Thursday, January 8, 2015

Alzheimer's Disease

Do you know someone who is experiencing the following?

¡   Short-term memory
¡ Disorientation
¡ Mood and behavior changes
¡ Deepening confusion about events, time, place, and person
¡ Often has distrustful impression with no apparent reason

        Listed above are just some of the symptoms of Alzheimer's Disease as defined by the Alzheimer's Association. Symptoms vary for every person and may be different depending on the progression of the disease. Alzheimer's disease is commonly thought of as a condition of the elderly. Although these factors tremendously affect the onset and progression of the disease, it is not a normal part of aging. Alzheimer's disease may also develop in younger individuals usually from ages 40 to 50+, referred to as early onset Alzheimer's.

What is Alzheimer's Disease? 
        It is a type of dementia in which brain cells are progressively damaged by the formation of misfolded proteins and neurofibrillary tangles. The plaques formed block communication between cells and the distribution of nutrients to the different parts of the brain causing further damage and atrophy (degeneration of nerve cells).

                               Healthy Brain (left) and Alzheimer's Brain (right)

Looking Closely: 
            The brain is made up of neurons that are interconnected by synapses through which electrical signal (information) is passed on from one neuron to another. This mechanism creates a vast network that enables us to process information and to perform both voluntary and autonomic body processes.
            In the brain of a person with Alzheimer's disease, the interconnections between neurons are disrupted by senile plaques and neurofibrillary tangles resulting to the death of neurons. Lesions usually begin to form at the hippocampus, a part of the brain that is greatly associated with forming new memories.

How are the lesions (senile plaques and neurofibrillary tangles) formed? 
1. Senile Plaques 
              The protein found on the surface of the brain called APP protein is cleaved off by an enzyme releasing another protein called Amyloid-beta. This protein called amyloid-beta is usually regulated and disintegrated. Meanwhile, senile plaques which cause Alzheimer's Disease results from the dysregulation and clumping of amyloid-beta proteins in the brain. The plaques formed disrupts communication between neurons and is primarily suspected to stimulate an inflammatory response that causes the death of brain cells.
2. Neurofibrillary tangles
               The neurons of the brain consists of microtubules that act as a passageway for nutrients and other transports. These tubes are essential for the neuron's survival. Tau proteins  are attached to the microtubules to stabilize and prevent from collapsing. In individuals with Alzheimer's disease, tau proteins disintegrate from the microtubules resulting to the dissociation of the neuron's structure. The formation of defective tau proteins results to neurofibrillary tangles in the neuron. The disrupted microtubule and formation of neurofibrillary tangles results to degeneration of neurons, and eventually cell death.

Understanding the mechanism behind Alzheimer's disease:


Progression of Alzheimer's Disease: 
          As plaques and tangles start to form in the hippocampus, it can spread throughout the other parts of the brain resulting to symptoms that are gradually observed in patients with Alzheimer's. The progression rate of the disease varies for every individual. Affected individuals live an average of 8 years and may extend to more than a decade. Progression of Alzheimer's Disease are categorized into stages. 
1. Early Stage
          It is important to note that damage to the brain usually occur over a period of time before symptoms show. During the early stage, minor changes in the behavioral and cognitive functioning are observed. These symptoms are often attributed to stress and normal aging resulting to late diagnosis of possible onset of Alzheimer's disease. 
Difficulties/Symptoms: Short-term memory
                                    Misplacing valuables
                                    Trouble with planning and performing tasks
                                    Difficulty in searching for words or names to say

 2. Mild to Moderate Alzheimer's 
          Plaques and tangles spread to other regions of the brain progressively affecting not only memory, thinking, and planning, but also speech expression and comprehension. 
Difficulties/Symptoms: More frequent forgetfulness of recent events
                                    Difficulty solving arithmetic problems
                                    Difficulty recognizing people around them
                                    Moody and withdrawn

 3. Moderate to Severe Alzheimer's 
          In the later stages, damage extends throughout the cortex causing atrophy/shrinking due to cell death. Symptoms may vary for each individual. The most severe stage includes inability to communicate, to perform basic daily activities, and to recognize family members. Some individuals may lose the ability to do body actions that are simply part of normal people's everyday lives. These individuals become very dependent as they become at risk for more problems such as aspiration (choking), pressure ulcers (skin breakdown), etc. 
Difficulties/Symptoms: Inability to swallow
                                    Incontinence
                                    Gradual decline of comprehension
          All individuals in any of these stages have an increased potential risk for secondary problems mentioned above (i.e. falls, skin breakdown, etc.). It is important to involve family members and to have a long-term plan of care for these patients. 

