alzheimer's disease

Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.

Focus onFocus onAlzheimer’s DiseaseAlzheimer’s Disease

(Relates to Chapter 60, (Relates to Chapter 60, “Nursing Management:“Nursing Management:

Alzheimer’s Disease and Dementia,” Alzheimer’s Disease and Dementia,” in the textbook)in the textbook)


Cognitive ProblemsCognitive Problems

• Three most common in adultsThree most common in adults• DementiaDementia• Delirium—acute confusionDelirium—acute confusion• DepressionDepression

• Often associated with dementia and Often associated with dementia and deliriumdelirium

• Three most common in adultsThree most common in adults• DementiaDementia• Delirium—acute confusionDelirium—acute confusion• DepressionDepression

• Often associated with dementia and Often associated with dementia and deliriumdelirium


DementiaDementia

• Syndrome characterized by dysfunction Syndrome characterized by dysfunction or loss of or loss of • MemoryMemory• OrientationOrientation• AttentionAttention• LanguageLanguage• Judgment Judgment • ReasoningReasoning

• Syndrome characterized by dysfunction Syndrome characterized by dysfunction or loss of or loss of • MemoryMemory• OrientationOrientation• AttentionAttention• LanguageLanguage• Judgment Judgment • ReasoningReasoning


DementiaDementia

• Other characteristics that can Other characteristics that can manifestmanifest• Personality changesPersonality changes• Behavioral problems such asBehavioral problems such as

• Agitation Agitation • DelusionsDelusions• HallucinationsHallucinations

• Other characteristics that can Other characteristics that can manifestmanifest• Personality changesPersonality changes• Behavioral problems such asBehavioral problems such as

• Agitation Agitation • DelusionsDelusions• HallucinationsHallucinations


DementiaDementia

• Problems disrupt individual’s Problems disrupt individual’s • WorkWork• Social responsibilitiesSocial responsibilities• Family responsibilities Family responsibilities

• Physicians usually diagnose when Physicians usually diagnose when two or more brain functions are two or more brain functions are significantly impairedsignificantly impaired

• Problems disrupt individual’s Problems disrupt individual’s • WorkWork• Social responsibilitiesSocial responsibilities• Family responsibilities Family responsibilities

• Physicians usually diagnose when Physicians usually diagnose when two or more brain functions are two or more brain functions are significantly impairedsignificantly impaired


DementiaDementia

• Not a normal part of agingNot a normal part of aging• Affects 15% of older Americans Affects 15% of older Americans • ~100 causes of dementia~100 causes of dementia• 60% to 80% cases of dementia patients 60% to 80% cases of dementia patients

have Alzheimer’s disease (AD)have Alzheimer’s disease (AD)• Half of the patients in most long-term Half of the patients in most long-term

care facilities have dementiacare facilities have dementia

• Not a normal part of agingNot a normal part of aging• Affects 15% of older Americans Affects 15% of older Americans • ~100 causes of dementia~100 causes of dementia• 60% to 80% cases of dementia patients 60% to 80% cases of dementia patients

have Alzheimer’s disease (AD)have Alzheimer’s disease (AD)• Half of the patients in most long-term Half of the patients in most long-term

care facilities have dementiacare facilities have dementia


Etiology and PathophysiologyEtiology and Pathophysiology

• Due to treatable and nontreatable Due to treatable and nontreatable conditionsconditions

• Two most common causesTwo most common causes• Neurodegenerative conditionsNeurodegenerative conditions

• 60% to 80% of cases60% to 80% of cases

• Vascular disordersVascular disorders

• Due to treatable and nontreatable Due to treatable and nontreatable conditionsconditions

• Two most common causesTwo most common causes• Neurodegenerative conditionsNeurodegenerative conditions

• 60% to 80% of cases60% to 80% of cases

• Vascular disordersVascular disorders


Etiology and PathophysiologyEtiology and Pathophysiology

• Important risk factorsImportant risk factors• Advanced ageAdvanced age• Family historyFamily history

• Important risk factorsImportant risk factors• Advanced ageAdvanced age• Family historyFamily history


DementiaDementiaEtiology and PathophysiologyEtiology and Pathophysiology

• Infectious diseases can result in Infectious diseases can result in vascular and neurodegenerative vascular and neurodegenerative changes that can lead to dementiachanges that can lead to dementia• Bacterial meningitis Bacterial meningitis • Viral encephalitisViral encephalitis

