Alzheimer Disease and Memory Care

Alzheimer Disease
and Memory Care
Saeed Khayyat Kakhki
Master Student of Geriatric Nursing at TUMS

Topics
• Introduction
• Epidemiology
• Alzheimer Disease Types
• Pathophysiology
• Risk factors
• Clinical manifestations
• AD Stages
• Diagnosis
• Treatment & Care
• Covid-19 & AD
• References

Introduction
• Alzheimer Disease is the most common form of dementia.
• Is a progressive, degenerative, irreversible dementia.
– The amount of damage done by the disease increases over time
– The nerve cells in the brain degenerate or break down
– Damage done to the brain cells can't be repaired
– there is no known cure for this disease
• Gradual onset and continuing decline of memory, changes
in judgment or reasoning, and inability to perform familiar
tasks.

Epidemiology
-Facts and Figures

Alzheimer Disease Types
Two Types:
1- Sporadic AD can
strike adults at any age,
but usually occurs after
age 65.
2- Familial autosomal
dominant Alzheimer
Disease (FAD), which
runs in certain families.

Alzheimer Disease Types (Count…)
Sporadic AD:
❑ makes up 90 to 95 percent of cases of the disease.
❑ People with this form may or may not have a family
history of the disease.
❑ Children of someone with Sporadic Alzheimer Disease
have a somewhat higher risk of developing AD, when
compared to people with no family history of the disease.

Alzheimer Disease Types (Count…)
Familial Autosomal Dominant Alzheimer Disease (FAD)
❑ FAD is rare and makes up only 5 to 10 % of all cases of
Alzheimer Disease.
❑ FAD is passed from generation to generation due to a
dominant inheritance pattern.
❑ If a parent has the mutated gene, each child has a 50 %
chance of inheriting it.

Pathophysiology
There are 3 consistent neuropathological
hallmarks:
❑ Amyloid-rich senile plaques
❑ Neurofibrillary tangles
❑ Neuronal degeneration
These changes eventually lead to clinical
symptoms, but they begin years before
the onset of symptoms

Pathophysiology (Count…)
There are 3 consistent neuropathological hallmarks:
❑ Amyloid-rich senile plaques
Immunocytochemical staining of senile plaques in the iso cortex of
a brain of a human with AD (anti amyloid antibody)
❑ Neurofibrillary tangles
Immunocytochemical staining of neurofibrillary tangles in the iso
cortex of the brain of a human with AD (anti-tau antibody)
❑ Neuronal degeneration
Loss of ACh activity correlates with the severity of AD
These changes eventually lead to clinical symptoms, but they
begin years before the onset of symptoms

Pathophysiology (Count…)
-Summery

Risk Factors
• Advancing age
• Family history of Alzheimer Disease
• Low education levels
• Head injury
• Down Syndrome
• Environmental factors

Clinical manifestations
• Changes in mental abilities & functions
• Changes in emotions and mood
• Changes in behavior
• Changes in physical abilities

Clinical manifestations (Count…)
-Changes in mental abilities & functions
• AD affects ability to understand, think, remember and communicate.
• inability to learn new things and make decisions.
• trouble remembering people’s names, where he is, or what he was about to
do.
• misplace things, repeat questions or comments, forget appointments despite
reminders
• may continue to remember past events clearly.
• unable to do the simple tasks done for years.
• difficulty understanding what is being said and making self understood.

-Changes in mental abilities & functions
Apraxia: loss of ability to carry out a complex action, not due to weakness
• Early may affect ability to use appliances, devices
• Later may affect dressing, toileting, other functions
Agnosia: inability to recognise familiar faces or objects
• Early may not recognize less familiar surroundings (e.g. cottage, son’s house)
• Later fail to recognize faces, even of family, or self in mirror
Aphasia: inability to communicate due to problems with language function
• Often an early symptom of AD
• Word-finding difficulty increases
• Later, sentences become garbled or miss important words
• Later still, fewer and fewer meaningful words
• Eventually may progress to inability to speak or communicate

-Changes in emotions and mood
• usually less expression, less lively and more withdrawn than
before - “apathy”
• may also lose the ability to control moods and emotions.
• may become sad, angry, laugh inappropriately, worry a great
deal over small things or be suspicious of people close to her.
• whole personality may seem different.

