The most prevalent form of dementia. First diagnosed by Alois Alzheimer in 1907 Course from onset to death might exceed 10 years. Patients with a 10- to 20- year course has a more gradual and subtle decline. Average life expectancy from onset to death: 8 years
The most significant risk factor: AGE Other risk factors: history of head injury, lower levels of education, and being female Stages: Mild Moderate Severe
CAUSES: Cholinergic hypothesis: the most recognized and accepted Levels of acetylcholine are reduced in the brain ACTH: primary neurotransmitter that affects an individual’s ability to acquire new information, make simple and complex decisions, and retain memories
Destruction of cholinergic cell bodies (major site: nucleus Basalis of Meynert) by oxidative stress. Free radicals are produced killing these cells. Tau protein is altered and forms twisted rope-like bundles within a cell, resulting in neurofibillary tangles. Deposits of beta amyloid plaque outside of the neurons. Cell death may result from overabundance of these plaques. The more amyloid plaques deposited , the greater the impairment is thought to be.
Genetics. Early onset Chromosome 21:amyolid precursor protein gene Presenilin1 gene found in Chromosome 14 Presinilin 2 gene found on chromosome 1 Linked to the development of amyloid plaques Apolipoprotein (Apo-E4) found on chromosome 19
Shrinking of the brain, weighing about 2/3 of the weight of the normal brain. Atrophy begins in the temporal and parietal regions and processes the entire brain. Smaller gyri and larger sulci undergo atrophic changes. The more the brain shrinks, the larger the ventricles become.
Antioxidants have been found to promote healthy neurons. Free radicals, bits of oxygen fragments that are produced in the dying neuron, start a chain reaction that ends with nerve cell destruction.
We need to eat at least 5 kinds of Fruits & Vegetables
ENVIRONMENTAL ISSUES Excessive aluminum from using aluminum cookware or using a deodorant has not been proven to cause Alzheimer’s disease. Dental amalgams were not also found to cause AD. No viral agent transmits this disease.
The NUN STUDY
NONTRADITIONAL FINDING The NUN STUDY Conducted by Davin Snowdon of the Sanders- Brown Center on Aging at the University of Kentucky Longitudinal study of the School Sisters of Notre Dame 678 nuns volunteered
Has some unexpected findings: A sister who has lived more than 100 years old showed no cognitive decline though there is abundance of both plaque and tangle formations. Another nun in her 70s had profound dementia yet had few tangles and plaques.
Complex use of language and advanced education were two background issues that were isolated in the nuns who had the highest ability. Nuns with a positive lifetime attitude were found to be in the highest cognitive group.
Memory loss The most noticeable initial problem Long term memory remains intact at first. Word- finding difficulty: the easiest problem for the nurse to assess. Trouble understanding a conversation, comprehending the plot of a book, or following a TV program frequently occurs. Withdrawing from a former routine and pleasurable activities because of a lack of interest and of initiative further contributes to further cognitive decline.
Misinterpreting the environment. Visual hallucinations are common. Charles Bonnet Syndrome Common among those who have visual impairments (macular degeneration). Often quite vivid and elaborate. Often have visual hallucinations of dead relatives. Least common: olfactory, tactile, and gustatory hallucinations
Delusions Paranoia about spouses having extramarital affairs, stealing money and rearranging things at home Misidentifications Calling a family member or a friend by another person’s name.
Sundown syndrome A period, usually in the afternoon or early evening, during which a patient becomes more agitated and less redirectable. Sundowning: more accurate term Loss of ability to care for oneself. Incontinence of bowel and/ or bladder and wandering are unmanageable behaviors that make home care no longer possible for any caregivers.
FOUR A’s of Alzheimer’s Disease and Adaptive Actions Agnosia: Impaired ability to recognize or identify familiar objects and people in the absence of a visual or a hearing impairment. Assess and adapt for visual impairment. Do not expect the patient to remember you; introduce yourself. Cover mirrors or pictures if they cause distress. Name objects and demonstrate their use. Keep area free of ingestible hazards (toiletries, chemicals, checkers, buttons, and unmonitored medicines).