• Infectious diseases can result in Infectious diseases can result in vascular and neurodegenerative vascular and neurodegenerative changes that can lead to dementiachanges that can lead to dementia• Bacterial meningitis Bacterial meningitis • Viral encephalitisViral encephalitis


DementiaDementia Etiology and PathophysiologyEtiology and Pathophysiology

• Dementia caused by treatable Dementia caused by treatable conditions can be reversed conditions can be reversed

• Prolonged exposure or disease may Prolonged exposure or disease may make dementia irreversible make dementia irreversible

• Dementia caused by treatable Dementia caused by treatable conditions can be reversed conditions can be reversed

• Prolonged exposure or disease may Prolonged exposure or disease may make dementia irreversible make dementia irreversible



• Vascular dementia Vascular dementia • Loss of cognitive function due to brain Loss of cognitive function due to brain

lesions caused by cardiovascular lesions caused by cardiovascular diseasedisease• Ischemic lesionsIschemic lesions• Ischemic–hypoxic lesionsIschemic–hypoxic lesions• Hemorrhagic brain lesionsHemorrhagic brain lesions

• Vascular dementia Vascular dementia • Loss of cognitive function due to brain Loss of cognitive function due to brain

lesions caused by cardiovascular lesions caused by cardiovascular diseasedisease• Ischemic lesionsIschemic lesions• Ischemic–hypoxic lesionsIschemic–hypoxic lesions• Hemorrhagic brain lesionsHemorrhagic brain lesions



• Vascular dementia (cont’d) Vascular dementia (cont’d) • Result of Result of decreased blood supply from decreased blood supply from

narrowing and blocking of arteries that narrowing and blocking of arteries that supply brainsupply brain

• Can be caused by a single stroke or Can be caused by a single stroke or multiple stokesmultiple stokes

• Vascular dementia (cont’d) Vascular dementia (cont’d) • Result of Result of decreased blood supply from decreased blood supply from

narrowing and blocking of arteries that narrowing and blocking of arteries that supply brainsupply brain

• Can be caused by a single stroke or Can be caused by a single stroke or multiple stokesmultiple stokes



• Vascular dementia (cont’d) Vascular dementia (cont’d) • Predisposed risks of vascular dementiaPredisposed risks of vascular dementia

• SmokingSmoking• Cardiac dysrhythmias Cardiac dysrhythmias • HypertensionHypertension• Hypercholesterolemia Hypercholesterolemia • Diabetes mellitus Diabetes mellitus • Coronary artery diseaseCoronary artery disease

• Vascular dementia (cont’d) Vascular dementia (cont’d) • Predisposed risks of vascular dementiaPredisposed risks of vascular dementia

• SmokingSmoking• Cardiac dysrhythmias Cardiac dysrhythmias • HypertensionHypertension• Hypercholesterolemia Hypercholesterolemia • Diabetes mellitus Diabetes mellitus • Coronary artery diseaseCoronary artery disease



• Predisposed risks of dementia and Predisposed risks of dementia and Alzheimer’s diseaseAlzheimer’s disease• Metabolic syndromeMetabolic syndrome

• Predisposed risks of dementia and Predisposed risks of dementia and Alzheimer’s diseaseAlzheimer’s disease• Metabolic syndromeMetabolic syndrome


DementiaDementia Clinical Manifestations Clinical Manifestations

• Onset of dementia depends on causeOnset of dementia depends on cause• Insidious and gradualInsidious and gradual• AbruptAbrupt

• Vascular dementia tends to be abrupt or Vascular dementia tends to be abrupt or progress in a stepwise patternprogress in a stepwise pattern

• Onset of dementia depends on causeOnset of dementia depends on cause• Insidious and gradualInsidious and gradual• AbruptAbrupt

• Vascular dementia tends to be abrupt or Vascular dementia tends to be abrupt or progress in a stepwise patternprogress in a stepwise pattern


DementiaDementia Clinical Manifestations Clinical Manifestations

• Etiology of dementia difficult to Etiology of dementia difficult to distinguish based on symptoms alonedistinguish based on symptoms alone

• Etiology of dementia difficult to Etiology of dementia difficult to distinguish based on symptoms alonedistinguish based on symptoms alone