-Changes in behavior
• kinds of behavior change and the length of time they are present
are different for each person.
• may be challenging for the caregivers or family to deal with
• may have meaning - may be a reaction to a situation, or an
attempt to communicate or perform a function or activity

-Changes in behavior
-Typical Behaviors
• pacing
• repetitive actions
• hiding things
• constant searching
• undressing
• disturbed sleep
• false beliefs
• physical outbursts
• restlessness, agitation
• swearing
• arguing, anger
• inappropriate sexual advances
• hallucinations

-Changes in physical abilities
Decreased physical or functional ability:
• at first difficulty with finances, driving or cooking
• later have difficulty feeding, dressing or bathing
• eventually lose bladder and bowel control
• become less and less able to move about

NOTEs:
•The type of change and the speed at which Alzheimer Disease
progresses is different for each person.
•The disease may progress quickly in some people, while others
have many years during which they can live relatively normal
lives.

Finally:
▪Memory loss is severe and the past is forgotten.
▪will lose ability to speak, walk and feed self
▪will appear to have little or no reaction at all to people or her surroundings.
▪will still be able to hear, respond to emotions and be aware of touch.
▪will lead to complete dependence and finally to death, often from another
illness such as pneumonia.
▪will need 24-hour-a-day care.
▪ this care may continue at home or the care may be given in a long-term
care facility, depending on available resources.

Diagnosis
✓ Need information from the person and from knowledgeable
family members or friends.
✓ History of all medical, psychiatric illnesses, all medications.
✓ Onset, duration, progression of symptoms.
✓ Functional status, activities of daily living (ADL)
✓ Differentiate between dementia, depression, delirium
Delirium is temporary confusion, Dementia is usually permanent and progressive
Depression can easily look like dementia with memory loss, apathy and loss of function

Diagnosis (Count…)
Mental status test
▪ Mini Mental Status Exam (MMSE)
▪ Tests memory, orientation, concentration, aspects of language, construction ability
Physical Examination
▪ Focus on neurological system, evidence of stroke or other
illnesses causing memory problem

Treatment & Care
Primary goals:
to enhance quality of life & maximize functional performance
by improving cognition, mood, and behavior
Treatment includes:
❑ Identification and treatment of contributing factors
❑ Assessment of function and meeting functional needs
❑ Memory aids and coping strategies
❑ Sleep Problems
❑ Medications (Pharmacologic)

Treatment & Care (Count…)
-Function and Safety
❑ Safety checklist
Driving, risk of fires, wandering, not eating, financial risk,
medications, behavior
❑ Mobilize family support
Supplement with Home Care, hired care, other formal services

-Memory Aids
❑ Memory books, reminder systems, automatic bill payment
❑ mental stimulation may prevent or postpone decline in memory
❑ Individual and group therapy
❑ Communication with family & caregivers

-Coping Strategies
❑ Monitor personal comfort
Check for pain, hunger, thirst, constipation, full bladder, fatigue,
infections and skin irritation. Maintain a comfortable room temperature.
❑ Avoid being confrontational or arguing about facts
For example, if a person expresses a wish to go visit a parent who died
years ago, don't point out that the parent is dead. Instead, say, "Your
mother is a wonderful person. I would like to see her too."
❑ Redirect the person's attention
Try to remain flexible, patient and supportive by responding to the
emotion, not the behavior.

-Coping Strategies
❑ Create a calm environment
Avoid noise, glare, insecure space and too much background
distraction, including television.
❑ Allow adequate rest between stimulating events.
❑ Provide a security object
❑ Look for reasons behind each behavior
Consult a physician to identify any causes related to
medications or illness.

-Sleep Problems
❑ Maintain regular times for meals and for going to bed and getting
up
❑ Seek morning sunlight exposure
❑ Encourage regular daily exercise, but no later than four hours before
bedtime
❑ Avoid alcohol, caffeine and nicotine
❑ Treat any pain
❑ If the person is taking a cholinesterase inhibitor (tacrine, donepezil,
rivastigmine or galantamine), avoid giving the medicine before bed

-Sleep Problems
❑ Make sure the bedroom temperature is comfortable
❑ Provide nightlights and security objects
❑ If the person awakens, discourage staying in bed while awake;
use the bed only for sleep
❑ Discourage watching television during periods of wakefulness.