Please click on the link to learn more about the Stages of Alzheimer's Disease. 
         
          Signs and Symptoms of Alzheimer's disease in different stages are described above. The Alzheimer's Association identified 10 warning signs that can be useful in learning more about early symptoms. The list should not be used as a substitute for professional diagnosis. 
Please click on the link to learn more about the 10 Warning Signs of Alzheimer's Disease. 

Diagnosis: 
          An absolute diagnosis of Alzheimer's disease could only be done by performing autopsy after death. Nevertheless, other methods or tools may be used by professionals to examine a person's cognitive and behavioral functioning related to Alzheimer's disease or other problems. 
         
Treatment/Intervention: 
          There is known specific treatment for Alzheimer's Disease. Drugs and non-medical interventions are used to relieve or decrease symptoms associated with cognitive decline. 

The most common classes of drugs used to decrease symptoms include the following: 
1. Cholinesterase Inhibitors  

Therapeutic Use: 
- Primarily used for mild to moderate Alzheimer's
- Used to prevent or delay the onset of symptoms in patients with mild to moderate stage of Alzheimer's.

Mechanism of Action:
          According to research, the brain of people with Alzheimer's disease show loss of cell in the brain that uses a neurotransmitter called acetylcholine (Ach) that plays an important role in thinking and memory. The death of these nerve cells may be caused by the lack of Ach that acts as a chemical signal promoting communication from one nerve cell to another. The lack of Ach can be prevented by inhibiting cholinesterase, an enzyme that breaks down Ach. As a result of using cholinesterase inhibitors, the breakdown of Ach is lessened and Ach levels increase in the synaptic gap between neurons enhancing cell communication. 

Side Effects: Increased Parasympathetic activities which includes excessive sweating, changes in vision and balance, difficulty breathing, decreased heart rate, increased frequency of urine elimination, diarrhea 

How to Handle Side Effects: 
- Consult the medical provider on how to handle side effects of the drug. 
- Patient and family must be informed how to reach help when symptoms exacerbates.
- Patient's environment must be clear of hazards and supportive
- Patient must have access to the toilet or be frequently asked and assisted during the activity. 
- Patient may be at risk for skin breakdown and must be re-positioned if dependent. 

2. N-Methyl D-aspartate (NMDA) Receptor Antagonists 

Therapeutic Use: 
- Primarily used for moderate to severe Alzheimer's 
- Used to slow the progression of certain symptoms in later stages. The drug does not in any way prevent the progression of the disease but only relieves some symptoms and improve performance of activities. 

Mechanism of Action: 
          NMDA Receptor Antagonists bind to NMDA receptors on nerve cells to inhibit its activation by glutamate, an excitatory neurotransmitter. Glutamate is a neurotranmitter that plays a vital role in cognitive processes of the brain. When levels of glutamate are too low or too high, it may cause damage to neurons and may eventually lead to cell death. Excessive levels of glutamate causes too much excitation of nerve cells leading to cell death. 

Side Effects: dizziness, fatigue, headache, sedation, hypertension, diarrhea, weight gain, urinary frequency

How to Handle Side Effects: 
- Consult the medical provider on how to handle side effects of the drug. 
- Patient and family must be informed how to reach help when symptoms exacerbates.
- Patient's environment must be clear of hazards and supportive
- Patient must have access to the toilet or be frequently asked and assisted during the activity. 
- Patient may be at risk for skin breakdown and must be re-positioned if dependent. 
- Patient may feel dizzy or sleepy and should avoid engaging in activities that require high concentration or strength after taking the medication. 

