule out other causes of symptoms
• Standard laboratory tests for AD include TSH, CBC, serum B12, folate, CMP, and STI testing

Genetics of Alzheimer's Disease

• APOE-e4 is the first identified risk gene and has the strongest impact on risk
• Estimated 40-65% of people diagnosed with AD have the APOE-e4 gene

Pharmacologic Therapy for Alzheimer's Disease

• Acetylcholinesterase inhibitors:
  • Work by inhibiting acetylcholinesterase, increasing acetylcholine levels
  • Temporarily stabilize symptoms related to language, memory, and reasoning for 6-12 months
  • Examples: galantamine (early to moderate stages), donepezil and rivastigmine (all stages)
  • Side effects: decreased appetite, nausea, diarrhea, headaches, dizziness
  • Adverse effects: GI bleeding, bradycardia
  • Patient and caregiver teaching: monitor pulse rate, avoid medications that increase GI bleeding risk
• NMDA receptor antagonists:
  • Block the effects of glutamate
  • Do not reverse existing damage, but slow new damage
  • Typically prescribed for moderate-to-severe stages of AD
  • Example: memantine (Namenda)
  • Side effects: dizziness, constipation, confusion, headache, fatigue, increased blood pressure
  • Caution: avoid activities requiring mental alertness or coordination until tolerance is established, take with food

Diagnosis of Alzheimer's Disease

• No definitive way to diagnose AD except through brain autopsy
• Practitioners rely on differential diagnosis to rule out other causes of symptoms
• Standard laboratory tests for AD include TSH, CBC, serum B12, folate, CMP, and STI testing

Genetics of Alzheimer's Disease

• APOE-e4 is the first identified risk gene and has the strongest impact on risk
• Estimated 40-65% of people diagnosed with AD have the APOE-e4 gene

Pharmacologic Therapy for Alzheimer's Disease

• Acetylcholinesterase inhibitors:
  • Work by inhibiting acetylcholinesterase, increasing acetylcholine levels
  • Temporarily stabilize symptoms related to language, memory, and reasoning for 6-12 months
  • Examples: galantamine (early to moderate stages), donepezil and rivastigmine (all stages)
  • Side effects: decreased appetite, nausea, diarrhea, headaches, dizziness
  • Adverse effects: GI bleeding, bradycardia
  • Patient and caregiver teaching: monitor pulse rate, avoid medications that increase GI bleeding risk
• NMDA receptor antagonists:
  • Block the effects of glutamate
  • Do not reverse existing damage, but slow new damage
  • Typically prescribed for moderate-to-severe stages of AD
  • Example: memantine (Namenda)
  • Side effects: dizziness, constipation, confusion, headache, fatigue, increased blood pressure
  • Caution: avoid activities requiring mental alertness or coordination until tolerance is established, take with food

Medications for AD Symptoms

• Antipsychotics are used to treat delusions or hallucinations
• Anxiolytics are used to treat anxiety
• SSRI antidepressants are used to treat depression

Nonpharmacologic Therapy

• Exercise has been demonstrated to be effective in treating AD
• Reality orientation therapy involves orienting individuals to person, time, place, and situations at regular intervals
• Validation therapy involves searching for emotion or intended meaning in verbal expressions and behaviors
• Reminiscence therapy uses the process of reflecting on past events to help retain long-term memory and provide comfort

Reality Orientation Therapy

• Involves orienting individuals to person, time, place, and situations at regular intervals
• Uses verbal communication and visual cues (pictures, clocks, calendars, orientation boards)
• Should be part of routine care and carried out by all members of the healthcare team

Validation Therapy

• Involves searching for emotion or intended meaning in verbal expressions and behaviors
• Aims to elicit a response that identifies an unmet need
• Does not unnecessarily challenge the patient’s perception of reality

Reminiscence Therapy

• Uses the process of reflecting on past events to help retain long-term memory
• Can provide comfort, self-esteem, identity, and purpose
• Can help prevent isolation and withdrawal

Medications for AD Symptoms

• Antipsychotics are used to treat delusions or hallucinations
• Anxiolytics are used to treat anxiety
• SSRI antidepressants are used to treat depression

Nonpharmacologic Therapy

• Exercise has been demonstrated to be effective in treating AD
• Reality orientation therapy involves orienting individuals to person, time, place, and situations at regular intervals
• Validation therapy involves searching for emotion or intended meaning in verbal expressions and behaviors
• Reminiscence therapy uses the process of reflecting on past events to help retain long-term memory and provide comfort