DementiaDementia Clinical ManifestationsClinical Manifestations

• Acute or subacute pattern of change Acute or subacute pattern of change may be more indicative of an may be more indicative of an infectious or metabolic changeinfectious or metabolic change

• Acute or subacute pattern of change Acute or subacute pattern of change may be more indicative of an may be more indicative of an infectious or metabolic changeinfectious or metabolic change



• ClassificationsClassifications• MildMild• ModerateModerate• SevereSevere

• ClassificationsClassifications• MildMild• ModerateModerate• SevereSevere



• Initial symptoms are related to Initial symptoms are related to changes in cognitive functionchanges in cognitive function

• Family members often report to Family members often report to doctordoctor• Memory lossMemory loss• Mild disorientationMild disorientation• Trouble with words and/or numbersTrouble with words and/or numbers

• Initial symptoms are related to Initial symptoms are related to changes in cognitive functionchanges in cognitive function

• Family members often report to Family members often report to doctordoctor• Memory lossMemory loss• Mild disorientationMild disorientation• Trouble with words and/or numbersTrouble with words and/or numbers


DementiaDementiaDiagnostic StudiesDiagnostic Studies

• Focused on cause Focused on cause • Reversible or nonreversible Reversible or nonreversible

• Thoroughly evaluate patient historyThoroughly evaluate patient history• MedicalMedical• NeurologicNeurologic• Psychologic Psychologic

• Focused on cause Focused on cause • Reversible or nonreversible Reversible or nonreversible

• Thoroughly evaluate patient historyThoroughly evaluate patient history• MedicalMedical• NeurologicNeurologic• Psychologic Psychologic


DementiaDementia Diagnostic StudiesDiagnostic Studies

• Physical examination to rule out Physical examination to rule out other medical conditionsother medical conditions

• Screen forScreen for• Cobalamin (vitamin BCobalamin (vitamin B1212) deficiencies ) deficiencies

• HypothyroidismHypothyroidism• Possibly neurosyphilis Possibly neurosyphilis

• Physical examination to rule out Physical examination to rule out other medical conditionsother medical conditions

• Screen forScreen for• Cobalamin (vitamin BCobalamin (vitamin B1212) deficiencies ) deficiencies

• HypothyroidismHypothyroidism• Possibly neurosyphilis Possibly neurosyphilis



• Mild cognitive impairmentMild cognitive impairment• May be able to compensate, making May be able to compensate, making

diagnoses difficultdiagnoses difficult• American Academy of Neurology American Academy of Neurology

recommendsrecommends• Cognitive evaluationCognitive evaluation• Ongoing clinical monitoring due to Ongoing clinical monitoring due to

increased risk of developing dementiaincreased risk of developing dementia

• Mild cognitive impairmentMild cognitive impairment• May be able to compensate, making May be able to compensate, making

diagnoses difficultdiagnoses difficult• American Academy of Neurology American Academy of Neurology

recommendsrecommends• Cognitive evaluationCognitive evaluation• Ongoing clinical monitoring due to Ongoing clinical monitoring due to

increased risk of developing dementiaincreased risk of developing dementia



• Mental status testingMental status testing• Mini mental state examination Mini mental state examination

• Commonly used toolCommonly used tool• Assesses cognitive functioningAssesses cognitive functioning

• Mental status testingMental status testing• Mini mental state examination Mini mental state examination

• Commonly used toolCommonly used tool• Assesses cognitive functioningAssesses cognitive functioning



• Depression often mistaken for Depression often mistaken for dementia and vice versadementia and vice versa

• Manifestations of depression, Manifestations of depression, especially in older adultsespecially in older adults• SadnessSadness• Difficulty thinking and concentrating Difficulty thinking and concentrating

• Depression often mistaken for Depression often mistaken for dementia and vice versadementia and vice versa

• Manifestations of depression, Manifestations of depression, especially in older adultsespecially in older adults• SadnessSadness• Difficulty thinking and concentrating Difficulty thinking and concentrating



• Manifestations of depression (cont’d)Manifestations of depression (cont’d)• FatigueFatigue• Apathy Apathy • Feelings of despairFeelings of despair• InactivityInactivity

• Manifestations of depression (cont’d)Manifestations of depression (cont’d)• FatigueFatigue• Apathy Apathy • Feelings of despairFeelings of despair• InactivityInactivity



