alzheimer s disease and related dementias-2014
TRANSCRIPT
ALZHEIMER’S DISEASE AND RELATED DEMENTIAS
LEHMAN COLLEGE
NUR 409
Definition of Dementia
Refers to the loss of memory, reasoning, judgment, and language that it interferes with everyday life.
Changes may occur gradually or quickly
Cognition Cognition is the act or process of thinking,
perceiving, and learning. Cognitive activities that become impaired in
dementia include: Decision-making Judgment Memory Spatial orientation Thinking, Reasoning Verbal communication
A client with dementia may undergo behavioral and personality changes as well, depending on the area(s) of the brain affected.
Alzheimer’s Disease (AD) Most common form of dementia among
persons aged 65 and older Intellectual deterioration severe enough to
interfere with occupational or social performance.
Decline in two or more areas of cognition: Memory, language, calculation, visuospatial
perception, judgment, abstraction, or personality AD constitutes about 50% or all dementias
Multi-infarct disease is the second most common cause of irreversible dementia
Types of infarct disease Blood clots blocking small blood vessles in the
brain and destroy brain tissue Lewy body dementia is similar to Alzheimer’s
disease but may progress more rapidly Lewy bodies are abnormal brain cells Pick’s disease another form of dementia
Brain is quickly injured from hypoxia, reduced blood flow or drugs: Alzheimer’s disease Multi-infarct dementia Alcoholic dementia Huntington’s chorea AIDs related dementia Toxic or traumatic brain injury Malignant disease
Alzheimer’s Disease Etiology and risk factors
Cause of Alzheimer’s disease unknown Increasing age is a risk factor Genetic factors involvement of five
chromosomes Clinical situations associated with AD include:
Elevated homocystein Inflammation Stroke Oxidative damage from free radicals
Pathophysiology Alzheimer’s disease disrupts:
Communication, metabolism, repair of neurons Presence of beta-amyloid plaques, which are
proteins that are dense and insoluble deposits around the brain.
Neurofibrillary tangles which is an irreversible change in the tracts of healthy neurons, which then begin to degenerate leading to memory failure, personality changes, and problems with activities of daily living.
Acetylcholine is also decreased in clients with AD
Gross changes in the brain of persons with AD include: Enlarged ventricles, hippocampal shrinkage,
generalized atrophy, shrunken gyri A decline in cholinergic neurons in the basal
nucleus leads to loss of choline acetyltransferase in the neocortex and hippocampus
Also involves neurotransmitter changes. The decline in cholinergic neurons in the basal nucleus leads to loss of choline acetyltransferase in the neocortex and hippocampus.
Clinical Manifestations Impairment of decision-making beginning
insidiously and progressing. Preclinical Alzheimer’s Disease
Hippocampus—responsible for short and long-term memory
Mild Alzheimer’s Disease Memory disturbance Poor judgment and problem-solving skills Careless in work habits and household chores May become confused and get lost May become irritable, suspicious, agitated or
apathetic
Moderate Alzheimer’s Disease May demonstrate language disturbance,
characterized by impaired word-finding Motor disturbance apraxia—difficulty in using
everyday objects: toothbrush, comb, razor Hyperorality: put things in the mouth Worsening irritability and depression, psychosis,
incontinence may occur Severe Alzheimer’s Disease
Inability to recognize familiar faces Voluntary movement is minimal
Clinical Manifestations
AD characterized by relentless impairment of decision-making that generally begins insidiously and usually progresses slowly
Onset of AD typically occurs in late middle age, 65 years or older; some familial cases can occur in ages 40’s—50’s
Classification of Alzheimer’s Disease Preclinical Alzheimer’s Disease
Begins near the Hippocampus Affected regions begin to shrink leading to
memory loss Mild Alzheimer’s Disease
Memory disturbance, confused and disoriented at times. Clients begin to get lost. Routine activities take longer
Person may become irritable, suspicious, indifferent, moody, agitated, apathetic
Moderate Alzheimer’s Disease Client may demonstrate language disturbance,
impaired word finding Apraxia—difficulty in motor activities—doing
everyday activities. Resulting in safety issues. Hyperorality, depression and irritability may worsen. Wandering at night is common.
Severe Alzheimer’s Disease Plaques and tangles are widespread. Patients do
not recognize family or friends. Do not communicate in any way. Voluntary movement is minimal; limbs become rigid with flexor posturing. Urinary and fecal incontinence is frequent. Aspiration and aspiration pneumonia are frequent
Diagnostic Findings Diagnosis made by exclusion (although there
are many types of tests under study) r/o known causes: toxic or metabolic
abnormalities, drug side effects, cerebrovascular disease, neoplasm, infection.