Reality Orientation Therapy

• Involves orienting individuals to person, time, place, and situations at regular intervals
• Uses verbal communication and visual cues (pictures, clocks, calendars, orientation boards)
• Should be part of routine care and carried out by all members of the healthcare team

Validation Therapy

• Involves searching for emotion or intended meaning in verbal expressions and behaviors
• Aims to elicit a response that identifies an unmet need
• Does not unnecessarily challenge the patient’s perception of reality

Reminiscence Therapy

• Uses the process of reflecting on past events to help retain long-term memory
• Can provide comfort, self-esteem, identity, and purpose
• Can help prevent isolation and withdrawal

Complementary Health Approaches

• There is no strong evidence that any complementary health approach or diet can prevent cognitive impairment.
• Music and art therapy can relieve symptoms associated with cognitive decline, such as pain, agitation, and hypertension.
• Mindfulness meditation and caregiver education can reduce stress in caregivers.

Nursing Process: Assessment

• Serial assessments monitor disease progression and ability to manage safely in the current living environment.
• Observation and patient interview are crucial for diagnosis.

Patient Presentation

• Patients with mild dementia may not display noticeable signs or symptoms.
• Family members may report changes in memory or cognitive abilities, indicating a problem.
• As dementia progresses, patients exhibit signs of difficulty maintaining self-care, difficulty focusing on tasks, and changes in gait.

Patient Interview

• Assess family history of AD and other dementias.
• Review medical history, medications, and supplement use.
• Evaluate changes in cognition, communication, memory, and behavior.
• Assess alterations in mood, sleep patterns, and ability to perform ADLs.
• Evaluate drug and alcohol use and risk for environmental toxins.

Mental Status Examination

• The MMSE is the most commonly used test to assess cognitive status.

Physical Examination

• Be alert for signs of abuse, neglect, depression, malnutrition, elimination difficulties, and skin integrity issues.
• Conditions that mimic dementia and AD symptoms include:
  • Drugs and alcohol
  • Eyes and ears disorders
  • Metabolic and endocrine disorders
  • Emotional disorders
  • Neurologic disorders
  • Trauma or tumors
  • Infection
  • Arteriovascular disease

Complementary Health Approaches

• There is no strong evidence that any complementary health approach or diet can prevent cognitive impairment.
• Music and art therapy can relieve symptoms associated with cognitive decline, such as pain, agitation, and hypertension.
• Mindfulness meditation and caregiver education can reduce stress in caregivers.

Nursing Process: Assessment

• Serial assessments monitor disease progression and ability to manage safely in the current living environment.
• Observation and patient interview are crucial for diagnosis.

Patient Presentation

• Patients with mild dementia may not display noticeable signs or symptoms.
• Family members may report changes in memory or cognitive abilities, indicating a problem.
• As dementia progresses, patients exhibit signs of difficulty maintaining self-care, difficulty focusing on tasks, and changes in gait.

Patient Interview

• Assess family history of AD and other dementias.
• Review medical history, medications, and supplement use.
• Evaluate changes in cognition, communication, memory, and behavior.
• Assess alterations in mood, sleep patterns, and ability to perform ADLs.
• Evaluate drug and alcohol use and risk for environmental toxins.

Mental Status Examination

• The MMSE is the most commonly used test to assess cognitive status.

Physical Examination

• Be alert for signs of abuse, neglect, depression, malnutrition, elimination difficulties, and skin integrity issues.
• Conditions that mimic dementia and AD symptoms include:
  • Drugs and alcohol
  • Eyes and ears disorders
  • Metabolic and endocrine disorders
  • Emotional disorders
  • Neurologic disorders
  • Trauma or tumors
  • Infection
  • Arteriovascular disease

Functional Status Assessment

• Assess changes in ability to manage daily activities (ADLs) and instrumental activities of daily living (IADLs) in patients with Alzheimer's disease (AD)
• Use direct questioning of patients or family members or screening tools like the Functional Activities Questionnaire (FAQ)
• Identify loss of function over time in activities such as:
  • Telephone use
  • Meal preparation
  • Handling medications
  • Managing finances
  • Housekeeping
  • Shopping
  • Traveling within the community
  • Bathing
  • Dressing
  • Eating
  • Toileting
  • Walking across a small room
  • Transferring from bed to chair