• Severe depression can result in poor Severe depression can result in poor concentration and attentionconcentration and attention

• Dementia and depression occurring Dementia and depression occurring together can cause extreme together can cause extreme intellectual deteriorationintellectual deterioration

• Depression alone or with dementia is Depression alone or with dementia is treatabletreatable

• Severe depression can result in poor Severe depression can result in poor concentration and attentionconcentration and attention

• Dementia and depression occurring Dementia and depression occurring together can cause extreme together can cause extreme intellectual deteriorationintellectual deterioration

• Depression alone or with dementia is Depression alone or with dementia is treatabletreatable



• Computed tomography (CT)Computed tomography (CT)• Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)• To characterize central nervous To characterize central nervous

system (CNS) changes:system (CNS) changes:• Single-photon emission computed Single-photon emission computed

tomography (SPECT)tomography (SPECT)• Positron emission tomography (PET)Positron emission tomography (PET)

• Computed tomography (CT)Computed tomography (CT)• Magnetic resonance imaging (MRI)Magnetic resonance imaging (MRI)• To characterize central nervous To characterize central nervous

system (CNS) changes:system (CNS) changes:• Single-photon emission computed Single-photon emission computed

tomography (SPECT)tomography (SPECT)• Positron emission tomography (PET)Positron emission tomography (PET)


Mild Cognitive ImpairmentMild Cognitive Impairment

• State of cognitive and functional State of cognitive and functional ability below defined norms that does ability below defined norms that does not meet criteria for dementianot meet criteria for dementia

• Memory impaired but function Memory impaired but function normallynormally

• State of cognitive and functional State of cognitive and functional ability below defined norms that does ability below defined norms that does not meet criteria for dementianot meet criteria for dementia

• Memory impaired but function Memory impaired but function normallynormally



• Characteristics Characteristics • Memory complaintMemory complaint• Abnormal memory for ageAbnormal memory for age• Intact activities of daily livingIntact activities of daily living• Normal general cognitive functioningNormal general cognitive functioning

• Characteristics Characteristics • Memory complaintMemory complaint• Abnormal memory for ageAbnormal memory for age• Intact activities of daily livingIntact activities of daily living• Normal general cognitive functioningNormal general cognitive functioning



• Criteria for mild cognitive Criteria for mild cognitive impairment (MCI)impairment (MCI)• Memory complaint, preferably Memory complaint, preferably

confirmed by another personconfirmed by another person• Measurable memory impairment Measurable memory impairment

detected with standard assessment testsdetected with standard assessment tests

• Criteria for mild cognitive Criteria for mild cognitive impairment (MCI)impairment (MCI)• Memory complaint, preferably Memory complaint, preferably

confirmed by another personconfirmed by another person• Measurable memory impairment Measurable memory impairment

detected with standard assessment testsdetected with standard assessment tests



• MCI Criteria (cont’d)MCI Criteria (cont’d)• Normal overall thinking and cognitive Normal overall thinking and cognitive

functioning functioning • Ability to perform activities of daily Ability to perform activities of daily

livingliving

• MCI Criteria (cont’d)MCI Criteria (cont’d)• Normal overall thinking and cognitive Normal overall thinking and cognitive

functioning functioning • Ability to perform activities of daily Ability to perform activities of daily

livingliving



• Causes of MCICauses of MCI• StressStress• AnxietyAnxiety• DepressionDepression• Physical illnessPhysical illness

• Percentage of patients with MCI who Percentage of patients with MCI who develop AD is unknowndevelop AD is unknown

• Causes of MCICauses of MCI• StressStress• AnxietyAnxiety• DepressionDepression• Physical illnessPhysical illness

• Percentage of patients with MCI who Percentage of patients with MCI who develop AD is unknowndevelop AD is unknown



• Presently no widely accepted Presently no widely accepted guidelines for treatmentguidelines for treatment• Insufficient evidenceInsufficient evidence• Research is being conductedResearch is being conducted

• Primary treatment consists of Primary treatment consists of ongoing monitoringongoing monitoring• Observe for 10 warning signs of ADObserve for 10 warning signs of AD

• Presently no widely accepted Presently no widely accepted guidelines for treatmentguidelines for treatment• Insufficient evidenceInsufficient evidence• Research is being conductedResearch is being conducted

• Primary treatment consists of Primary treatment consists of ongoing monitoringongoing monitoring• Observe for 10 warning signs of ADObserve for 10 warning signs of AD


