Dementia and Alzheimer’s Disease And nursing Care plan

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• Three most cognitive problems in adults

– Delirium (acute confusion)

– Dementia

– Depression

• These problems often occur together

 

Dementia

• A syndrome characterized by

– Dysfunction or loss of memory

– Orientation

– Attention

– Language

– Judgment and reasoning

– Changes in behavior

• Results in alterations in the individual’s ability to work, social and family responsibilities, and activities of daily living (ADL)

• The World Health Organization defines dementia as a syndrome caused by disease of the brain, usually of a chronic or progressive nature, in which there is disturbance of multiple cortical functions, calculation, learning capacity, language, and judgment.

• Occurs most often in older adults

•As the average life span of humans ↑, the number of those affected with dementia ↑

• In the US, half of all patients in long-term care facilities have Alzheimer’s disease (AD) or a related dementia

 

Dementia Etiology and Pathophysiology

• Causes of dementia

– Neurodegenerative disorders (most common)

– Vascular diseases

– Toxic or metabolic diseases

– Immunologic diseases or infections

– Systemic diseases

– Trauma

– Cancer

– Ventricular disorders

– Seizure disorders

– Drugs

 

Dementia Clinical Manifestations

• Onset of symptoms may be insidious and gradual or somewhat more abrupt

• Often dementia associated with neurologic degeneration is gradual and progressive over time

• Clinical manifestations of dementia are classified as mild, moderate, or severe

• Early (mild)

– Forgetfulness beyond what is seen in a normal person

– Short-term memory impairment

– Difficulty recognizing numbers

– Loss of initiative and interests

– Decreased judgment

– Geographic disorientation

• Middle (moderate)

– Impaired ability to recognize close family or friends

– Agitation

– Wandering, getting lost

– Loss of remote memory

– Confusion

– Impaired comprehension

– Forgets how to do simple tasks

– Apraxia

– Receptive and expressive aphasia

– Insomnia

– Delusions

– Illusions, hallucinations

– Behavioral problems

• Late (severe)

– Little memory

– Cannot understand words

– Difficulty eating and swallowing

– Repetitious words or sounds

– Unable to perform self-care activities

– Immobility

– Incontinence

 

Dementia Diagnostic Studies

• Depression is often mistaken for dementia in older adults, and, conversely, dementia for depression

 

Manifestations of depression

– Sadness

– Difficulty thinking and concentrating

– Fatigue

– Apathy

– Feelings of despair

– Inactivity

• When dementia and depression occur together, the intellectual deterioration may be more extreme

• Depression, alone or with dementia, is treatable

• Diagnosis of dementia related to vascular causes is based on

– Presence of cognitive loss

– Presence of vascular brain lesions

– Exclusions of other causes of dementia

• Computed tomography (CT) or magnetic resonance imaging (MRI) can be used in the evaluation of patients with dementia

• Currently, there are no recommended genetic markers or cerebrospinal fluid (CSF) markers

• Vascular dementia can be prevented

• Preventive measures include treatment of risk factors

• Cholinesterase inhibitors that are used for patients with AD are also helpful in patients with vascular dementia

- Ten years ago few Americans had heard of Alzheimer’s disease…

- Yet today this progressive, irreversible brain disease is recognized as one of the most devastating diseases of our time…
and of our future

 

Statistics

• Currently affects as many as 4-5 million people

• As society ages, more and more people will have Alzheimer’s disease (AD)

• By 2030 AD will affect >8 million and by 2050 >14 million

 

Alzheimer’s Disease  AD

• Alzheimer’s disease (AD) is a chronic, progressive, degenerative disease of the brain

• Most common form of dementia

• Accounts for 60-80% of all cases of dementia

• The incidence of AD is approximately the same for all ethnic groups although the risk may be slightly higher in African-Americans and Hispanic-Americans

• Individuals with Down syndrome are at high risk for AD

 

Alzheimer’s Disease Etiology and Pathophysiology

• The exact etiology of AD is unknown

• Age is the most important risk factor

• AD is not a normal part of aging

• When AD develops in someone:

<60 years old, known as early onset AD

>60 years old, known as late onset AD

• Persons in whom a clear pattern of inheritance within a family is established are said to have familial Alzheimer’s disease (FAD)

• Others in whom no familial connection can be made are termed sporadic

• Characteristic findings in AD are the presence of abnormal clumps (neuritic or senile plaques) and tangled bundles of fibers (neurofibrillary tangles) in the brain

• The neuritic plaque is a cluster of degenerating axonal and dendritic nerve terminals that contain amyloid-beta protein

• Neurofibrillary tangles are seen in the cytoplasm of abnormal neurons in those areas of the brain most affected by AD

 

Alzheimer’s Disease Clinical Manifestations

- Alzheimer’s disease gradually strips away one’s mental and physical capacities

- Pathologic changes often precede clinical manifestations of dementia anywhere from 5 to 20 years

- Mild cognitive impairment refers to a state of cognition and functional ability between normal aging and early AD

- Manifestations of AD can be categorized similar to those for dementia as mild, moderate, and late

- The rate of progression from mild to late is highly variable from individual to individual

- Ranges from 3 to 20 years

- Behavioral manifestations of AD result from changes that take place with the brain

- They are neither intentional nor controllable by the individual with AD

- Some patients develop psychotic manifestations

• Cognitive impairments with the progression of AD

– Dysphasia

– Apraxia

– Visual agnosia

– Dysgraphia

 

Alzheimer’s Disease Diagnostic Studies

• Primarily a diagnosis of exclusion

• No single clinical test can be used to diagnose AD

• Emphasis on early and careful evaluation of the patient in patients with cognitive impairment .

•Comprehensive patient evaluation includes

– Complete health history

– Physical examination

– Neurologic assessments

– Mental status assessments

– Laboratory tests

• Brain imaging tests:

– CT

– MRI

– MRS

– SPECT

– PET

 

Alzheimer’s Disease Early Warning Signs

• Memory loss that affects job skills

• Difficulty performing familiar tasks

• Problems with language

• Disorientation to time and place

• Poor or decreased judgment

• Problems with abstract thinking

• Misplacing things

• Changes in mood or behavior

• Changes in personality

• Loss of initiative

 

Alzheimer’s Disease Collaborative Care

• At this time there is no cure for AD

• Collaborative management of AD is aimed at improving or controlling decline in cognition and controlling the undesirable manifestations that the patient may exhibit

 

Alzheimer’s Disease Drug Therapy

• Cholinesterase inhibitors

– Are used in the treatment of mild and moderate dementia

– Have been shown to either improve or stabilize cognitive decline in some people with AD

– Do not reverse the progression of the disease

• Drug therapy is often used for the management of behavioral problems that occur in patients with AD

• Conventional antipsychotic drugs can be used to manage acute episodes of agitation, aggressive behavior, and psychosis

 

Alzheimer’s Disease Nursing Assessment

• Subjective data to obtain

– Important health information

• Past health history

• Medications

– Functional health patterns

• Health perception-health management

• Nutritional-metabolic

• Elimination

• Activity-exercise

•Objective data to obtain

–General

• Disheveled appearance, agitation

– Neurologic

• Early, middle, late

– Possible findings

 

Alzheimer’s Disease Planning

• The overall goals

– Maintain functional ability for as long as possible

– Maintain a safe environment with a minimum of injuries

– Have personal care needs met

– Have dignity maintained

 

Alzheimer’s Disease Health Promotion

• At this time there is no known method of reducing the risk of AD

• Antioxidants may be beneficial

• Genetic testing for AD is not performed on a regular basis

• Early recognition and treatment of AD are important

 

Alzheimer’s Disease Acute Intervention

• The diagnosis of AD is traumatic for both the patient and the family

• The patient may respond with

– Depression

– Denial

– Anxiety and fear

– Isolation

– Feelings of loss

• The nurse is in an important position to assess for depression and suicidal ideation

• Antidepressant drugs and counseling may be appropriate interventions

• The nurse must assess family members and their abilities to accept and cope with the diagnosis

 