Behavior Assessment

• Assess for behavior changes associated with AD, including:
  • Depression
  • Anxiety
  • Irritability
  • Impulsivity
  • Poor judgment
  • Paranoia
  • Delusions
  • Hallucinations
• Identify events that precipitate behavior changes, such as a poor night's sleep
• Use tools like the Geriatric Depression Scale (GDS) to detect changes in mood
• Use the BEHAVE-AD to assess magnitude of disturbance in patient and caregiver safety

Caregiver/Living Environment

• Assess caregiver burden using:
  • Zarit Burden Interview (ZBI)
  • Caregiver Role Strain Index (CRI)
• Identify caregiver stress and strain

Communicating with Patients

• Adapt communication style to accommodate patient's language skills
• Give patients adequate time to respond
• Use prompts and ask for permission to involve caregivers if necessary

Functional Status Assessment

• Assess changes in ability to manage daily activities (ADLs) and instrumental activities of daily living (IADLs) in patients with Alzheimer's disease (AD)
• Use direct questioning of patients or family members or screening tools like the Functional Activities Questionnaire (FAQ)
• Identify loss of function over time in activities such as:
  • Telephone use
  • Meal preparation
  • Handling medications
  • Managing finances
  • Housekeeping
  • Shopping
  • Traveling within the community
  • Bathing
  • Dressing
  • Eating
  • Toileting
  • Walking across a small room
  • Transferring from bed to chair

Behavior Assessment

• Assess for behavior changes associated with AD, including:
  • Depression
  • Anxiety
  • Irritability
  • Impulsivity
  • Poor judgment
  • Paranoia
  • Delusions
  • Hallucinations
• Identify events that precipitate behavior changes, such as a poor night's sleep
• Use tools like the Geriatric Depression Scale (GDS) to detect changes in mood
• Use the BEHAVE-AD to assess magnitude of disturbance in patient and caregiver safety

Caregiver/Living Environment

• Assess caregiver burden using:
  • Zarit Burden Interview (ZBI)
  • Caregiver Role Strain Index (CRI)
• Identify caregiver stress and strain

Communicating with Patients

• Adapt communication style to accommodate patient's language skills
• Give patients adequate time to respond
• Use prompts and ask for permission to involve caregivers if necessary

PLST Intervention Model

• The Progressively Lowered Stress Threshold (PLST) model is supported by current clinical guidelines and guides nursing care during all stages of dementia and Alzheimer's disease.
• The model proposes environmental modifications to cope with progressive cognitive decline, and an escalation in anxiety, depression, or behaviors may indicate inadequate modifications.

Promoting Safety and Physiologic Integrity

• Emphasize adequate sleep, rest, nutrition, elimination, and pain control to promote safety and physiologic integrity.
• Discuss the risks and benefits of devices like medic alert systems and patient tracking or alert systems with patients and families.
• Avoid using physical and pharmacologic restraints, as they increase the risk of injury and death.
• The rate of accidents in individuals with Alzheimer's disease diagnosis increases dramatically.

Driving Safety

• Loss of driving ability can be a point of contention for patients and family members.
• Signs indicating unsafe driving include minor fender benders, getting lost, or ignoring traffic signals.
• Driver rehabilitation specialists can evaluate driving abilities and recommend terminating driving privileges.

Promoting Adaptive Functioning and Coping

• Communication strategies for individuals with Alzheimer's disease include:
  • Establishing eye contact and introducing oneself
  • Using calm, reassuring tone and simple vocabulary
  • Asking one question at a time and providing sufficient response time
  • Repeating questions, explanations, and instructions as required
• Behavioral strategies for caregivers include:
  • Recognizing unmet needs behind behaviors like wandering and restlessness
  • Preventing fatigue, using consistency and simple communication
  • Providing comforting and meaningful activities, quiet time, and reducing stimulation.

PLST Intervention Model

• The Progressively Lowered Stress Threshold (PLST) model is supported by current clinical guidelines and guides nursing care during all stages of dementia and Alzheimer's disease.
• The model proposes environmental modifications to cope with progressive cognitive decline, and an escalation in anxiety, depression, or behaviors may indicate inadequate modifications.

Promoting Safety and Physiologic Integrity

• Emphasize adequate sleep, rest, nutrition, elimination, and pain control to promote safety and physiologic integrity.
• Discuss the risks and benefits of devices like medic alert systems and patient tracking or alert systems with patients and families.
• Avoid using physical and pharmacologic restraints, as they increase the risk of injury and death.
• The rate of accidents in individuals with Alzheimer's disease diagnosis increases dramatically.