Alzheimer’s DiseaseAlzheimer’s Disease

• Chronic, progressive, degenerative Chronic, progressive, degenerative disease of the braindisease of the brain

• Most common form of dementiaMost common form of dementia• ~4.5 million Americans suffer from ~4.5 million Americans suffer from

ADAD

• Chronic, progressive, degenerative Chronic, progressive, degenerative disease of the braindisease of the brain

• Most common form of dementiaMost common form of dementia• ~4.5 million Americans suffer from ~4.5 million Americans suffer from

ADAD


Alzheimer’s DiseaseAlzheimer’s Disease

• Economic cost of caring in the United Economic cost of caring in the United States is at least $100 billion annuallyStates is at least $100 billion annually

• Burden on patient, family, Burden on patient, family, caregivers, and society as a wholecaregivers, and society as a whole

• Women more likely to develop ADWomen more likely to develop AD

• Economic cost of caring in the United Economic cost of caring in the United States is at least $100 billion annuallyStates is at least $100 billion annually

• Burden on patient, family, Burden on patient, family, caregivers, and society as a wholecaregivers, and society as a whole

• Women more likely to develop ADWomen more likely to develop AD


Alzheimer’s DiseaseAlzheimer’s DiseaseEtiology and PathophysiologyEtiology and Pathophysiology

• Exact etiology is unknownExact etiology is unknown• Similar to other forms of dementiaSimilar to other forms of dementia• Age is most important risk factorAge is most important risk factor

• Early onsetEarly onset• Late onsetLate onset

• Familial Alzheimer's diseaseFamilial Alzheimer's disease

• Exact etiology is unknownExact etiology is unknown• Similar to other forms of dementiaSimilar to other forms of dementia• Age is most important risk factorAge is most important risk factor

• Early onsetEarly onset• Late onsetLate onset

• Familial Alzheimer's diseaseFamilial Alzheimer's disease



• Changes in brain structure and Changes in brain structure and functionfunction• Amyloid plaquesAmyloid plaques• Neurofibrillary tanglesNeurofibrillary tangles• Loss of connections between cells and Loss of connections between cells and

cell deathcell death

• Changes in brain structure and Changes in brain structure and functionfunction• Amyloid plaquesAmyloid plaques• Neurofibrillary tanglesNeurofibrillary tangles• Loss of connections between cells and Loss of connections between cells and

cell deathcell death


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Fig. 60-1Fig. 60-1



• People develop some plaques in their People develop some plaques in their brain tissuebrain tissue

• In AD plaques are greater in certain In AD plaques are greater in certain partsparts• Clusters of insoluble plaque Clusters of insoluble plaque

•ββ-Amyloid, other proteins, remnants of -Amyloid, other proteins, remnants of neurons, non-nerve cells, and other cellsneurons, non-nerve cells, and other cells

• People develop some plaques in their People develop some plaques in their brain tissuebrain tissue

• In AD plaques are greater in certain In AD plaques are greater in certain partsparts• Clusters of insoluble plaque Clusters of insoluble plaque

•ββ-Amyloid, other proteins, remnants of -Amyloid, other proteins, remnants of neurons, non-nerve cells, and other cellsneurons, non-nerve cells, and other cells



• Where plaques develop in the parts Where plaques develop in the parts of the brain used forof the brain used for• Memory Memory • Cognitive functionCognitive function

• Hippocampus Hippocampus

• Eventually develops in the cerebral Eventually develops in the cerebral cortexcortex

• Where plaques develop in the parts Where plaques develop in the parts of the brain used forof the brain used for• Memory Memory • Cognitive functionCognitive function

• Hippocampus Hippocampus

• Eventually develops in the cerebral Eventually develops in the cerebral cortexcortex



Fig. 60-2Fig. 60-2



• Neurofibrillary tanglesNeurofibrillary tangles• Abnormal collections of twisted protein Abnormal collections of twisted protein

threads inside nerve cellsthreads inside nerve cells• Main component is a protein called tauMain component is a protein called tau

• Neurofibrillary tanglesNeurofibrillary tangles• Abnormal collections of twisted protein Abnormal collections of twisted protein

threads inside nerve cellsthreads inside nerve cells• Main component is a protein called tauMain component is a protein called tau



