Alzheimer’s Diseasewww

8/8/2019 Alzheimers Diseasewww

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yAD is a progressive, irreversible,degenerative neurologic disease thatbegins insidiously and is characterizedby gradual loss of cognitive functionand disturbances in behaviour andaffect.


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yIt is marked by progressive

deterioration, which affectsboth the memory and

reasoning capabilities of anindividual.


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yAD is the most common formof dementia.

yAD Alzheimers is a uniquecondition that is not the result

of common aging and naturalsenility.


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Types of AD:1. Familial Alzheimers Disease:

y This is a form of Alzheimer's disease that

is known to be entirely inherited. In affectedfamilies, members of at least twogenerations have had Alzheimer's disease.FAD is extremely rare, accounting for lessthan 1% of all cases of Alzheimer's disease. Ithas a much earlier onset (often in the 40s)and can be clearly seen to run in families.


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2.Early-onset Alzheimer's Disease:y This is a rare form of Alzheimer's disease in

which people are diagnosed with the diseasebefore age 65. People with Down syndrome areparticularly at risk for a form of early onset

Alzheimer's disease. Adults with Downsyndrome are often in their mid- to late 40s orearly 50s when symptoms first appear. Early-onset Alzheimer's appears to be linked with agenetic defect on chromosome 14, to which late-

onset Alzheimer's is not linked. A conditioncalled myoclonus a form of muscle twitchingand spasmc is also more commonly seen in early-onset Alzheimer's than in late-onset Alzheimer's.


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3. Late-onset Alzheimers Disease:y This is the most common form ofAlzheimer's disease, accounting for

about 90% of cases and usuallyoccurring after age 65. Late-onset

Alzheimer's disease strikes almost half

of all people over the age of 85 and mayor may not be hereditary. Late-onsetdementia is also called sporadic

Alzheimer's disease.


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yRisk Factors:1.Age

yThe greatest known risk factor for Alzheimers isincreasing age. Most individuals with the diseaseare 65 or older. The likelihood of developing

Alzheimers doubles about every five years afterage 65. After age 85, the risk reaches nearly 50percent.

2. Family historyAnother risk factor is family history. Research hasshown that those who have a parent, brother orsister, or child with Alzheimers are more likely to

develop Alzheimers.


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y The risk increases if more than onefamily member has the illness. Whendiseases tend to run in families, either

heredity (genetics) or environmentalfactors or both may play a role.

yIn some families, clusters of cases are

seen. A gene called Apolipoprotein E(ApoE) appears to be a risk factor forthe late-onset form of Alzheimers.


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yT

here are three forms of this gene: ApoE2

,ApoE3 and ApoE4. While inheritance ofApoE4 increases the risk of developing thedisease, ApoE2 substantially protects

against it. Some current research is focusedon the association between these two formsof ApoE and Alzheimer's disease. Several

other genes also appear to influence thedevelopment of Alzheimers disease.


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yPotential Contributing Factors:Cardiovascular disease:

Risk factors associated with heart diseaseand stroke, such as high blood pressure andhigh cholesterol, may also increase one's risk of

developing Alzheimer's disease. High bloodpressure may damage blood vessels in thebrain, disrupting regions that are important in

decision-making, memory and verbal skills.This could contribute to the progression of thedisease. High cholesterol may inhibit theability of the blood to clear protein from the

brain.


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Head injury

yThere appears to be a strong link

between serious head injury andfuture risk of Alzheimers.


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Cerebral hypoxiayAfter recovery from hypoxia (brought

on by such conditions as carbonmonoxide poisoning or acuterespiratory failure), the patient may

experience total amnesia for the event,along with sensory disturbances, suchas numbness and tingling.


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Head traumay Depending on the traumas severity, amnesia may lastfor minutes, hours, or longer. Usually, the patientexperiences brief retrograde and longer anterogradeamnesia as well as persistent amnesia about the

traumatic event. Severe head trauma can causepermanent amnesia or difficulty retaining recentmemories. Related findings may include alteredrespirations and LOC; headache; dizziness; confusion;

visual disturbances, such as blurred or double vision;and motor and sensory disturbances, such ashemiparesis and paresthesia, on the side of the bodyopposite the injury.


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Herpes simplex encephalitis

yRecovery from herpes simplex encephalitiscommonly leaves the patient with severeand possibly permanent amnesia.