Other Non-Medical Intervention: 
- Proper Nutrition
- Appropriate physical activities as tolerated
- Maintenance of a safe and supportive environment 

Please consult a medical provider to learn more about the drugs and how it should be used. 
For more information please visit: Alzheimer's Disease Medication Fact Sheet

 Nursing Care Interventions: 
          It is important that you assess your patient or family member often (e.g. skin color, temperature, skin breakdown). Learn strategies on how to recognize and assess pain in individuals with Alzheimer's disease. These individuals may still stand up even after breaking a hip. Pain and discomfort are not clearly expressed and may not be expressed verbally. Remember that these individuals have declining sensation, cognition, and communication skills. So as a caregiver, it is your responsibility to keep a close watch at your patient. Visit nih.gov: A special kind of care for patients with Alzheimer's Disease to learn more about what you should expect as a caregiver, possible causes of certain behaviors and how to manage it. 

 The following guidelines were excerpted from NIH.gov. 
Room and Environment Assessment:
  • Avoid numerous room changes. Change increases confusion and anxiety.
  • Avoid placing the patient in a room located in a high noise, high traffic area.
  • Keep the television off until the patient turns it on or requests it.
  • Remove artwork containing people or animals if the patient interprets them as real-life intruders.
  • Keep lighting as free of shadows and glare as possible.
  • Avoid clutter. It can increase confusion, agitation and the risk of falls.
  • If the patient can understand written words, then large, bold lettered signs can serve as cues to the bathroom, closet and personal items.
Safety:
  • Provide a safe, structured, well-ventilated environment.
  • Have consistent family/caregiver to attend the patient.
  • Place the patient in a room that allows easy and careful observation.
  • Place bed in low position.
  • Don't leave anything at the bedside that might harm the patient.
  • Patient may have the tendency to leave the house/place of residence. Make sure patient is in an easily observed place where caregivers may be able to see the patient’s activities.
Eating:
  • Do not ask the patient to fill out a menu. Ask the family about food preferences.
  • Simplify the food tray. Keep small, colored dishes on the unit to allow for smaller portions and the ability to offer one or two food items at a time. 
  • Smaller, more frequent meals may work better for the patient than the standard three large meals.
  • Cueing the patient to eat by using verbal reminders along with a light touch to the forearm increases food intake.
  • Finger foods, cups with lids and broad-handled utensils may make mealtime easier for the patient.
  • Late stage patients may chew, but need frequent reminders to swallow.
  • Plate guards and bibs with pockets catch spills and protect the patient's clothing.
  • Offer the patient fluids frequently throughout the day. 
Bathing:
  • Bathe the patient at his "best" time of day.
  • If possible, bathe the patient at the time he normally bathes at home.
  • Avoid using the shower. A hand-held showerhead provides better control of the water.
  • Allow the patient to do as much as possible. Break down the task into simple steps using verbal and visual cues.
  • When assisting the patient, give the bath slowly. To avoid agitation, tell the patient what you are going to do one step at a time.
  • Use soft music, talking or snacks as pleasant distractions.
  • Keep the patient warm! During a bed bath, cover body parts except the parts that are being washed.
  • Sounds amplify off tile walls. Running water can sound frightening.
  • Be flexible. A "bird bath" may be more acceptable to the patient.
Toileting:
  • Clear a path to the toilet or commode.
  • Place bed in view of toilet.
  • To help cue the patient, place a picture of a toilet or a written sign on bathroom door.
  • Place your patient on a two-hour toileting schedule.
  • Use a nightlight to make it easier for the patient to find the toilet in the middle of the night.
  • Observe your patient for constipation. Ask questions about abdominal discomfort. Watch for non-verbal signs of discomfort such as grimacing or clutching. Do not ask the patient if he has had a bowel movement.



 Visit Teepa Snow's video about how to effectively assess pain in patients with Alzheimer's: 


Nursing Diagnoses Related to Alzheimer's Disease: 
1. Disturbed Sleep Pattern
2. Impaired Physical Mobility
3. Self-care Deficit
4. Imbalanced Nutrition
5. Altered Thought Processes 
Source: http://nanda-diagnosis.blogspot.com/2012/11/12-nursing-diagnosis-for-alzheimers.html

 Nursing Diagnosis: Altered Thought Processes
Actual/Potential:
Actual; degree of symptom depends on stage and severity of Alzheimer’s Disease
Related to:
Irreversible neuronal damage
Plan:
-          Maintain a calm and secure place for the individual.
-          Refrain from travelling for long distances. The goal is to maintain a familiar and stable environment for the individual.
-          Activities must be done in a schedule to promote pattern in daily living.
Nursing Interventions:
-          Emphasize the importance of the role of family members and well-recognized people so as to foster trust, and lessen suspicious thoughts and feeling of insecurity.
-          Coordinate and communicate with family members/caregiver and patient about effective schedule and pattern of activities daily (e.g. daily schedule of meals, bath/shower, leisure activities).
-          During the early stages, emphasize the importance of engaging in brain stimulating activities and provide resources and options. During the late stages, encourage the involvement of family members in providing basic care and “quality time” towards the patient.   
-    Lastly, explain to caregiver her role and resources to care for one's self as well. Efficient care is only given when the person -in-charge is calm, well-rested and nourished. 