-Caregiver Support
❑ Caregiver may be instrumental in maintaining the person’s
independence
❑ Caregiver burden and stress
❑ Caregivers have more health problems than non-caregivers
❑ Caregiver education, counselling and support shown to improve
function and delay need for nursing home

-Medications (Pharmacologic Treatment)
❑ Cognitive enhancers
Aim to increase memory & function (memory loss, confusion, and
problems with thinking and reasoning) of Alzheimer's disease.
Do not treat underlying disease
❑ Behavior and mood changes
Treat complications
❑ Preventive Medications

Cognitive Enhancers
❑ Donepezil (Stage1-3: 5mg PO qHS may increase 10 mg/day after 4-6 weeks)
▪A cholinesterase inhibitor.
▪Increase the level of acetylcholine in the brain.
▪About 30% of people get stomach upset, vomiting, diarrhea or other side
effects.
▪Benefits seen in memory tests (- 1) point on MMSE and a global test of
memory, behavior and function
▪Benefits are modest - most people do not improve but remain stable for 4-6
months instead of getting steadily worse

Cognitive Enhancers
❑ Rivastigmine (1.5 mg q12h) & Galantamine (4 mg q12h)
▪ are also cholinesterase inhibitors like donepezil
▪They have similar benefits, side effects, and cost, but are
both taken twice instead of once a day

Cognitive Enhancers
❑ Memantine (5 mg Once Daily)
▪Licensed in Canada December 2004
▪Partial activator of NMDA(N-methyl-D-aspartate) receptor, prevents
overstimulation by glutamate
▪Few side effects
▪Studies show similar degree of benefit in moderate to severe Alzheimer
disease (MMSE <14) as donepezil, either alone or added to donepezil
▪Limit benefits to memory, function, behavior

Generic Brand® Approved for Side Effects
Donepezil Aricept All stages
Nausea, vomiting, loss of appetite,
muscle cramps and increased frequency
of bowel movements.
Galantamine Razadyne Mild to moderate Nausea, vomiting, loss of appetite and
increased frequency of bowel
movements.Rivastigmine Exelon Mild to moderate
Memantine Namenda Moderate to severe
Headache, constipation, confusion and
dizziness.
Memantine
+Donepezil
Namzaric Moderate to severe
Nausea, vomiting, loss of appetite,
increased frequency of bowel
movements, headache, constipation,
confusion and dizziness.

❑ Other cognitive enhancers
▪Tacrine (Not at Canada Pharmacopeia)
▪Gingko biloba (Few side effects)
▪Vitamin E
One study, using 2000 Units daily, suggested benefit in delaying
need for nursing home.
Recent study says that Vitamin E has no benefit!
Concern recently about serious cardiovascular side effects

❑ Medication for Mood and Behavior
✓ Depression is common in people with Alzheimer Disease.
✓ If severe enough, anti-depressant medications can be safely
used.
✓ Some anti-depressants worsen memory and should be
avoided.

✓ Behavior changes are common and may increase caregiver
burden and decrease quality of life
✓ Often there is an underlying cause to the behavior (pain,
constipation, infection, drug side effect)
✓ Environmental changes or behavioral approaches may be
effective.

✓ For uncontrollable agitation, aggression, hallucinations or
delusions, anti-psychotic medication may be needed.
✓ Haloperidol, chlorpromazine or newer, risperidone,
olanzapine or quetiapine can be used.
✓ All can cause serious side effects and need careful
adjustment and monitoring.

❑ Preventive Medications
▪observational studies suggest that women taking Estrogen
are less likely to develop Alzheimer disease.

Covid-19 & AD
COVID‐19 outbreak is indirectly affecting the clinical conditions of people living
with dementia and cognitive disturbances.
❑ Tips for Dementia Caregivers
✓ Most likely, dementia does not increase risk for COVID-19, just like
dementia does not increase risk for flu.
✓ dementia-related behaviors, increased age and common health
conditions that often accompany dementia may increase risk.
EXAMPLE: people with Alzheimer's disease and all other dementia may
forget to wash their hands or take other recommended precautions to
prevent illness. In addition, diseases like COVID-19 and the flu may
worsen cognitive impairment due to dementia.

Covid-19 & AD (Count…)
❑ Tips for Dementia Caregivers
✓ Most likely, dementia does not increase risk for COVID-19, just like
dementia does not increase risk for flu.
✓ dementia-related behaviors, increased age and common health
conditions that often accompany dementia may increase risk.
EXAMPLE: people with Alzheimer's disease and all other dementia may
forget to wash their hands or take other recommended precautions to
prevent illness. In addition, diseases like COVID-19 and the flu may
worsen cognitive impairment due to dementia.

❑ Tips for Dementia Caregivers at Home
✓ For people living with dementia, increased confusion is
often the first symptom of any illness. If a person living
with dementia shows rapidly increased confusion, contact
your health care provider for advice. Unless the person is
having difficulty breathing or a very high fever, it is
recommended that you call your health care provider instead
of going directly to an emergency room. Your doctor may be
able to treat the person without a visit to the hospital.