Associated findings include signs andsymptoms of meningeal irritation, such asheadache, fever, and altered LOC, along

with seizures and various motor and sensory

disturbances (such as paresis, numbness,and tingling).


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HysteriayHysterical amnesia, a

complete and long-lastingmemory loss, begins andends abruptly and is typicallyaccompanied by confusion.


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SeizuresyIn temporal lobe seizures, amnesia occurssuddenly and lasts for several seconds tominutes. The patient may recall an aura ornothing at all. An irritable focus on the left side

of the brain primarily causes amnesia for verbalmemories, whereas an irritable focus on theright side of the brain causes graphic andnonverbal amnesia. Associated signs and

symptoms may include decreased LOC duringthe seizure, confusion, abnormal mouthmovements, and visual, olfactory, and auditoryhallucinations.


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DrugsyAnterograde amnesia can be

precipitated by general anesthetics,

especially fentanyl, halothane, andisoflurane; barbiturates, mostcommonly pentobarbital and

thiopental; and certainbenzodiazepines, especially triazolam.


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Electroconvulsive TherapyyThe sudden onset of retrograde or

anterograde amnesia occurs with

electroconvulsive therapy. Typically, theamnesia lasts for several minutes toseveral hours, but severe, prolonged

amnesia occurs with treatments givenfrequently over a prolonged period.


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Temporal lobe surgery

yUsually performed on only onelobe, this surgery causes brief,slight amnesia. However,

removal of both lobes results inpermanent amnesia.


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CausesNo single factor has been identified as the cause of

Alzheimer's disease.

1.Genetics

Mutations in genes on chromosomes 1, 14 and21.

2.Non-genetics factor

-Age

-Gender

-Race

-Head Injury


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Stages of AlzheimersyPre-dementia- The most noticeable

deficit is memory loss, which shows up as

difficulty in remembering recently learnedfacts and inability to acquire newinformation.

-Apathy can be observed at this stage, and

remains the mostpersistent neuropsychiatric symptomthroughout the course of the disease.


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E

arly Dementiay Difficulties with language, executivefunctions, perception(agnosia), or execution ofmovements (apraxia) are more prominent than

memory problems.y Older memories of the person's life (episodic

memory), facts learned (semantic memory),and implicit memory (the memory of the body

on how to do things, such as using a fork to eat)are affected to a lesser degree than new facts ormemories.


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Moderate DementiaySpeech difficulties become evident due

to an inability to recall vocabulary,which leads to frequent incorrect wordsubstitutions (paraphasias).

y

Reading and writing skills are alsoprogressively lost. Complex motorsequences become less coordinated astime passes.


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yDuring this phase, memory problemsworsen, and the person may fail to recogniseclose relatives.

yLong-term memory, which was previously

intact, becomes impaired.yCommon manifestations

are wandering, irritability and labile affect,

leading to crying, outbursts ofunpremeditated aggression, or resistance tocare giving. Sundowning can also appear.


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Advance DementiayLanguage is reduced to simple phrases or

even single words, eventually leading to

complete loss of speech.yMuscle mass and mobility deteriorate to the

point where they are bedridden, and they

lose the ability to feed themselves.yAggressiveness can still be present, extreme

apathy and exhaustion are much more

common results.


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Four As of AD1. Amnesia: inability to learn new information

or to recall previously learned information.

2. Agnosia: failure to recognize or identify

objects despite intact sensory function.3. Aphasia: language disturbances that can

manifest in both understanding andexpressing the spoken word.

4. Apraxia: inability to carry out motoractivities despite intact motor function.


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Signs and SymptomsEarly symptoms

-Forgetfullness

-Loss of concentration

-Forgetting names


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Progressing symptomsy

-Memory Lossy -Language Deterioration

y -Disorientation

y -Forgetting how to do every tasks

y -Impaired visual skillsy -Confusion

y -Thinking difficulty

y -Impaired spatial skills

y - Poor judgementy -Difficulty speaking

y --Difficulty reading


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yCHANGES IN PERSONALITYThe personalities of people withdementia can change dramatically.They may become extremely confused,suspicious, fearful, or dependent on afamily member.What's normal aging?People's personalities do change

somewhat with age.


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y

LOSSOF INITIATIVEA person with Alzheimer's disease maybecome very passive, sitting in front of theTV for hours, sleeping more than usual, or

not wanting to do usual activities.What's normal aging?Sometimes feeling weary of work or social

obligations.