• Tau proteinsTau proteins• Provide support for intracellular Provide support for intracellular

structurestructure• Hold microtubules together as railroad Hold microtubules together as railroad

ties hold railroad tracksties hold railroad tracks• Tau proteins alter in ADTau proteins alter in AD• Microtubules twist together in a helical Microtubules twist together in a helical

fashion forming neurofibrillary tanglesfashion forming neurofibrillary tangles

• Tau proteinsTau proteins• Provide support for intracellular Provide support for intracellular

structurestructure• Hold microtubules together as railroad Hold microtubules together as railroad

ties hold railroad tracksties hold railroad tracks• Tau proteins alter in ADTau proteins alter in AD• Microtubules twist together in a helical Microtubules twist together in a helical

fashion forming neurofibrillary tanglesfashion forming neurofibrillary tangles



• Gradual loss of connections between Gradual loss of connections between neuronsneurons• Leads to damage and then death of Leads to damage and then death of

neuronsneurons• Affected parts of brain shrink Affected parts of brain shrink

• Brain atrophy Brain atrophy • Significant in final state of ADSignificant in final state of AD

• Gradual loss of connections between Gradual loss of connections between neuronsneurons• Leads to damage and then death of Leads to damage and then death of

neuronsneurons• Affected parts of brain shrink Affected parts of brain shrink

• Brain atrophy Brain atrophy • Significant in final state of ADSignificant in final state of AD


Comparison of Normal Brain Comparison of Normal Brain and Brain of AD Patientand Brain of AD Patient

Fig. 60-3Fig. 60-3


Alzheimer’s DiseaseAlzheimer’s DiseaseGenetic FactorsGenetic Factors

• May play significant role in how the May play significant role in how the brain processes brain processes ββ-amyloid protein-amyloid protein• ↑↑ ββ-Amyloid protein -Amyloid protein ↑↑ risk risk

• First gene associated with ADFirst gene associated with AD• Epsilon (E)-4 allele of apolipoprotein E Epsilon (E)-4 allele of apolipoprotein E

(ApoE) gene on chromosome 19(ApoE) gene on chromosome 19

• May play significant role in how the May play significant role in how the brain processes brain processes ββ-amyloid protein-amyloid protein• ↑↑ ββ-Amyloid protein -Amyloid protein ↑↑ risk risk

• First gene associated with ADFirst gene associated with AD• Epsilon (E)-4 allele of apolipoprotein E Epsilon (E)-4 allele of apolipoprotein E

(ApoE) gene on chromosome 19(ApoE) gene on chromosome 19


Alzheimer’s DiseaseAlzheimer’s DiseaseGenetic FactorsGenetic Factors

• ApoE comes in several forms of ApoE comes in several forms of allelesalleles• Three occur most commonlyThree occur most commonly• Inherit one allele from each parentInherit one allele from each parent

• ApoE may clear amyloid plaquesApoE may clear amyloid plaques• Presence of ApoE-4 Presence of ApoE-4 ↑↑ risk of late- risk of late-

onset ADonset AD

• ApoE comes in several forms of ApoE comes in several forms of allelesalleles• Three occur most commonlyThree occur most commonly• Inherit one allele from each parentInherit one allele from each parent

• ApoE may clear amyloid plaquesApoE may clear amyloid plaques• Presence of ApoE-4 Presence of ApoE-4 ↑↑ risk of late- risk of late-

onset ADonset AD


Alzheimer’s DiseaseAlzheimer’s Disease Etiology and PathophysiologyEtiology and Pathophysiology

• Researchers interested in link Researchers interested in link between inflammation and ADbetween inflammation and AD• Theory suggests formation of free Theory suggests formation of free

radicals damages neurons radicals damages neurons loss of loss of functionfunction

• Oxidative damage leads to Oxidative damage leads to inflammationinflammation

• Researchers interested in link Researchers interested in link between inflammation and ADbetween inflammation and AD• Theory suggests formation of free Theory suggests formation of free

radicals damages neurons radicals damages neurons loss of loss of functionfunction

