Alzheimer's Disease (AD)

• Alzheimer's Disease (AD) is also known as Senile Dementia of the Alzheimer Type (SDAT).
• AD is the most common form of dementia, lasting 2 to 20 years.
• Alzheimer's is a progressive, irreversible, degenerative neurologic disease.
• AD is characterized by gradual losses of cognitive function, and disturbances in behavior & personality.

Dementia Defined

• Dementia is a syndrome, usually chronic or progressive.
• It involves deterioration in cognitive function beyond normal aging expectations.
• Worldwide, approximately 50 million people have dementia, with nearly 10 million new cases each year (WHO, 2019).

AD Facts

• AD is a complex brain disorder caused by a combination of various factors.
• The exact cause of Alzheimer's disease is currently unknown.
• There is no known cure for Alzheimer's disease at this time.
• The prevalence of Alzheimer's increases with increasing age.
• The youngest diagnosed case was at age 19 associated with a rare genetic mutation.

Discovery of AD

• Alois Alzheimer, a German doctor, first described the symptoms of a patient in 1906.
• A colleague coined the name "Alzheimer's disease" in a 1910 medical book.

Auguste Deter

• Auguste Deter was the first person diagnosed with Alzheimer's disease, notably a German woman.
• Deter's symptoms included memory loss, abnormal behavior, and shrinkage of brain tissues.

Statistics

• Alzheimer's is the 6th leading cause of death for older adults.
• An estimated 13.4 million Americans will have Alzheimer's disease by 2050, and there is currently no cure.
• 70% of older adults with dementia are associated with Alzheimer's disease.
• According to the Alzheimer's Foundation of America (AFA), the risk of getting AD doubles every 5 years after age 65.

Major Types of AD

• Familial/Early-Onset AD is a rare, progressive dementia, accounting for less than 1% of all cases.
• Familial AD is frequently associated with genetic mutations.
• Familial AD can occur in middle-aged adults.
• Sporadic/Late-Onset AD is the most common type.
• Sporadic AD is associated with progressive dementia and cognitive decline.

Predisposing Factors

• Increasing age is a predisposing factor that can start as young as 40 years old, but is more common with those 65 years and older.
• Family history is a predisposing factor, specifically having at least one other relative with AD.
• Gender is a predisposing factor that affects men & women equally.
• Consumption of products with Aluminum, present in plaques & tangles (drinks in can, kitchen wares).
• Consuming Processed foods, and exposure to fertilizers, containing nitrates.
• Obesity is a predisposing factor.

Precipitating Factors

• Neurotransmitter changes, principally affecting Acetylcholine, are precipitating factors.
• Head Trauma, such as whiplash injuries, is a precipitating factor.
• Down's Syndrome: an extra copy of chromosome 21 carries Amyloid Precursor Protein (APP) gene, which can lead to build-up of protein clumps in the brain.
• Seizure Disorders are precipitating factors.
• Too much production of stress hormones is a precipitating factor
• Stroke, Hypertension, and poorly controlled Diabetes Mellitus are precipitating factors.

Pathophysiology

• The cause can be unknown with predisposing and precipitating factors.
• Neuropathic damage occurs in the cerebral cortex, causing neurofibrillary tangles and senile/neuritic plaques.
• Atrophy of brain size, inflammation, vascular damage, free radicals production, and mitochondrial dysfunction are all effects of AD.
• Biochemical changes interfere with neurotransmission.
• Decreased production of acetylcholine results, causing disrupted memory processing and a loss of connection between neurons.

Hallmarks of AD

• Neurofibrillary Tangles: Tangled masses of non-functioning neurons.
• Senile/Neuritic Plaques: Deposits of amyloid protein, part of a larger protein called amyloid precursor protein (APP) in the brain.

