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Alzheimer’s disease: Management
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Alzheimer’s disease: Management


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Alzheimer’s disease: Management

Alzheimer’s disease: Management

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  • 1. Alzheimer’s Disease
  • 2. Overview
  • 3. Alzheimer's disease
    A progressive degenerative disorder of the cerebral cortex (especially the frontal lobe)
    Most common form of dementia
    5% of people older than age 65 have a severe form of this disease
    12% suffer from mild to moderate dementia
  • 4.
  • 5. Alzheimer's disease
    Characterized by:
    Progressive impairment in memory, cognitive function, language, judgment, and ADL
    Ultimately, patients cannot perform self-care activities and become dependent on caregivers
    Prognosis: poor
  • 6. Pathophysiology and Etiology
  • 7. Gross pathophysiologic changes:
    cortical atrophy
    enlarged ventricles
    basal ganglia wasting
    Changes in the proteins of the nerve cells of the cerebral cortex
    accumulation of neurofibrillary tangles and neuritic plaques (deposits of protein and altered cell structures on the interneuronal junctions)
    granulovascular degeneration
    loss of cholinergic nerve cells (important in memory, function, cognition)
  • 8.
  • 9.
  • 10.
  • 11. Biochemically:
    neurotransmitter systems are impaired
    Cause: unknown
    Risk factors:
    genetics and female gender
    Viruses, environmental toxins, silent brain infarcts, and previous head injury may also play a role
  • 12. Clinical manifestations
  • 13. Disease onset: subtle and insidious
    Initially, a gradual decline of cognitive function from a previously higher level
    Short-term memory impairment is commonly the first characteristic in earliest stages of the disease
    Forgetful and difficulty learning and retaining new information
    Difficulty planning meals, managing finances, using a telephone, or driving without getting lost
  • 14.
  • 15. Functional deficits:
    Language disturbance (word-finding difficulty)
    Visual-processing difficulty
    Inability to perform skilled motor activities
    Poor abstract reasoning and concentration
    Personality changes:
    Personal neglect of appearance
    Disorientation to time and space
  • 16. Middle stage:
    Repetitive actions (perseveration)
    Nocturnal restlessness
    Apraxia (impaired ability to perform purposeful activity)
    Aphasia (inability to speak)
    Agraphia (inability to write)
    Signs of frontal lobe dysfunction:
    Loss of social inhibitions
    Loss of spontaneity
  • 17.
  • 18. Middle and late stages:
    Wandering behavior
    Patients in the advanced stage of Alzheimer's disease require total care
    Urinary and fecal incontinence
    Increased irritability
    Unresponsiveness or coma
  • 19.
  • 20.
  • 21. complications
  • 22. Increased incidence of functional decline
    Injury due to lack of insight, hallucinations, confusion, wandering, own violent bahavior
    Pneumonia and other infections, especially if the patient doesn't get enough exercise
    Malnutrition and dehydration due to inattention to mealtime and hunger or lack of ability to prepare meals
  • 23.
  • 24.
  • 25. Diagnostic evaluation
  • 26. Detailed patient history with corroboration by an informed source
    to determine cognitive and behavioral changes, their duration, and symptoms that may be indicative of other medical or psychiatric illnesses
    Noncontrast computed tomography (CT) scan, Magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT)
    to rule out other neurologic conditions
    • Neuropsychological evaluation (mental status assessment)
    to identify specific areas of impaired mental functioning in contrast to areas of intact functioning
  • 27.
  • 28.
  • 29. Laboratory tests:
    complete blood count, sedimentation rate, chemistry panel, thyroid-stimulating hormone, test for syphilis, urinalysis, serum B12, folate level, and test for HIV
    to rule out infectious or metabolic disorders
    Commercial assays for cerebrospinal fluid (CSF) tau protein and beta-amyloid
    Genetic testing
    In families with a history of Alzheimer's disease, test to confirm AD or to provide information to at-risk family members regarding their likelihood for development of AD
  • 30. management
  • 31. Primary goals of treatment for Alzheimer's disease:
    To maximize functional abilities and improve quality of life by enhancing mood, cognition, and behavior
    No curative treatment exists
    Cholinesterase inhibitors
    first treatment for cognitive impairment of AD
    Improve cholinergic neurotransmission to help delay decline in function over time
  • 32.
