ALZHEIMERS 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.

Alzheimers 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 Alzheimers
disease but may progress more rapidly
Lewy bodies are abnormal brain cells
Picks disease another form of dementia

Brain is quickly injured from hypoxia, reduced

blood flow or drugs:

Alzheimers disease
Multi-infarct dementia
Alcoholic dementia
Huntingtons chorea
AIDs related dementia
Toxic or traumatic brain injury
Malignant disease

Alzheimers Disease

Etiology and risk factors

Cause of Alzheimers 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

Alzheimers 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 Alzheimers Disease

Hippocampusresponsible for short and long-term

memory

Mild Alzheimers 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 Alzheimers Disease

May demonstrate language disturbance,

characterized by impaired word-finding
Motor disturbance apraxiadifficulty in using
everyday objects: toothbrush, comb, razor
Hyperorality: put things in the mouth
Worsening irritability and depression, psychosis,
incontinence may occur

Severe Alzheimers 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 40s50s

Classification of Alzheimers
Disease
Preclinical Alzheimers Disease

Begins near the Hippocampus

Affected regions begin to shrink leading to
memory loss

Mild Alzheimers 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 Alzheimers Disease

Client may demonstrate language disturbance,

impaired word finding
Apraxiadifficulty in motor activitiesdoing
everyday activities. Resulting in safety issues.
Hyperorality, depression and irritability may
worsen. Wandering at night is common.

Severe Alzheimers 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 patients with

Hepatic disease, or for clients with weight
less than 100 pounds.

Change site of patch daily

Side Effects

GastrointestinalNausea, vomiting, diarrhea, anorexia, weight loss

Skin Reactionsmay cause mild irritation to dermatitis. Change patch site daily, clean
with cool water
NeurologicalMay cause tremor or worsen tremor in Parkinsons clients

Combat oxygen-free radicals

Use of vitamin E and selegiline have been

studied. Do support in assisting to delay the
later stages of Alzheimers and show some
improvements in levels of independence

Ginko biloba

May improve cognitive function fro 612

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

Clients needs will be communicated (early

stages); later stages focus on interpretation of
clients expressions

Interventions

Early: speak slowly and simply. Use the patients

language. Use calming tone of voice. As disease
progresses use of other techniques
Nonverbal behavior also importantfrustration,
anger, hostility

Decrease environmental stimuli

Approach the patient calmly
Limit demands on patinet
Use distraction
Elicit listening behaviorhold 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 clients to reminisce
Use of repetition

Risk for Injury

Outcome

Clients 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