Alzheimer’s Disease (AD) /Reading & Sharing

Alzheimer’s Disease (AD) is the most common form of dementia, a general term for memory loss and other cognitive abilities serious enough to interfere with daily life. AD accounts for 60% to 80% of dementia cases. According to a 2017 report, AD affects an estimated 6.08 million people in the United States. Although the disease is associated with old age, it could somewhat develop at any age (Bature, Guinn, Pang & Pappas, 2016). Approximately 200,000 people younger than 65 years with AD constitute the younger-onset US population with AD (Brookmeyer, Abdalla, Kawas & Corrada, 2017).

By definition, Alzheimer’s disease (AD) is a progressive neurodegenerative disease clinically characterized by impairment of cognitive and functional abilities as well as behavioral symptoms. It has been reported that individuals with AD experience a long asymptomatic (preclinical) phase in which neuropathological changes occur but cognitive ability is normal, followed by a symptomatic (prodromal or pre-dementia) phase of progressive cognitive decline before the onset of functional impairment and overt dementia. In addition, it has been discovered that cognitive impairment can be detected way before the onset of dementia symptoms (Dubois, Padovani, Scheltens, Rossi, Agnello & Saykin 2016).

Typically, a family member or close family friend is the one to notice the signs and symptoms of Alzheimer’s disease (AD) first. Hallmark symptoms are short-term memory loss and denial of such memory loss, language difficulty, and behavioral changes (Grossman & Porth, 2014). Those within the early stages of  AD tend to forget where things are placed and often get lost easily. They have difficulty remembering how to perform tasks and fail to remember appointments. There may be mild personality changes such as social withdrawal and lack of spontaneity. With progression of the disease, extreme confusion, disorientation and the inability to perform activities of daily living occur (Ferri, 2018). Personal hygiene is neglected and language impairment becomes more prevalent. Patients may become agitated, aggressive, suspicious of others, and have sleep difficulties. Severe Alzheimer’s is the last stage and is characterized by the loss of the ability to respond to the environment and most patients in this stage are bedridden and require total care (Grossman & Porth, 2014).

There is no definitive diagnostic test for Alzheimer’s disease (AD). Diagnosis is made based on clinical history, physical exam, and neurological examination (Ferri, 2018). A diagnosis of AD requires the presence of dementia established by clinical examination and documentation by results of a Mini-Mental State Examination (MMSE) or similar metal status test (Grossman & Porth, 2014). For a diagnosis of Alzheimer’s to be made there should be no disturbance in consciousness and there should be an absence of systemic or brain disorder which would account for the memory or cognitive deficits (Grossman & Porth, 2014). Brain imaging, CT (computed tomography) scan, or MRI (magnetic resonance imaging) is done to exclude other brain diseases. Metabolic screening should be done to rule out vitamin B12 deficiency, thyroid dysfunction, and electrolyte imbalance, which are all known reversible causes of dementia (Grossman & Porth, 2014). Patients should also be screened for depression, vascular disorders, organ failure, infection, and cancer (Ferri, 2018). Medication lists should also be reviewed.

There is no cure for Alzheimer’s disease (AD). Patients are treated according to their symptoms. Cholinesterase inhibitors are used to treat mild to moderate Alzheimer’s (Ferri, 2018). Memantine is used to treat moderated to severe symptoms (Ferri, 2018). Caregivers should be taught that Alzheimer’s patients do not adapt to change very well. There should be little if no change in where they live or the person taking care of them. Living spaces should be simplified, as well as simplifying daily routines. Door locks and hand rails are necessary. Identification bands should be worn at all times in case of wandering behavior. Patients and families should be taught about the risk of driving, and cooking, as with leaving the stove unattended. Encourage physical activity and socialization as tolerated.

In addition to above treatment management, both nonpharmacological and pharmacologic interventions are needed to optimally treat the cognitive, behavioral and psychological symptoms of Alzheimer’s disease (AD). Patients Nonpharmacological methods include increasing physical activity and cognitive engagement demonstrate modest potential at halting disease progression (Epperly & Dunay, 2017). The US Preventative Services Task Force considers it a class B recommendation for all patients that show symptoms of hypertension should receive treatment and adults over age 65 years should consider omega-3 fatty acid supplementation in order to prevent and slow AD (McCance & Huether, 2014). An issue of the American Family Physician explains that cholinesterase inhibitors, including donepezil (Aricept) 5 to 10 mg per day), galantamine (Razadyne) at least 16 mg per day, or rivastigmine (Exelon) 6 to 12 mg per day orally or 9.5 mg per day transdermally should be considered for treatment of cognitive and functional decline in patients with mild to moderate AD (Epperly & Dunay, 2017). For those with moderate to severe AD, the addition of memantine (Namenda) 20 mg per day is recommended (Epperly & Dunay, 2017). The use of cholinesterase inhibitors and memantine are class A recommendations from the US Preventative Services Task Force in preventing AD progression.

Patient & Family Education: Research by Lou et al. (2015), demonstrated that when counseling patients following a diagnosis of AD, it is essential to involve the patient’s family and others who will play a supporting role in the discussion. It is important to emphasize that not only the patient but also those who support the patients will likely experience reactions of sadness and anger and that these are normal reactions to such a diagnosis. As the patient’s symptoms become more pronounced, a dialogue must be opened regarding the patient’s wishes for care when he or she is no longer able to make the necessary choices. Durable power of attorney should be discussed. Medical advance directives should be considered while the patient is still able to participate in the decision-making process. Family members should be careful to select qualified and trustworthy individuals to be involved in the management of the patient. Caregivers need to balance attention to the patient’s physical needs. Any suspicions of elder abuse should be immediately addressed. Patients should continue to engage in activities that they enjoy doing. Maintaining an optimal quality of life is key.

References:

Bature, Guinn, Pang & Pappas (2016). Signs and symptoms preceding the diagnosis of Alzheimer’s disease: a systematic scoping review of literature from 1937 to 2016. British Medical Journal, 7 (8). Retrieved from http://bmjopen.bmj.com

Brookmeyer, R., Abdalla, N., Kawas, C. H., & Corrada, M. M. (2017). Forecasting the prevalence of preclinical and clinical Alzheimer’s disease in the United States. Alzheimer’s & Dementia.

Dubois, B., Padovani, A., Scheltens, P., Rossi, A., Agnello, G. & Saykin, A. (2016). Timely diagnosis for Alzheimer’s disease: A literature review on benefits and challenges. Journal of Alzheimer’s Disease, 49 (3). Retrieved from https://www.ncbi.nlm.nih.gov

Epperly, T., & Dunay, M. (2017). Alzheimer disease: Pharmacologic and nonpharmacologic therapies for cognitive and functional symptoms. American Family Physician, 12(95), 771-778. Retrieved January 9, 2018, from https://www.aafp.org/afp/2017/0615/p771.html.

Ferri, F. (2018). 2018 Ferri’s Clinical Advisor. Philadelphia, PA: Elsevier.

Grossman, S. C., & Porth, C. M. (2014). Porth’s pathophysiology: Concepts of altered health states (9th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.

Lou, Q., Liu, S., Huo, Y. R., Liu, M., Liu, S., & Ji, Y. (2015). Comprehensive analysis of patient and caregiver predictors for caregiver burden, anxiety and depression in Alzheimer’s disease. Journal of Clinical Nursing, 24(17/18), 2668-2678. doi:10.1111/jocn.12870

McCance, K., & Huether, S. (2014). Pathophysiology: The Biologic Basis for Disease in Adults and Children, 7th Edition. St Louis: Mosby.