ALZEIMERS DISEASE

 

DEFINITION

Alzheimer s disease is a chronic progressive degenerative disease of the brain.It is characterized by the permanent destruction of the brain cells

 

INCIDENCE

The incidence rate is same for all the ethnic group although the incidence will be more in African Americans and Hispanic Americans. Women are more likely to develop Alzeimers than that of men.Individuals with Down s syndrome are at high risk for developing Alzeimer s disease.Theymay develop clinical symptoms at the age of 20 or by the age of 40.Age is also a major risk factor for dementia.

ETIOLOGY

• The exact etiology is unknown.
• Age is a factor which influences the development of Alzeimersdisease.When AD develops in someone less than less than 60 years of age it is called it is referred to as early onset AD.When AD develops over 60 years it is called late onset AD.
• When family is influenced it is called familial Alzeimers disease.

PATHOPHYSIOLOGY

Genetic factors plays a major important role in how the brain processes the amyloid beta protein.Overproduction of the amyloid beta protein results in AD.Amyloid beta(A-Beta)is a part of larger protein called amyloid precursor protein(APP).Large amounts of APP are produced in the brain.Abnormally high levels of A Beta causes inflammatory response and ultimately neuron deathThree genes are said to produce AD.
An important part of the neurofibrillary tangle is a protein called as TAU.This provides support to the intracellular structures .If the tau protein is altered the microtubules twist together in a helical fashion.This ultimately forms neurofibrillary tangles which is observed in patients with AD.The presence of neuritic plaques or neurofibrillary tangles results in neuronal death
Autopsy report of the brain tissues of a patient with AD shows the presence of neurofibrilalry tangle formation
Cholinergic neurones are associated in patients with AD or dementia especially in regions essential for memory and cognition.Otherneurotransmittersystemsincludesserotoninn and norepinephrine.

FLOW CHART REPRESENTATION

CLINICAL MANIFESTATIONS

• EARLY WARNING SIGNS OF ALZEIMERS DISEASE
• Memory loss that affects job skills-Frequent forgetfulness or unexplained confusion in the home or in the workplace is a signal.This type of memory loss goes beyond forgetting an assignment,colleagues name or phone number.
• Difficulty in performing familial tasks-People with Alzeimers disease may cook a meal and forget to serve or will forget that the meal is made.
• Problems with language-Most people will find difficulty in finding the right word in time to time,theyamy also forget simple words and uses inappropriate words making their speech difficult to understand.
• Disorientation to time and place-The patient will forget the day or the time or the week
• Poor and decreased judgement-The patient will not dress according to the weather(not bringing a sweater in a cold evening)He may also wear a bathrobe or a sweater on a very hot day
• Problems with abstract thinking-The person willnot be able to recognize numbers or even to do simple calculations
• Misplacing things-Misplacing of keys,purses or wallets.The person with Alzeimers disease will place things in inappropriate placesEg:cooking utensils in the clothing drawers. But having no memory how they are inside that drawers
• Changes in mood or behaviour-Rapid mood swings with no apparent reason
• Changes in personality-The personality will change fOReg someone who is very easy going will become very angry
• Loss of initiative-The person becomes uninterested or uninvolved in activities
• The manifestations of dementia can be classified smild,moderate and severe.
• Some patients will develop psychotic manifestations(delusion,illusion,hallucination)
• Cognitive impairments like dysphasia(difficulty in oral communication)apraxia(inability to manipulate objects or perform purposeful acts),Visual agnosia(inability to recognize objects by sight),Dysgraphia(difficulty in communication by writing)
• The patient willnot be able to recall long term memory and loses the ability to recognize family members and friends
• Aggression and tendency to wander.

DIAGNOSTIC EVALUATIONS

• History collection and physical examination
• Neuropsychological testing including mini mental status examination
• Thyroid function tests
• Liver function test
• Screening for depression

MANAGEMENT

COLLABORATIVE THERAPY

• Drug therapy for cognitive problems
• Drug therapy for behavioural problems
• Behavioural modifications
• Moderate exercise
• Assistance for functional independence
• Music particularly for meals and bathing
• Assistance with support of the caregiver

PHARMACOLOGICAL THERAPY
DECREASED MEMORY AND COGNITION
Cholinesterase inhibitors

• Donepezil(Aricept)
• Rivastigmine(Exelon)
• Galantamine(Remenyl)

Depression
Selective serotonin reuptake inhibitors

• Sertraline
• Fluvoxamine
• Citalopram
• Tricyclic antidepressants
• Nortryptiline(Aventyl,Pamelor)
• Amytryptiline(Elavil)
• Imipramine(Tofranil)

Atypical antidepressants

• Trazadone
• Behavioural problems

Conventional antipsychotics

• Loxapine(Loxitane)
• Haloperidol(Haldol)

Atypical antipsychotics(Neuroleptics)

• Resperidone
• BOlanzapine
• Benzodiazepines
• Lorezepam
• Temezepam

Sleep disturbances

• Zolpidem

NURSING MANAGEMENT

NURSING ASSESSMENT
Subjective and objective data should be obtained from the patient.The usual questions asked are When did you first recognize the memory loss?How the memory loss progressed etc....