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yMISPLACING THINGS

A person with Alzheimer's disease mayput things in unusual places: an ironmight go in the freezer or a wristwatch

in the sugar bowl.What's normalaging?Misplacing keys or a wallet temporarily.


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yCHANGES INMOOD ORBEHAVIORSomeone with Alzheimer's disease mayshow rapid mood swings from calmto tears to anger for no apparentreason.What's normal aging?Occasionally feeling sad or moody.


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yPOORORDECREASED JUDGMENT

Those with Alzheimer's may dressinappropriately, wearing several layers on a

warm day or little clothing in the cold. They

may show poor judgment about money, likegiving away large sums totelemarketers.What's normal aging?Making a questionable or debatable decision

from time to time.


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yPROBLEMS WITH ABSTRACT

THINKINGSomeone with Alzheimer's disease mayhave unusual difficulty performing

complex mental tasks, like forgettingwhat numbers are and how they shouldbe used.What's normal aging?

Finding it challenging to balance acheckbook.


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y

PROBLEM

S WITH LANGUAGEPeople with Alzheimer's disease often forgetsimple words or substitute unusual words,making their speech or writing hard to

understand. They may be unable to find thetoothbrush, for example, and instead ask for"that thing for my mouth."What's normal

aging?Sometimes having trouble finding the rightword.


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Diagnostic Tests:y Brain CT Scan: (hydrocephalus, tumor, atrophy,

hematoma)

y Brain MR

IScan

y Vitamin b12 (b12 deficiency)

y Electroencephalography (EEG)

y Urinalysis ( excessive protein and sugar)

y Neuropsychological tests

y MemoryTest

y CognitiveTest


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Nursing Diagnosisy Ineffective family processes related to decline in

patients cognitive function

y Deficient knowledge of family/care giver related

to care for patient as cognitive function declinesy Impaired social interaction related to cognitive

decline

y

Deficient self-care, bathing/hygiene, feeding,toileting related to cognitive decline

yActivity intolerance related to imbalance inactivity/rest pattern.


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NursingManagementySupporting cognitive function

-a calm, predictable environment helps

people with AD interpret their surroundingsand activities.

-a quiet, pleasant manner of speaking, clear

and simple explanations and use of memoryaids and cues help minimize confusion anddisorientation and give patients a sense ofsecurity.


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-prominently displays clock and calendar s mayenhance orientation to time

-color coding the doorway may help patients whohave difficulty locating their room.

-active participation may help patients maintaincognitive, functional, and social interaction abilitiesfor a longer period.

Promoting physical safety

-a safe home environment allows the patient to moveabout as freely as possible and relieves the family ofconstant worry about safety


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-to prevent falls and injuries, all obvious hazards

should be remove (a hazard-free environmentallows the patient maximum independence and asense of autonomy)

-adequate lighting especially in halls, stairs andbathrooms is necessary

-nightlights are helpful particularly if the patienthas increased confusion at night (sundowning)

-doors leading from the house must be secured-outside the home, all activities must besupervised to protect the patient.


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Promoting independence in self-care activities-simplify daily activities by organizing them into short,achievable steps so that the patient experiences a sense

of accomplishment

Reducing Anxiety and Agitation-despite profound cognitive losses, patients are

sometimes aware of their diminishing abilities.-patient needs constant emotional support thatreinforces a positive self-image


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-the environment should be kept familiar and noise-free

-excitement and confusion can be upsetting and mayprecipitate a combative, agitated state known ascatastrophic reaction (overreaction to excessivestimulation).The patient may respond to

screaming, crying, or becoming abusive (this maybe the persons only way of expressing an inability tocope with the environment. When this occurs, it isimportant to remain calm and unhurried. Dont

force the patient to proceed with the activitybecause it will increases agitation. It is better topostpone the activity until later, even to another daybecause frequently the patient quickly forgets what

triggered the reaction.