Driving Safety

• Loss of driving ability can be a point of contention for patients and family members.
• Signs indicating unsafe driving include minor fender benders, getting lost, or ignoring traffic signals.
• Driver rehabilitation specialists can evaluate driving abilities and recommend terminating driving privileges.

Promoting Adaptive Functioning and Coping

• Communication strategies for individuals with Alzheimer's disease include:
  • Establishing eye contact and introducing oneself
  • Using calm, reassuring tone and simple vocabulary
  • Asking one question at a time and providing sufficient response time
  • Repeating questions, explanations, and instructions as required
• Behavioral strategies for caregivers include:
  • Recognizing unmet needs behind behaviors like wandering and restlessness
  • Preventing fatigue, using consistency and simple communication
  • Providing comforting and meaningful activities, quiet time, and reducing stimulation.

Counselling Family Members

• Nurses play a crucial role in counselling family members dealing with ambivalence and guilt when deciding to transfer patients to a skilled nursing facility.

Transfer Trauma or Relocation Syndrome

• Transfer trauma or relocation syndrome is a phenomenon characterized by a worsening of symptoms due to the stress of moving to a new environment.
• To minimize transfer trauma, nurses should aim to retain as many aspects of the home environment and previous routine as possible.

Providing End-of-Life Care

• The primary focus of nursing care for patients in the final stage of Alzheimer's disease (AD) is to promote quality of life and minimize discomfort associated with physiologic decline and cognitive deficits.
• Palliative care for individuals with AD is challenging due to the patient's inability to communicate their needs.

Family Dynamics and Grief

• Unresolved relationship issues between family members and caregivers may lead to difficulties in treatment decisions and increase the risk of complicated grieving.

Evaluation and Outcomes

• Patient outcomes are evaluated based on the understanding that patients can only achieve short-term outcomes due to the progressive nature of the disease.
• The primary goal is to ensure that patients and families achieve optimal wellness for their specific stage of the disease.

Counselling Family Members

• Nurses play a crucial role in counselling family members dealing with ambivalence and guilt when deciding to transfer patients to a skilled nursing facility.

Transfer Trauma or Relocation Syndrome

• Transfer trauma or relocation syndrome is a phenomenon characterized by a worsening of symptoms due to the stress of moving to a new environment.
• To minimize transfer trauma, nurses should aim to retain as many aspects of the home environment and previous routine as possible.

Providing End-of-Life Care

• The primary focus of nursing care for patients in the final stage of Alzheimer's disease (AD) is to promote quality of life and minimize discomfort associated with physiologic decline and cognitive deficits.
• Palliative care for individuals with AD is challenging due to the patient's inability to communicate their needs.

Family Dynamics and Grief

• Unresolved relationship issues between family members and caregivers may lead to difficulties in treatment decisions and increase the risk of complicated grieving.

Evaluation and Outcomes

• Patient outcomes are evaluated based on the understanding that patients can only achieve short-term outcomes due to the progressive nature of the disease.
• The primary goal is to ensure that patients and families achieve optimal wellness for their specific stage of the disease.

Brain Regions and Symptoms of Damage

Limbic System (including Hippocampus)

• Loss of recent memories ( forgetfulness of recent events) before remote memories
• Fluctuating emotions and depression
• Difficulty learning new information

Frontal Lobe

• Problems with intentional movement (loss of motor control)
• Difficulty planning and organization
• Emotional lability (mood swings)
• Loss of walking, talking, and swallowing ability

Occipital Lobe

• Loss of reading comprehension
• Hallucinations (visual disturbances)

Parietal Lobe

• Difficulty recognizing places, people, and objects (agnosia)
• Hallucinations and seizures
• Unsteady movement (ataxia) and poor coordination
• Expressive aphasia (difficulty expressing thoughts in words)
• Agraphia (difficulty with writing)

Temporal Lobe

• Impaired memory (difficulty recalling past events)
• Difficulty learning new things and forming new memories
• Receptive aphasia (difficulty understanding spoken language)

Brain Regions and Symptoms of Damage

Limbic System (including Hippocampus)

• Loss of recent memories ( forgetfulness of recent events) before remote memories
• Fluctuating emotions and depression
• Difficulty learning new information