Clinical Manifestations: 5 A's of AD

• Amnesia: Memory loss, including difficulty remembering one's identity, location, or recognizing others.
• Anomia: Difficulty recalling the names of objects.
• Agnosia: Difficulty recognizing familiar objects.
• Apraxia: Difficulty performing familiar tasks or movements.
• Aphasia: Difficulty with language and expressing thoughts.

Early Stage of AD

• Forgetfulness & subtle memory loss is most common, but AD develops differently for every individual.
• Experiencing small difficulties in work & social activities.
• Maintaining adequate cognitive function.
• The ability to function independently.
• Misplacing things, forgetting appointments & important life events, and experiencing disorientation to date & time.

With Further Progression of AD

• Patients will recognize that they are experiencing a problem, and can no longer deny memory issues.
• Forgetfulness impacts many daily actions.
• Inability to recognize familiar faces, places, & objects and becoming lost in familiar environments are cardinal signs.
• Repetition of the same stories & asking the same questions.
• Conversation becomes difficult with word-finding difficulties (aphasia).
• Inability to formulate concepts & think abstractly.
• Exhibits impulsive behavior, which is caused by an inability to recognize the consequences of actions.
• Difficulty in performing ADLs, such as operating simple appliances, and handling money.
• Personality changes may include becoming depressed, suspicious, paranoid, hostile, and even combative.
• Experience mood swings and aggression.

Severe Stage of AD

• Speaking deteriorates to nonsense syllables.
• Agitation increases.
• Wandering at night.
• Dysphagia & incontinence develop.
• Inability to perform basic ADLs, assistance is required for eating & toileting.

Terminal Stage of AD

• Patient becomes immobile.
• Total care is required.
• Bodily functions are gradually lost
• Ability to recognize family members or caregivers occasionally.
• Death occurs as a result of complications such as pneumonia, malnutrition, or dehydration.

Prognosis

• On average, the life expectancy following diagnosis is approximately seven years.
• Fewer than 3% of individuals live more than fourteen years after diagnosis.

Diagnostic Findings

• An autopsy is the only definitive diagnosis of AD.
• AD is a diagnosis of exclusion, using several methods & tools to determine whether a patient with memory problems has AD.
  • Possible AD is where dementia may be due to another cause.
  • Probable AD is where no other cause for dementia can be found.

Goal of Diagnosis

• The goal is to rule out other causes of dementia that are reversible such as depression, delirium, alcohol or drug abuse, or inappropriate drug dosage or drug toxicity.
• How Is It Done? When the medical history, physical examination and laboratory tests have excluded ALL known causes of other dementias.

History Taking Considerations

• Family history
• Medical history
• Social and Cultural history
• Medication history

Physical Examination Considerations

• Physical exam may all refute or support a diagnosis of probable AD.
  • Complete Blood Count (CBC)
  • Vitamin B12 levels
  • Thyroid Hormone levels
  • EEG, CT Scan, MRI
  • Examination of CSF

Functional & Mental Examination

• Use Geriatric Depression Scale (GDS) because depression can mimic early-stage AD & co-exists in many patients.
• Use Mini-Mental Status Examination (MMSE) to assess cognitive status & screening for AD.

MMSE Scoring:

• Equal to >25 = NORMAL
• 21-24 = MILD
• 10-20 = MODERATE
• <10 = SEVERE

Medical Management

• Primary Goal: to manage the cognitive & behavioral symptoms.
• There is NO cure, but there are several medications to slow the progression of the disease.
• US-FDA approved medications to treat AD symptoms; however, none of these agents stops the progression of the disease.

Cholinesterase Inhibitors

• Enhance acetylcholine uptake in the brain, thus maintaining memory skills for a period of time.
• Used for mild to moderate symptoms to treat thinking, language, judgment & other thought processes.
• Cognitive ability can improve within 6 to 12 months of therapy.

CARE Mnemonic (Cholinesterase Inhibitors)

• C: tacrine (Cognex)
• A: donepezil hydrochloride (Aricept)
• R: galantamine hydrobromide (Razdyne
• E: rivastigmine tartrate (Exelon)
• rivastigmine (Exelon Patch) is for severe AD and recommended to continue as long as possible.