• Oxidative damage leads to Oxidative damage leads to inflammationinflammation



• Researchers (cont’d)Researchers (cont’d)• Another area is focusing on link Another area is focusing on link

between cardiovascular disease and ADbetween cardiovascular disease and AD• Common risk factors of heart disease Common risk factors of heart disease

are associated with increased risk of are associated with increased risk of ADAD

• Researchers (cont’d)Researchers (cont’d)• Another area is focusing on link Another area is focusing on link

between cardiovascular disease and ADbetween cardiovascular disease and AD• Common risk factors of heart disease Common risk factors of heart disease

are associated with increased risk of are associated with increased risk of ADAD



• Early findings show people who Early findings show people who engage in activities that involve engage in activities that involve information processing have a information processing have a decreased risk of developing ADdecreased risk of developing AD• ReadingReading• Crossword puzzlesCrossword puzzles• Learning a new languageLearning a new language

• Early findings show people who Early findings show people who engage in activities that involve engage in activities that involve information processing have a information processing have a decreased risk of developing ADdecreased risk of developing AD• ReadingReading• Crossword puzzlesCrossword puzzles• Learning a new languageLearning a new language


Alzheimer’s DiseaseAlzheimer’s DiseaseClinical ManifestationsClinical Manifestations

• Pathologic changes precede clinical Pathologic changes precede clinical manifestations by 5 to 20 yearsmanifestations by 5 to 20 years

• Alzheimer’s Association has Alzheimer’s Association has developed a list of 10 warning signsdeveloped a list of 10 warning signs

• Pathologic changes precede clinical Pathologic changes precede clinical manifestations by 5 to 20 yearsmanifestations by 5 to 20 years

• Alzheimer’s Association has Alzheimer’s Association has developed a list of 10 warning signsdeveloped a list of 10 warning signs



• Early signs of Alzheimer’s diseaseEarly signs of Alzheimer’s disease1.1. Memory loss that affects job skillsMemory loss that affects job skills2.2. Difficulty performing familiar tasksDifficulty performing familiar tasks3.3. Problems with languageProblems with language4.4. Disorientation to time and placeDisorientation to time and place5.5. Poor or Poor or ↓↓ judgment judgment6.6. Problems with abstract thinkingProblems with abstract thinking

• Early signs of Alzheimer’s diseaseEarly signs of Alzheimer’s disease1.1. Memory loss that affects job skillsMemory loss that affects job skills2.2. Difficulty performing familiar tasksDifficulty performing familiar tasks3.3. Problems with languageProblems with language4.4. Disorientation to time and placeDisorientation to time and place5.5. Poor or Poor or ↓↓ judgment judgment6.6. Problems with abstract thinkingProblems with abstract thinking



• Early signs of AD (cont’d)Early signs of AD (cont’d)7.7. Misplacing thingsMisplacing things

8.8. Changes in mood or behaviorChanges in mood or behavior

9.9. Changes in personalityChanges in personality

10.10. Loss of initiative Loss of initiative

• Early signs of AD (cont’d)Early signs of AD (cont’d)7.7. Misplacing thingsMisplacing things

8.8. Changes in mood or behaviorChanges in mood or behavior

9.9. Changes in personalityChanges in personality

10.10. Loss of initiative Loss of initiative



• Categorized similarly to those for Categorized similarly to those for dementiadementia• MildMild• ModerateModerate• LateLate

• Progression is variable from person to Progression is variable from person to person and ranges from 3 to 20 yearsperson and ranges from 3 to 20 years

• Categorized similarly to those for Categorized similarly to those for dementiadementia• MildMild• ModerateModerate• LateLate

• Progression is variable from person to Progression is variable from person to person and ranges from 3 to 20 yearsperson and ranges from 3 to 20 years



• Initial sign is subtle deterioration in Initial sign is subtle deterioration in memorymemory

• Inevitably progresses to more Inevitably progresses to more profound memory lossprofound memory loss

• Manifestations easier to recognize Manifestations easier to recognize when family members or patient when family members or patient seeks medical helpseeks medical help

• Initial sign is subtle deterioration in Initial sign is subtle deterioration in memorymemory

• Inevitably progresses to more Inevitably progresses to more profound memory lossprofound memory loss

• Manifestations easier to recognize Manifestations easier to recognize when family members or patient when family members or patient seeks medical helpseeks medical help



• Recent events and new information Recent events and new information cannot be recalledcannot be recalled

• Behavioral manifestations are not Behavioral manifestations are not intentional or controllable because of intentional or controllable because of ongoing loss of neuronsongoing loss of neurons

• Some develop psychotic Some develop psychotic manifestationsmanifestations

• Recent events and new information Recent events and new information cannot be recalledcannot be recalled