Aphasia: Language disturbances are exhibited in both expressing and understanding spoken words. Expressive aphasia is the inability to express thoughts in words; receptive aphasia is the inability to understand what is said. Assess and adapt for hearing loss. Observe for use of gestures, tone and facial expressions. Provide help with word finding. Restate your understanding of behaviors and word findings. Acknowledge feelings expressed verbally and nonverbally. Use simple words and phrases; be concise and organized. Allow time for response. Listen carefully and encourage nonverbal praise. Use pictures, symbols, and sign- ins.
Amnesia: Inability to learn new information or to recall previously learned information. Do not expect patient to remember you; introduce yourself. Do not test the patient’s memory unnecessarily. Operate in the here and now. Provide orientation cues. Remember, you must adapt when the patient cannot change. Compensate for patient’s lost judgment or reasoning.
Apraxia: Inability to carry out motor activities despite intact motor function. Assess and adapt for motor weakness and swallowing difficulties. Simplify tasks: give step- by- step instructions and time for response. Initiate motion for patient with gentle guidance or touch.
NURSE- PATIENT RELATIONSHIP
GOLDEN RULE: Promote maximum functioning and have patience. Communication strategies: Nurse must be pleasant, smile, be kind, use good eye contact, and to repeat, be patient. TIPS: If an interaction is going poorly, stop, walk away (providing it is safe to do so), and return in a few minutes with a fresh start. Remember, effective communication starts with nonverbal behavior, so use a kind voice and make eye contact. Be positive and stay with pleasant subjects. Do not use sasrcasm, jokes, and metaphor because the patient’s loss of abstract thinking makes understanding these language subtleties almost impossible.
Recognize that patients might not be able to tell the difference between a real argument and an impassioned discussion about a new movie. Observing staff members in such a debate can be frightening and confusing to these patients. Use short sentences, do not use complex ones. Give directions slowly, one step at a time. Do not finish sentences for patients; give them time to finish their thoughts. Approach patients from the front in case they have visual or hearing impairments, Lots of chatter can be confusing, because patients struggle to track one conversation when several are going around them.
Scheduling strategies: Develop a schedule that provides structure to the day, because patients adapt better when they have a predictable routine. Focus on patient- centered activities. Develop singular activities because multiple activities overwhelm the patients. For example, turn off the television while the patient is putting together a puzzle. Provide a group exercise with one subject approached at a time. Too mush stimulation increases anxiety and might lead to agitation.
Nutritional strategies: Make sure that patients eat properly by tailoring dietary needs to the patient. Serve smaller meals several times per day. If too much food is on the plate,, the patient might be overwhelmed. Also, finger foods work well for people who will not stay at the table. Find out about a patient’s favorite foods and provide them as much as possible. Remember that beverage supplements can provide nutrition when regular food intake lessens.
Toileting strategies Seek to keep the patient physically comfortable. Provide immaculate attention to personal hygiene and toileting needs. Take the patient to the bathroom every 2 hours to promote continence.
Wandering strategies Wandering: leaving one’s residence, unsupervised, and getting lost. Might leave in search their own residences in search of their “homes” or have day- night reversal and walk at night. Wandering paths (for long term care facilities): must be continuous and without end. Windows, interesting art on the walls, and an unobstructed hallway provide a safe place to wander as well. Make the exit door less obvious and paint attractive scenes. Photograph the patients and keep the patient updated and on the file (“safe return program”) Safe return armbands Global positioning devices (necklaces and
Miliue management Room temperature and lighting should be the patient’s preference Reduce noxious sounds that might offend or frighten patients TV should not be allowed (unless purposeful viewing) Match roommate’s personalities when possible
Memory aids Big blocks for each date (in a calendar) Notes are good reminders (but must know to look for them) Directions must be written in large print to instruct patients on how to operate new appliances Use one universal remote control (for several appliances) Pillboxes for a day or a month (might have an alarm)