✓ People living with dementia may need extra and/or written
reminders and support to remember important hygienic practices
from one day to the next.
✓ Consider placing signs in the bathroom and elsewhere to remind
people with dementia to wash their hands with soap for 20
seconds.
✓ Alcohol-based hand sanitizer with at least 60% alcohol can be a
quick alternative to hand-washing if the person with dementia
cannot get to a sink or wash his/her hands easily.

✓ Ask your pharmacist or doctor about filling prescriptions for
a greater number of days to reduce trips to the pharmacy.
✓ Think ahead and make alternative plans for the person with
dementia should adult day care, respite, etc. be modified or
cancelled in response to COVID-19.
✓ Think ahead and make alternative plans for care
management if the primary caregiver should become sick.

❑ Tips for Supporting Persons with Dementia who Receive Home-Based
Services
✓ Family should Contact the home health care provider and ask them to
explain their protocols to reduce the spread of COVID-19.
✓ Check the home health care professional’s temperature before they enter
your home. Anyone with a temperature over 38° C should be excluded
from providing care.
✓ Family should Ask the health care professional if they have been exposed
to anyone who has tested positive and if so, do not allow them into your
home.

❑ Tips for Supporting Persons with Dementia who Receive Home-
Based Services
✓ Ensure that the health care professional washes their hands upon
arrival and regularly throughout their time in your home.
✓ Family should Ask the health care professional to wear a mask.
✓ Be aware that bringing anyone into your home increases the risk
of spreading COVID-19, even if CDC guidance is followed.

❑ Tips for Supporting Persons with Dementia who live in long-term care
or residential care settings
✓ Check with the facility regarding their procedures for managing COVID-
19 risk. Ensure they have your emergency contact information and the
information of another family member or friend as a backup.
✓ Do not visit your family member if you have any signs or symptoms of
illness.
✓ Depending on the situation in your local area, facilities may limit or not
allow visitors. This is to protect the residents but it can be difficult if you
are unable to see your family member.

❑ Tips for Supporting Persons living with dementia who are in
the hospital
✓ While many hospitals are restricting or limiting visitors to
help curb the spread of COVID-19 and protect patients and
staff, there are still ways to support the person living with
dementia during their hospitalization. CDC guidance allows
care partners of persons with dementia to visit if they are
essential to the person’s physical or emotional well-being.

the hospital
✓ Be sure to familiarize yourself with the safety requirements of
the hospital beforehand.
✓ Bring your own face mask and put it on before arriving at the
facility.
✓ Wash your hands regularly and avoid touching your face.
✓ Limit your visit to the room of the person living with dementia.
(Avoid going to other locations in the hospital.)

the hospital
If you are unable to visit in person:
✓ Communicate with the person through phone or video calls.
✓ Give your contact information to the attending nurse and ask
for it to be written on the white board in the person’s room.
Find out what kind of communication will be possible and
how you can expect to receive updates.

References
1- Hazzard WR, Halter JB. Hazzard's geriatric medicine and gerontology. Univerza v Ljubljani, Medicinska
fakulteta; 2016.
2- Eliopoulos C. Gerontological nursing. Lippincott Williams & Wilkins; 2013 Feb 1.
3- Touhy TA, Jett KF. Ebersole & Hess' Toward Healthy Aging-E-Book: Human Needs and Nursing Response.
Elsevier Health Sciences; 2020 Mar 6.
4- Alzheimer Association website(https://www.alz.org/) Access Date: 12/2/2020
5- World Health Organization website(https://www.who.int/) Access Date: 12/2/2020
6- Center for disease control and prevention website(https://www.cdc.gov/) Access Date: 12/2/2020
7- van der Kant R, Goldstein LS, Ossenkoppele R. Amyloid-β-independent regulators of tau pathology in Alzheimer
disease. Nature Reviews Neuroscience. 2020 Jan;21(1):21-35.
8- Ferini-Strambi L, Galbiati A, Casoni F, Salsone M. Therapy for Insomnia and Circadian Rhythm Disorder in
Alzheimer Disease. Current Treatment Options in Neurology. 2020 Feb 1;22(2):4.
9- Urrestarazu E, Iriarte J. Clinical management of sleep disturbances in Alzheimer’s disease: current and emerging
strategies. Nature and science of sleep. 2016;8:21.
10- Canevelli M, Valletta M, Blasi MT, Remoli G, Sarti G, Nuti F, Sciancalepore F, Ruberti E, Cesari M, Bruno G.
Facing Dementia During the COVID‐19 Outbreak. Journal of the American Geriatrics Society. 2020 Aug 1.

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