Nursing Management

• Nurses play a vital role in recognition of Alzheimer's Disease, especially those hospitalized older adults, through in-depth assessment & routine re-evaluation.

Goals of Nursing Interventions

• To promote patient function & independence for as long as possible.
• To promote the patient's physical safety.
• To promote independence in self-care activities.
• To reduce anxiety and agitation.
• To improve communication and socialization and intimacy.
• To promote adequate nutrition with balanced activities & rest.
• To support & educate family & caregivers.

Supporting Cognitive Function (Nursing)

• A calm, predictable environment with limited stimuli helps interpret surroundings & activities.
• Establish a regular routine.
• Use a quiet, pleasant manner of speaking, clear & simple explanations, & use of memory aids & cues helps minimize confusion, disorientation, & sense of security.
• Enhance time orientation by prominently displaying clocks & calendars.
• Use color-coded doorways to easily locate respective rooms.
• Active participation to maintain functional abilities for a longer period.

Promoting Physical Safety (Nursing)

• It is important to remove all obvious hazards and install handrails.
• Adequate lighting in the halls, stairs, and bathrooms is necessary.
• Nightlights are helpful to manage increased confusion at night (sundowning).
• Driving should be prohibited and with supervision.
• Repeat instructions as needed and use reminders (i.e., post-it notes).
• Doors leading from the house must be secured.
• Take additional precautionary measures (such as gentle persuasion, distraction, or by placing close to nursing station) due to unfamiliar surroundings & wandering behavior for hospitalized patients.
• Restraints should be avoided because they increase agitation & may lead to injury.

Independence in Self-Care Activities (Nursing)

• Simplify daily activities by organizing them into short, achievable steps so that the patient experiences a sense of accomplishment.

Reducing Anxiety & Agitation (Nursing)

• Catastrophic Reaction is a combative, agitated state caused by overreaction to excessive stimulation.
• Remain calm & unhurried.
• Use measures to quiet the patient, such as moving to a familiar environment, music therapy, stroking, or rocking the patient.

Improving Communication (Nursing)

• Use clear, easy-to-understand sentences to convey messages.
• Lists & simple written instructions may serve as reminders, which may be helpful for earlier stages of AD.
• Use tactile stimuli (hugs, hand pats), usually interpreted as signs of affection, concern, and security.

Socialization & Intimacy Needs (Nursing)

• Recreational activities & hobbies such as walking, exercising, and socializing can improve the quality of life.
• Taking care of plants or a pet can be satisfying and an outlet of energy.
• Do not eliminate need for intimacy. Encourage spouses to talk about any sexual concerns, and sexual counseling may be necessary.

Adequate Nutrition (Nursing)

• Keep it simple & calm, without confrontations.
• Prepare familiar foods that look appetizing & taste good.
• Cut food into small pieces & liquids must be thickened to prevent choking.
• Use an apron or a smock, rather than a bib, to protect clothing while eating.

Nursing Considerations: The 5 C's

• Calendar
• Clock
• Colors
• Consistency of caregiver
• Cognex (Tacrine)

Preventive Measures

• Alzheimer's disease has no definitive cause and no known cure.
• Healthy habits may help ward it off.
• Exercise with the recommendation of 30 minutes of moderately vigorous aerobic exercise, 3 – 4 days/week.
• Eat a Mediterranean diet that includes fresh vegetables & fruits, whole grains, olive oil, nuts, legumes, fish, moderate amounts of poultry, eggs, dairy, and moderate amounts of red wine and red meat only sparingly.
• Get enough sleep aiming for 7 to 8 hours per night.
• Learn new things engaging in Cognitively stimulating activities which may be helpful in preventing AD.
• Connect socially.
• Drink - but just a little with conflicting evidence about the benefit of moderate alcohol intake & reduced risk of Alzheimer's, which pertains to wine in particularly.