PLANNING
The overallplanning includes maintaining functional ability as long as possible.Maintaining safe environment with minimum injuries,have personal needs methave dignity maintained decrease the caregivers stress and cop up with the long term caregiving

NURSING DIAGNOSIS

INTERVENTIONS

• Include family members in planning and providing care and plan appropriate interventions
• Determine physical,social and psychological history of the patiet,habits and routines to maintain a familiar routines
• Prepare for interaction by eye to eye contact by touch and provide respect to the patient
• Give one single and simple direction at atime to reduce the confusion
• Use distractions
• Provide the patient ageneral information about the weather and use appropriate cues sucha s calenders,pictures and seasonal decorations to relieve anxiety.
• Refrain from arguing with the patient

Self caredeficit(bathing ,dressing,toileting)related to memory deficit and impairment s manifested by inability to bathe dress himself
Interventions
Self care assistance-

• Monitor the patients ability to perform self care activities
• Use continuous repetition of the daily routinesbecause memory loss impairs patients ability to plan sequential activities.
• Assist patient in ADL
• Teach the family members regarding the care of the patient

Self care assistance bathing and hygiene

• Provide desired personal articles such as bath soap and hair brush ,to enhance memory and provide care
• Facilitate patients bathing to facilitate independant hygiene

Self care assistance Dressing Grooming

• Provide patients clothing in appropriate area
• Provide assistance in dressing

Self care assistance-Toiletting

• Assist patient in toileting for maintaining regularity
• Facilitate toilet hygiene after completion of elimination to prevent skin breakdown

Risk for injury related to impaired judgement,possible gait instability,muscle weakness and sensory perceptual alteration

• Identify physical or cognitive deficits of the patient and decrese the chance of falling
• Provide assistive devices like walker,a steady gait and provide ambulation support
• Ensure that the patient is wearing the shoes appropriately,fasten securely and have a non-skid soles to provide support during ambulation
• Insist the patient to wear prescribed glassed to enhance vision

Ineffective coping related to depression in response to the diagnosis of Alzeimers disease as manifested by depression,fatigue and social isolation

• Encourage social and community activities to relieve depressioin
• Encourage the user of spiritual resourses to provide calming
• Encourage the family to verbalize feeling about the patient nd increase communication and mutual understanding among the family members
• Determine the risk of violent and self harm behaviour

Ineffective therapeutic regimen related to decreasing level of cognitive function and memory

• Assist the patient to identify possible upcoming situations
• Provide information about the patients behaviour, life expectations, and prepare the patient for the future needs of daily living
• Include the family members in planning and implementation of the interventions

Wandering related to disease as evidenced by getting lost numerous times a day and patient statement of “I dont know where i m “

• Monitor environment for potential safety hazards to prevent injury to the patient
• Monitor patient for alterations in the physical and cognitive function that may lead to unsafe behaviour to assess for changes that may occur.
• Provide appropriate level of supervision
• Provide appropriate activities as diversion from restlessness associated with wandering

Care giver role strain related to family members illness as manifested by statements about stress

• Assess the health status of the caregivers to determine if health planning is needed
• Refer for medical evaluation if appropriate
• Discuss effects of caregiving with the caregiver to determine staus of the caregiver and to enable open discussion of the needs
• Encorage the support of other family members
• Provide financial and social service referrals to provide support to the caregiver
• Acknowledge caregivers fear of being unable to take care of the family members.
• Counsel and support caregivers

Anxiety related to uncertain outcome,perceivedpowerlessness,possible changes in role function as manifested by helplessness,fear,irritability,forgetfulness and inability to concentrate

• Assess the physical and emotional health staus of the caregiver and provide appropriate interventions
• Collaborate with the caregiver to plan for interventions
• Assist for planning of continued care of the patient

COMMON NURSING INTERVENTIONS
FOR BEHAVIOURAL PROBLEMS

• Caregivers should be aware of the behavioural problems.they should be informed that behavioural problems are not manifested from the vaccum.It can be due to Pain frustrations,temperatureextremes,frustruations etc..
• Identify the factors that may trigger the behaviour eg extremes of temperature
• Distract the patientEg:Providesnacks,car drives favourite music or videotapes.
• Reassuring the patient involves letting the patient know that he/she will be protected from danger.
• The side effects of the drug should be taken into consideration.

SAFETY

• The dangers includes injuries from falls,injury from ingestion of poisonous substances,wandering,injury to others and self due to sharp objects,fire or burns
• Side rails should be there to prevent injury
• Extension cords should be removed because the client may strip over them
• In bathroom nonskid mats should be used
• Wandering should be considered.It may be due to loss of memory,side effects of the drug and physical and emotional problems.The family members should be aware of the wandering nature of the patient and should protect him

PAIN MANAGEMENT

• Patients will have difficulty in expressing the pain because of the impairment in verbal communication.
• Pain should be treated with drug therapies and the patients behaviour should be monitored.

EATING AND SWALLOWING DIFFICULTIES

• Loss of interest in the food and decreased ability to feed himself results in imbalanced nutrition
• Pureed foods,thickenedliquids and nutritional suppliments are used when the patients swallowing is affected
• Patient should be reminded to chew the food before swallowing
• Distractions in the mealtime includes television which should be avoided
• Low lighting,and music will improve the eating behaviour
• Encourage self feeding and liquids should be encouraged.
• When oral feeding is not possible nasogastric feeding is initiated
• Percutaneous endoscopic gastrostomy can be performed(PEG)

ORAL CARE

• Patient will pocket food in the mouth resulting in tooth decay
• The mouth must be regularly washed and flossed and oral care should be given

INFECTION PREVENTION

• Urinary tract infection and pneumonia are the potential complications.
• Reduced fluid intake,prostate hyperplasia and urinary drainage devices causes bladder infection.Manifestations includes behaviour,fever,cough,and pain on urination are evaluated and appropriately treated and evaluated.

SKIN CARE

• Skin should be monitored closely.
• Rashes,areas of redness,and skin breakdown should be monitored
• Patients with immobility should be monitored carefully
• The skin should be monitored closely and the position should be changed and the bony prominences should be monitored

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