    • Donepezil (Aricept)
    Widely used in mild to moderate cases because it can be given once daily and is well tolerated
    Starting at 5 mg hs and increased to 10 mg after 4 to 6 weeks
    • Galantamine (Reminyl)
    Given with food in dosage of 4 to 12 mg bid
    Should be restarted at 4 mg bid if interrupted for several days
    Dose should be reduced in cases of renal or hepatic impairment
  • 33.
    • Rivastigmine (Exelon)
    Given 1.5 mg bid with meals and increased up to 6 to 12 mg per day
    • Memantine (Namenda)
    NMDA-receptor antagonist
    The first of a new class approved for moderate to severe Alzheimer's
    Dosage is 10 mg bid
    Can be used with a cholinesterase inhibitor
  • 34. Patients with depressive symptoms should be considered for antidepressant therapy
    Behavioral disturbances may require pharmacologic treatment
    anxiolytics, antipsychotics, anticonvulsants
    Nonpharmacologic treatments used to improve cognition:
    Environmental manipulation that decreases stimulation
    Pet therapy
    Music therapy
  • 35. Drug Alert
    Cholinesterase inhibitors
    initially aimed at improving memory and cognition
    seem to have an important impact on the behavioral changes that occur in patients with cognitive impairment
    improves the apathy, disinhibition, pacing, and hallucinations commonly noted in dementia
    Be alert for drug interactions with NSAIDs, succinylcholine-type muscle relaxants, cholinergic and anticholinergic agents, drugs that slow the heart, and other drugs that are metabolized by the hepatic CYP2D6 or CYP3A4 pathways
  • 36. Nursing assessment
  • 37. Perform cognitive assessment:
    orientation, insight, abstract thinking, concentration, memory, verbal ability
    Assess for changes in behavior and ability to perform ADLs
    Evaluate nutrition and hydration
    check weight, skin turgor, meal habits
    Assess motor ability, strength, muscle tone, flexibility
  • 38. Nursing diagnoses
  • 39. Bathing or hygiene self-care deficit
    Disabled family coping
    Disturbed thought processes
    Dressing or grooming self-care deficit
    Feeding self-care deficit
    Imbalanced nutrition: Less than body requirements
    Impaired verbal communication
    Ineffective coping
    Interrupted family processes
    Risk for infection
    Risk for injury
    Toileting self-care deficit
  • 40. Key outcomes
  • 41. The patient will
    perform bathing and hygiene needs
    maintain a regular bowel elimination pattern
    (Family members will) use support systems and develop adequate coping behaviors
    remain oriented to time, person, place, and situation to the fullest extent possible
    perform dressing and grooming needs within the confines of the disease process
    consume daily calorie requirements
  • 42. The patient will
    show no signs of malnutrition
    effectively communicate needs verbally or through the use of alternative means of communication
    use support systems and develop adequate coping behaviors
    (Family members will) discuss the impact of the patient's condition on the family unit
    remain free from signs and symptoms of infection
    (Family members will) identify strategies to make the patient's environment as safe as possible
    perform toileting needs within the confines of the disease process
  • 43. Nursing interventions
  • 44.