Epidemiology: 
          The number of Americans who have Alzheimer's disease is expected to grow throughout the years as the population age 65 and older increase. According to the Alzheimer's Organization, the number will grow more rapidly as the baby boom generation ages. It was estimated that 5.2 million Americans have Alzheimer's Disease in 2014. The organization further elaborated that 5 million were estimated to be 65 and older while 200,000 individuals have early onset Alzheimer's. 

Source: http://www.alz.org/downloads/Facts_Figures_2014.pdf
          The pie chart above shows that after the age of 65, the number of individuals with Alzheimer's Disease increases. These results are based on the statistics reported by the Alzheimer's Organization:

  • 1 in 9 people age 65 and older are estimated to have Alzheimer's Disease as reported by by the organization based on a study using the latest data from the 2010 U.S. Census and the Chicago Health and Aging Project. 
  • More women have Alzheimer's disease and/or other forms of Dementia compared to men. Among the 5 million people (age 65 and above) reported to have Alzheimer's disease in the US, 3.2 M are women and 1.8 M are men. These reported results were explained to be influenced by the longer life-expectancy among women on average and that risks of Alzheimer's disease is primarily increasing as one ages. 

Source: http://www.alz.org/downloads/Facts_Figures_2014.pdf
         (Note from Alzheimer's Association: "The Hispanic group for this
study was primarily Caribbean-American, while most
Hispanics in the United States are Mexican-American.
The prevalence in Caribbean-Americans may be more
similar to that in African-Americans, contributing to the
higher observed prevalence for Hispanics in this study
than estimated by the expert panel.")
          The important point made by the Alzheimer's Association is that genetic factors do not seem to be the most apparent reason for the large differences between the groups. Health conditions (such as Diabetes and high blood pressure) that may increase the risks for developing Alzheimer's disease and other forms of dementia are thought of to have greater influence on the differences. These conditions such as Diabetes and high blood pressure are more prevalent among African American and Hispanic groups.

 Bibliography: 
About Alzheimer's Disease: Diagnosis. (n.d.). Retrieved January 29, 2015, from 
http://www.nia.nih.gov/alzheimers/topics/diagnosis#options

 Acute Hospitalization and Alzheimer's Disease: A Special Kind of Care. (n.d.). Retrieved February 20, 2015, from http://www.nia.nih.gov/alzheimers/publication/acute-hospitalization-and-alzheimers-disease

Alzheimer's Disease & Dementia | Alzheimer's Association. (n.d.). Retrieved January 15, 2015, from http://www.alz.org/alzheimers_disease_what_is_alzheimers.asp

Alzheimer's & Dementia Risk Factors | Alzheimer's Association. (n.d.). Retrieved January 15, 2015, from http://www.alz.org/alzheimers_disease_causes_risk_factors.asp

 Alzheimer's Disease. (2014, July 25). Retrieved January 17, 2015, from http://www.cdc.gov/aging/aginginfo/alzheimers.htm#Who

 Alzheimer's Disease Medications Fact Sheet. (2014, January 1). Retrieved February 12, 2015, from http://www.nia.nih.gov/alzheimers/publication/alzheimers-disease-medications-fact-sheet

 Drug treatments for Alzheimer's disease. (2014, March 1). Retrieved February 12, 2015, from http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=147

Jun, I. (Educator). (2014, April 3). What is Alzheimer's disease? - Ivan Seah Yu Jun. Video retrieved from 
https://www.youtube.com/watch?v=yJXTXN4xrI8

 Swerdlow, R. (2007, September 1). Pathogenesis of Alzheimer’s disease. Retrieved January 15, 2015, from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2685260/

 The progression of Alzheimer's disease and other dementias. (n.d.). Retrieved January 29, 2015, from http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=133



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