CT scan useful to identify ventricular dilation and sulcal enlargement and cerebral atrophy
MRI, PET scans also helpful Laboratory data to support or dispute other
treatable causes: CBC, ESR, BUN, Creatinine, thyroid and liver function studies, calcium, B12, syphillis, HIV
Other Dementias
Multi-infarct dementia (MID) Blockage of small cerebral vessles (lacunar) Confusion, memory loss, emotional lability. Occurs more commonly in men than women Onset ages 60--75
Lewy body dementia Clinical manifestations range from traditional
parkinsonianism effects to loss of spontaneous movement (bradykinesia), rigidity, confusion or fluctuating cognition.
Visual hallucinations may be one of the first manifestations noted.
Other psychiatric symptoms may occur: delusions and depression
Outcome Management
Diagnosis best made by a multidisciplinary group that can assist the client and family
Goals: Helping maintain mental function Slow the process of deterioration
Outcome Management:
Multidisciplinary team to assist client and family
No cure Helping to maintain function and slowing the
process of deterioration
Medical Management Pharmacotherapy
Medications that retain acetylcholine in the neurojunctions such as Tacrine (Cognex), Donepezil (Aricept), Galathamine (Reminyl)
Drugs can have small but noticeable effects, depending on the stage of the disease, differences in the way the drugs act in different clients
None of the medications prevent the progression of the disease
Exelon Patch
Start with 4.6 mg for four weeks, then increase to 9.5 mg/24 hours. For moderate to severe Alzheimers may increase to 13.3 mg.
May need to lower dosage for patient’s with Hepatic disease, or for clients with weight less than 100 pounds.
Change site of patch daily
Side Effects
Gastrointestinal—Nausea, vomiting, diarrhea, anorexia, weight loss Skin Reactions—may cause mild irritation to dermatitis. Change patch site daily, clean
with cool water Neurological—May cause tremor or worsen tremor in Parkinson’s clients
.
Combat oxygen-free radicals Use of vitamin E and selegiline have been
studied. Do support in assisting to delay the later stages of Alzheimer’s and show some improvements in levels of independence
Ginko biloba May improve cognitive function fro 6—12
months; some research does not support this claim
Other medications Anti-anxiety, antipsychotics, antidepressants Should minimize use of these medications
Nursing Management
Complete history including use of secondary resources
Mini Mental State Examination Usual behaviors Impact on family
Nursing Diagnosis: Impaired Verbal Communication Outcome
Client’s needs will be communicated (early stages); later stages focus on interpretation of client’s expressions
Interventions Early: speak slowly and simply. Use the patient’s
language. Use calming tone of voice. As disease progresses use of other techniques
Nonverbal behavior also important—frustration, anger, hostility
Decrease environmental stimuli Approach the patient calmly Limit demands on patinet Use distraction Elicit listening behavior—hold hand, maintain
physical contact Pain assessment and management
Disturbed Thought Process
Outcome Client will have appropriate thought processing
Retention of information Interventions
Reorient client Allow client’s to reminisce Use of repetition
Risk for Injury
Outcome Client’s physical and environmental safety will be
maintained as evidenced by the absence of physical injury and the existence of a safe living environment
Interventions Safety in the home: electrical wiring, toxic
substances, loose rugs, hot tap water, inadequate lighting, dangerous objects
Self-Care Deficit
Outcomes Client will maintain self-care ability as evidenced
by completing the tasks they are capable of performing and receiving assistive with ADL they are incapable of performing
Interventions Encourage the client with AD to do as much as
possible, as long as it is safe and appropriate Give client plenty of time to complete tasks Remind client that step-by-step process is
required
Urge Urinary Incontinence
Outcomes Client will have optimal continence bladder and
bowel as evidenced by the client having clean clothing and bedding as much as possible having intact
Interventions Toileting schedule Bright signage for the bathroom Limit fluid intake after dinner
Caregiver Role Strain Outcomes
Family will demonstrate decreased role strain as evidenced by voicing their emotional concerns, seeking appropriate assistance, and providing adequate care for the client.
Interventions Allow family members to grieve the loss of the
person that they knew Provide formal supports as indicated Refer to support groups Respite care, Adult day care Nursing home care
Advanced Directives
Living wills Advanced directives Durable power of attorney