  • 45. Establish an effective communication system with the patient and his family
    to help them adjust to the patient's altered cognitive abilities
    Provide emotional support to the patient and his family
    Encourage them to talk about their concerns
    Listen carefully to them
    Answer their questions honestly and completely
    Use a soft tone and a slow, calm manner when speaking to him
    Because the patient may misperceive his environment,
  • 46. Allow the patient sufficient time to answer your questions
    his thought processes are slow, impairing his ability to communicate verbally
    Administer ordered medications to the patient and note their effects
    If the patient has trouble swallowing, check with a pharmacist to see if tablets can be crushed or capsules can be opened and mixed with a semi-soft food
    Protect the patient from injury
    Provide a safe, structured environment
    Provide rest periods between activities because these patients tire easily
  • 47. Encourage the patient to exercise
    to help maintain mobility
    Encourage patient independence
    allow ample time for the patient to perform tasks
    Encourage sufficient fluid intake and adequate nutrition
    Provide assistance with menu selection
    allow the patient to feed himself as much as he can
    Provide a well-balanced diet with adequate fiber
    Avoid stimulants, such as coffee, tea, cola, and chocolate
  • 48. Give the patient semisolid foods if he has dysphagia
    Insert and care for a nasogastric tube or a gastrostomy tube for feeding as ordered
    Because the patient may be disoriented or neuromuscular functioning may be impaired, take the patient to the bathroom at least every 2 hours
    Make sure he knows the location of the bathroom
    Assist the patient with hygiene and dressing as necessary
    Many patients with Alzheimer's disease are incapable of performing these tasks
  • 49. Patient teaching
  • 50. Teach the patient's family about the disease
    Explain that the cause of the disease is unknown
    Review the signs and symptoms of the disease
    Be sure to explain that the disease progresses but at an unpredictable rate and that patients eventually suffer complete memory loss and total physical deterioration
    Review the diagnostic tests that are to be performed and treatment the patient requires
    Advise family members to provide the patient with exercise
    Suggest physical activities, such as walking or light housework, that occupy and satisfy the patient
  • 51. Stress the importance of diet
    Limit the number of foods on the patient's plate so he doesn't have to make decisions
    If the patient has coordination problems, cut his food and to provide finger foods, such as fruit and sandwiches
    Suggest using plates with rim guards, easy-grip utensils, and cups with lids and spouts
    Allow the patient as much independence as possible while ensuring his and others' safety
    Create a routine for all the patient's activities, which helps them avoid confusion
    If the patient becomes belligerent, advise family members to remain calm and try to distract him
    Refer family members to support groups
  • 52. Teaching patient about alzheimer’s disease
  • 53. Counsel family members to expect progressive deterioration in the patient with Alzheimer's disease
    To help them plan future patient care, discuss the stages of this relentless neurodegenerative disease
    Bear in mind that family members may refuse to believe that the disease is advancing
    Be sensitive to their concerns and, if necessary, review the information again when they're more receptive
  • 54. Forgetfulness
    The patient becomes forgetful, especially of recent events
    He frequently loses everyday objects such as keys
    Aware of his loss of function, he may compensate by relinquishing tasks that might reveal his forgetfulness
    Because his behavior isn't disruptive and may be attributed to stress, fatigue, or normal aging, he usually doesn't consult a physician at this stage
  • 55. Confusion
    The patient has increasing difficulty at activities that require planning, decision making, and judgment, such as managing personal finances, driving a car, and performing his job
    He does retain skills such as personal grooming
    Social withdrawal occurs when the patient feels overwhelmed by a changing environment and his inability to cope with multiple stimuli
    Travel is difficult and tiring
    As he becomes aware of his progressive loss of function, he may become severely depressed
    Safety becomes a concern when the patient forgets to turn off appliances or recognize unsafe situations such as boiling water
    At this point, the family may need to consider day care or a supervised residential facility
  • 56. Decline in activities of daily living
    The patient at this stage loses his ability to perform such daily activities as eating or washing without direct supervision
    Weight loss may occur
    He withdraws from the family and increasingly depends on the primary caregiver
    Communication becomes difficult as his understanding of written and spoken language declines
    Agitation, wandering, pacing, and nighttime awakening are linked to his inability to cope with a multisensory environment
    He may mistake his mirror image for a real person (pseudohallucination)
    Caregivers must be constantly vigilant, which may lead to physical and emotional exhaustion
    They may also be angry and feel a sense of loss.
  • 57. Total deterioration
    In the final stage of Alzheimer's disease, the patient no longer recognizes himself, his body parts, or other family members
    He becomes bedridden, and his activity consists of small, purposeless movements
    Verbal communication stops, although he may scream spontaneously
    Complications of immobility may include pressure ulcers, urinary tract infections, pneumonia, and contractures
  • 58. Learning activity
  • 59. True or False: Alzheimer’s disease is a memory-related disease that is reversible with medications.
  • 60. FALSE
    Alzheimer’s disease is a progressive degenerative disorder of the brain that is irreversible
    The exact cause is unknown; initial stages include recent memory loss and impaired judgment, inability to learn and retain new information, and difficulty finding words; later stages include decreased abilility to care for self, wandering, agitation and hostility, and possibly eventually inability to walk, incontinence, and no intelligible speech
    Medications may help improve memory in early stages, but there is no cure
    It is typically diagnosed when other dementia-producing conditions have been ruled out
  • 61.
    THANK YOU!Have a nice day : )
    - RDG