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Improving Communication-to promote patients interpretation ofmessages, the nurse should remainunhurried and reduce noises and

distractions-use of clear, easy-to-understand sentencesconvey messages is essential because

patients frequently forget the meaning ofwords or have difficulty organizing andexpressing thoughts


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Providing

Socialization andIntimacy Needs

-socialization are comforting. Visits should be briefand non-stressful; reducing visitors to one or two

at a time helps reduce overstimulation-Hobbies and activities such as walking, exercisingand socializing can improve the quality of life

-care of plants or pet can also be satisfying and an

outlet of energy-touching and holding are often meaningfulsimple expressions of love


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Promoting Adequate Nutrition-Mealtime can be a pleasant social occasion or a timeof upset and distress and it should be kept simple andcalm without confrontations

-Patients prefer familiar foods that look appetizing and

taste good-To avoid any playing with food, one dish is offered at atime. Food is cut into small pieces to prevent choking.Liquids may be easier to swallow if they are convertedto gelatine

-Hot food and beverages are served warm, and thetemperature of the foods should be checked to preventburns


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Promoting Balanced Activity and Rest

-If sleep is interrupted or the patient cannotfall asleep, music, warm milk, or a back rubmay help patient to relax

-During the day patients should beencouraged to participate in exercisebecause a regular pattern of activity and

rest enhances night time sleep.-Long periods of daytime sleeping arediscouraged.


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UsefulMedications for Patients

with ADCholinesterase Inhibitors:Donepezil (Aricept)Action: Reversibly inhibit acetycholineesterase in the CNS

(cerebral cortex), resulting to increased acetycholine levelsbec. of slow degradation. It does not alter underlyingdementia but temporarily improves cognitive function inpatient with AD.

Side Effects:

-N

ausea and vomiting-Insomia-Headache and dizziness-Muscle cramps-Fatigue


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Nursing Considerations:

-Assess mental status: affect, mood behavioral changes,depression.

-Monitor for possible adverse reaction:

CNS: insomia, depression, seizures, vertigo, abnormal

crying, aphasian, abnormal dreams

CV: chest pain, hypertension, hypotension

EENT: cataract, sore throat, blurred vision, eyeirritation

GI: GI bleeding, epigastric pain

SKIN: Pruritus, urticaria

MUSCULOSKELETAL: muscle cramps, toothache


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Teaching:

-Explain that drug does not alter underlying degenerativedisease but can alleviate symptoms.

-Instruct patient/caregiver to monitor and report any signs ofadverse reactions

-Tell caregiver to give drug before bedtime

-Instruct to take the drug as prescribes, do not increase orabruptly decrease dose, this may result to seriousconsequences

Rivastigmine ( Exelon)

Action: Increased acethycoline level by inhibiting thecholinesterase enzyme which causes acetylcholinehydrolysis which may lead to some memory improvement.


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Side Effects

-Nausea and vomiting

-Abdominal pain-Loss of appetite

-Dizziness and headache

-Tremor

Nursing Considerations:-Assess mental status: affect, mood behavioral changes,

depression.

-Assess cognitive function

Teaching:- Instruct to take the drug as prescribes, do not increase

or abruptly decrease dose, this may result to seriousconsequences


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Galantamine (Reminyl)

Action: Unknown; may enhance cholinergic functioningby increasing the level of acetylcholine in the brain.

Side Effects:

-Nausea and vomiting

-Abdominal pain and diarrhea-Headache

-GI bleeding


-MonitorVS: watch out for bradycardia and hearblock

-Monitor for adverse reaction:

CNS: dizziness, tremor, depression, insomia, fatigue


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CV: Bradycardia

EENT

: RhinitisGI: Nausea, vomiting, diarrhea, abd. pain

HEMATOLOGIC: anemia

METABOILC: Weight loss

Teaching:-Advice patient/caregiver that drug should be taken withmeals

-Advice to monitor and report signs of adverse reaction

M

emantine (Abixa)Action: Antagonizes N-methyl-D-aspartate (NMDA)receptors. Persistent activation of theses receptorsseems to increase Alzheimers symptoms.


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Side Effects:

-Hallucination-Confusion

-Dizziness

-Headache

-Tiredness


-Assess mental status: affect, mood behavioral changes,

depression.-Monitor for possible adverse reaction:

CNS: Abnormal gait, aggressiveness, agitation,confusion


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CVA: depression, hallucination, insomia, ischemicattack

CV: edema, heart failure, hypertension

RESPIRATORY: cough, dyspnea, pneumonia

Teaching:

-Advice to monitor and report signs of adverse reaction

Theres no surgical procedure in AD

Documents

Alzheimer’s Diseasewww