Alzheimer’s Disease Nursing Management

• When interacting with the patient

– Use a calm, reassuring, nonthreatening approach

– Smile

– Approach the patient from the front

– Address the patient by name

– Limit decision making

– Have tolerance

• When interacting with the patient

– Frequently reorient the patient

– Acknowledge patient fears

– Respond to tone, not content

– Remove stimuli for hallucinations, fears

– Don’t argue with delusions

– Don’t reinforce delusions

 

Alzheimer’s Disease Ambulatory and Home Care

• Family members and friends care for the majority of individuals who suffer from AD in their homes

• Regular assessment, monitoring, and support are needed

• Patients need to be aware that the progression of the disease is variable

• Effective management of the disease can slow the progression of the disease and ↓ the burden on the patient, caregiver, and family

• Adult day care is available to the person with AD

• During the early and middle stages of AD the person can still benefit from stimulating activities that encourage independence and decision making in protective environment

• Behavioral problems

- Repetitiveness, delusions, illusions, hallucinations, agitation, aggression, altered sleeping patterns, and wandering

• Safety

- Minimize risk in the home environment

• Pain management

- Because of the difficulties with oral and written language associated with AD, patients may have difficulty expressing physical complaints, including pain

- The nurse must rely on other cues, including the patient’s behavior

• Eating and swallowing difficulties

- Feeding apraxia

• Oral care

• Infection prevention

• Elimination problems

 

Impact of Alzheimer’s Disease on the Family

Alzheimer’s disease destroys the active productive lives of the patient and devastates families emotionally, socially, and financially

 

Alzheimer’s Disease Caregiver Support

• AD is a disease that disrupts all aspects of personal and family life

• Persons caring for the person with AD spend significantly more time on caregiving tasks than do people caring for individuals with other illnesses

• Caregivers of patients with AD also exhibit more adverse consequences in terms of impact on their employment, mental and physical health, family conflict, and caregiver strain

• The nurse should work with the caregiver to determine stressors and strategies to reduce the burden of caregiving

• Caregiving stress or burden can have adverse outcomes for their health, especially for those who have chronic health problems

 

Lewy Body Disease

• Characterized by the presence of Lewy bodies (intraneural cytoplasmic inclusions) in the brainstem and cortex

• Disease has features of both AD and Parkinson’s disease

• Patients with this form of dementia exhibit disabling mental impairment progressing to dementia, fluctuation in cognitive function, visual hallucinations, and features of Parkinson’s disease, especially rigidity

• Diagnostic criteria for Lewy body dementia is based on clinical signs and symptoms and confirmed at autopsy by histologic examination of brain tissue

 

Creutzfeldt-Jakob Disease

• Creutzfeldt-Jakob disease (CJD) is a rare and fatal brain disorder thought to be caused by a prion protein

– A prion is a small infectious pathogen containing protein but lacking nucleic acids

• Worldwide, CJD affects one in a million individuals each year

• There are three types of CJD

– Sporadic CJD

– Hereditary CJD

– Acquired CJD

• A variant of CJD was first described in the mid-1980s and is also known as mad cow disease

• Earliest symptoms are

– Memory impairment and behavior changes changes

• The disease progresses rapidly with

– Mental deterioration

– Involuntary movements

– Weakness in the limbs

– Blindness

– Coma

• There is no diagnostic test for CJD

– Only autopsy and examination of brain tissue can confirm the diagnosis

• There is no treatment for CJD

• Emphasis is on reducing the risk of acquiring CJD via food products

 

Pick’s Disease

• Type of frontotemporal dementia

• A rare brain disorder characterized by disturbances in behavior, sleep, personality, and eventually memory

• Relentless in its progression

• Psychiatrists often see these patients first

• There is no specific treatment

• The diagnosis can be confirmed at autopsy

 

Normal Pressure Hydrocephalus

• An uncommon disorder characterized by an obstruction in the flow of CSF

• Symptoms include

– Dementia

– Urinary incontinence

– Difficulty in walking

• Possible causes

– Meningitis

– Encephalitis

– Head injury

• If diagnosed early, treatable by surgery

– A shunt is inserted to divert the fluid away from the brain

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