The case of Mr. R.

Alzheimers Disease

Mr. R.
89 y.o. male, NESB PMHx
T2DM (neuropathy + L) retinopathy), Alzheimers (7-8yrs, MMSE 24 in 2005), IHD, PVD, HT, CVA, B12 def, chol

SHx:
Lives with wife in SSH
x FA: x 3 steps (L ascending rail) + 1 threshold step (nil rail) x BA: x 3 steps (L ascending rail)

3 children very supportive, daughter is neighbour

Mr. R.
PMM:
nil aid, furniture walked, mainly housebound, s/v outdoors, nil falls reported

HOPC
adm 13/5/11 to St Vs
x 2/7 foot pain + 1/7 R) 2nd toe swelling, pain, redness cellulitis

R) 2nd toe amputated + R) angioplasty 18/5/11 T/F GEM 26/5/11

x Increase endurance, improve mob & function x D/C planning + supports

Alzheimers Disease
Most common form of dementia (50-70%) Two different types
Sporadic Alzheimers disease
x Any age usually >65 years x Most common form x ApoE14

Familial Alzheimers
x Usually in 40s or 50s x Very rare x 50% inheritance if a parent has a mutated gene

http://www.nia.nih.gov/Alzheimers/Resources/HighRes.htm

http://www.nia.nih.gov/Alzheimers/Resources/HighRes.htm

Alzheimers Disease

http://www.nia.nih.gov/Alzheimers/Resources/HighRes.htm

Aetiology
Unknown! ? environment, biochemical disturbances, immune processes Clinical diagnosis through process of elimination
(Alzheimers Australia, 2005)

Detailed medical Hx, thorough physical & neuro exam, test of intellectual function, psychiatric Ax, blood & urine tests Clinical diagnosis 80-90% accuracy

Symptoms

(National Institute on Aging, 2011)

Lapses in memory Difficulty word finding for everyday objects Persistent & frequent memory difficulties, especially of recent events Vagueness in everyday conversation Apparent loss of enthusiasm for previously enjoyed activities Taking longer to do routine tasks Forgetting well-known people or places Inability to process questions & instructions Deterioration of social skills Emotional unpredictability

Behaviour Changes
Aggressive Agitated Anxious Depressed Disinhibition Hallucinations & false ideas Sundowning Wandering

Physiotherapy Assessment
T/F
Supine sit with s/v Sit stand with 1 x assistance to ensure correct use of frame & arms

Amb with 4WW + 1 x min assist to steer & ensure correct use
Slow gait pattern, wide BOS, decreased trunk rotation, flexed posture

s/v 3 x steps + bilateral rail 1 x assist to 1 x threshold step with 4WW

Management
No cure
Drugs that appear to provide some stabilisation in cognitive function in pts
x Cholinesterase inhibitors x Glutamate regulator

Drugs for 2 symptoms e.g. restlessness, depression, sleep disturbance

Falls Prevention
2x rate of falls in cognitively normal elderly population Greater than expected impairments of gait & balance compared with age- & sex-matched controls
(Tinetti et al. 1988)

Impaired central processing due to structural & neurochemical degeneration

Psychotropic medications Incontinence Neurocardiovascular instability e.g. postural hypotension Multi-factorial nature of falls multi-disciplinary intervention
(Shaw & Kenny, 1998)

RCT: Rx orthostatic hypotension, improve gait & balance impairments, rationalise medications, modify environmental hazards reduced falls by 31% in 1 year
(Tinetti et al., 1994)

Communication Strategies

(Alzheimers Australia, 2010)

Short & simple sentences one idea at a time Allow plenty of time for processing Use body language gestures, facial expressions, pointing, demonstrating Avoid competing noises Stay still whilst talking and in their line of vision Everyone use the same approach repeating the same message Be flexible, behavioural acceptance

Physiotherapy
Progress mobility/gait re-education Programs with greater effect include exercises that challenge balance, use a higher dose of exercise, do not include a walking program
al., 2008)

(Sherrington et

Edu of carer to safely assist pt mobility & complete exercise program Provision of hip protectors & 4WW Practice on/off floor transfers
(Sherrington et al. 2008)

Occupational Therapy
Ax of ADLs, edu of carer, recommend PCA Home visit
Measurements of steps, chairs, bed Provision of OTT chair, armchair, bottle Organise location & instalment of rails Recommendations on how to make environment safer e.g. remove rugs, spaces that require clearing, remove automatic door closer, lock doors, thermostat

Social Work
Organise services EACH package Liaise with TCP Family meeting

Prognosis
Varies individually Leads eventually to complete dependence death Average 7-10 years with Alzheimers

References
http://www.medicinenet.com/alzheimers_disease_causes_stages_and_symptoms/article.htm Alzheimers Australia (2005). What is Alzheimers disease? Help sheet. Retrieved June 20, 2011, from http://www.alzheimers.org.au/understanding-dementia/alzheimers-disease.aspx Alzheimers Australia (2010). Managing changes in communication. Retrieved June 21, 2011, from http://www.alzheimers.org.au/services/managing-changes-in-communication.aspx National Institute on Aging (2011). Alzheimers Disease Education & Referral Center. Retrieved June 20, 2011, from http://www.nia.nih.gov/Alzheimers/AlzheimersInformation/Symptoms/ Tinetti, M.E., Speechley, M. & Ginter, S.F. (1988). Risk factors for falls among elderly persons living in the community. New England Journal of Medicine, 319, 1701-1707. Tinetti, M.E., Baker, D.I. & McAvay, G. et al. (1994). A multifactorial intervention to reduce the risk of falling among elderly people living in the community. New England Journal of Medicine, 331, 821-827. Shaw F.E. & Kenny, R.A. (1998). Can falls in patients with dementia be prevented? Age and Ageing, 27, 7-9. Sherrington, C.S., Whitney, J.C., Lord, S.R., Herbert, R.D., Cumming, R.G. & Close, J.C.T. (2008). Effective exercise for the prevention of falls: a systematic review and meta-analysis. The Journal of the American Geriatrics Society, 56, 12, 2234-2243.