Frontal Lobe

• Problems with intentional movement (loss of motor control)
• Difficulty planning and organization
• Emotional lability (mood swings)
• Loss of walking, talking, and swallowing ability

Occipital Lobe

• Loss of reading comprehension
• Hallucinations (visual disturbances)

Parietal Lobe

• Difficulty recognizing places, people, and objects (agnosia)
• Hallucinations and seizures
• Unsteady movement (ataxia) and poor coordination
• Expressive aphasia (difficulty expressing thoughts in words)
• Agraphia (difficulty with writing)

Temporal Lobe

• Impaired memory (difficulty recalling past events)
• Difficulty learning new things and forming new memories
• Receptive aphasia (difficulty understanding spoken language)

Stage I: Mild Cognitive Impairment

• Reduced concentration and memory lapses noticeable by others
• Difficulty learning new information
• Problems functioning in work or social settings
• Frequently losing or misplacing important objects
• Difficulties with planning and organization
• Forgetting recent events or conversations

Interventions for Stage I

• Patient/caregiver education and training
• Environmental modifications to promote safety
• Encourage planning for advanced stages of the disease while patients are still able to participate in decision making
• Use of cuing devices such as to-do lists, calendars, and verbal reminders

Stage II: Moderate Alzheimer's Disease

• Inability to carry out activities of daily living (ADLs) such as preparing meals for oneself
• Loss of ability to live independently
• Difficulty recalling one's address or phone number
• Increased problems finding words and communicating clearly

Interventions for Stage II

• Behavioral interventions such as distraction and provision of meaningful activities
• Continued use of cuing devices and established routines
• Assistance with ADLs
• Administration of anti-AD medications such as acetylcholinesterase inhibitors and NMDA inhibitors
• Administration of SSRIs and/or anxiolytics to address mood-related symptoms of depression and anxiety
• Occupational, physical, and speech therapy

Stage I: Mild AD

• Cognitive activity kits to maintain familiar words and objects
• Deliberate establishment of daily routines
• Referral to community resources, support groups, and counseling services
• Nonpharmacologic therapies such as validation, reality orientation, and reminiscence therapy
• Counseling regarding possible retirement or withdrawal from challenging aspects of one's job

Stage II: Moderate AD

• Inability to carry out activities of daily living (ADLs) independently
• Behavioral interventions such as distraction, provision of meaningful activities, and continued use of cuing devices and established routines
• Assistance with ADLs
• Administration of anti-AD acetylcholinesterase
• Nonpharmacologic therapies such as validation therapy and reminiscence therapy
• Consultation with a dietitian or nutritionist
• Respite care for family members and caregivers
• May require around-the-clock care or transition to a skilled nursing facility

Stage III: Severe AD

• Gradual inability to perform any ADLs, including bathing and toileting
• Assistance with all ADLs
• Continuation of earlier behavioral and pharmacologic therapies
• Round-the-clock care and/or admittance to a skilled nursing facility
• Eventual urinary and fecal incontinence
• Inability to identify family members and caregivers
• Extreme confusion and lack of awareness of one's surroundings
• Gradual loss of remote memory and ability to speak
• Frequent repositioning
• Hand feeding and/or liquid nutrition as appropriate
• Respite care for family members and caregivers
• End of life care

Acetylcholinesterase Inhibitors

• Reduce acetylcholine breakdown, increasing its availability in the brain.
• Examples: donepezil (Aricept), galantamine (Razadyne), and rivastigmine (Exelon).
• Have a modest effect in slowing an individual's rate of cognitive decline in Alzheimer's disease (AD).

N-Methyl-D-aspartate (NMDA) Receptor Antagonists

• Limit the effects of glutamate, which can be toxic to neurons.
• Examples: memantine (Namenda).
• May also be used for vascular dementia and Parkinson-related dementia.

Combination Drug

• Namzaric: a combination of memantine and donepezil.
• Used only after patients have been stabilized on memantine and donepezil.

Patient Education and Monitoring

• Emphasize the importance of taking medication as directed.
• Teach about discontinuation and resulting decline in function.
• Provide patient and caregiver education regarding side effects of dizziness, headache, GI upset, and fatigue.
• Promote adequate fluid intake.
• Monitor patient's pulse rate.
• Use with caution in patients with respiratory conditions (e.g., asthma, COPD).
• Avoid the use of antipsychotics, beta adrenergic blockers, corticosteroids, and anticholinergic drugs due to their antagonistic or synergistic effects.