• Behavioral manifestations are not Behavioral manifestations are not intentional or controllable because of intentional or controllable because of ongoing loss of neuronsongoing loss of neurons

• Some develop psychotic Some develop psychotic manifestationsmanifestations



• In AD that has progressedIn AD that has progressed• DysphasiaDysphasia• ApraxiaApraxia• Visual agnosiaVisual agnosia• DysgraphiaDysgraphia• Some long-term memory lossSome long-term memory loss• WanderingWandering

• In AD that has progressedIn AD that has progressed• DysphasiaDysphasia• ApraxiaApraxia• Visual agnosiaVisual agnosia• DysgraphiaDysgraphia• Some long-term memory lossSome long-term memory loss• WanderingWandering



• Late stagesLate stages• Long-term memory lossLong-term memory loss• Unable to communicateUnable to communicate• Cannot perform activities of daily Cannot perform activities of daily

living (ADLs)living (ADLs)• Patient may be unresponsive and Patient may be unresponsive and

incontinent, requiring total careincontinent, requiring total care

• Late stagesLate stages• Long-term memory lossLong-term memory loss• Unable to communicateUnable to communicate• Cannot perform activities of daily Cannot perform activities of daily

living (ADLs)living (ADLs)• Patient may be unresponsive and Patient may be unresponsive and

incontinent, requiring total careincontinent, requiring total care


Alzheimer’s DiseaseAlzheimer’s DiseaseDiagnostic StudiesDiagnostic Studies

• Diagnosis of exclusionDiagnosis of exclusion• No single clinical testNo single clinical test• Made once all other possible conditions Made once all other possible conditions

causing cognitive impairment have causing cognitive impairment have been ruled outbeen ruled out

• Diagnosis of exclusionDiagnosis of exclusion• No single clinical testNo single clinical test• Made once all other possible conditions Made once all other possible conditions

causing cognitive impairment have causing cognitive impairment have been ruled outbeen ruled out



• Comprehensive patient evaluationComprehensive patient evaluation• Complete health historyComplete health history• Physical examinationPhysical examination• Neurologic assessmentNeurologic assessment• Mental status assessmentMental status assessment• Laboratory testsLaboratory tests

• Comprehensive patient evaluationComprehensive patient evaluation• Complete health historyComplete health history• Physical examinationPhysical examination• Neurologic assessmentNeurologic assessment• Mental status assessmentMental status assessment• Laboratory testsLaboratory tests



• Brain imaging testsBrain imaging tests• CTCT• MRIMRI• SPECTSPECT• PETPET

• Allow monitoring in early stages and Allow monitoring in early stages and treatment responsetreatment response

• Brain imaging testsBrain imaging tests• CTCT• MRIMRI• SPECTSPECT• PETPET

• Allow monitoring in early stages and Allow monitoring in early stages and treatment responsetreatment response


PET Scan of Normal and PET Scan of Normal and Advanced AD BrainAdvanced AD Brain

Fig. 60-4Fig. 60-4



• Neuropsychologic testing can help Neuropsychologic testing can help document degree of cognitive document degree of cognitive impairmentimpairment• Mini mental state examinationMini mental state examination• Also used to determine a baseline to Also used to determine a baseline to

evaluate change over timeevaluate change over time

• Neuropsychologic testing can help Neuropsychologic testing can help document degree of cognitive document degree of cognitive impairmentimpairment• Mini mental state examinationMini mental state examination• Also used to determine a baseline to Also used to determine a baseline to

evaluate change over timeevaluate change over time



• Definitive diagnoses can only be Definitive diagnoses can only be made during an autopsy made during an autopsy

• Brain examined for presence ofBrain examined for presence of• Neurofibrillary tanglesNeurofibrillary tangles• Neuritic plaquesNeuritic plaques

• Definitive diagnoses can only be Definitive diagnoses can only be made during an autopsy made during an autopsy

• Brain examined for presence ofBrain examined for presence of• Neurofibrillary tanglesNeurofibrillary tangles• Neuritic plaquesNeuritic plaques


Alzheimer’s DiseaseAlzheimer’s DiseaseCollaborative CareCollaborative Care

• No cure No cure • Collaborative management aimed atCollaborative management aimed at

• Improving or controlling decline in Improving or controlling decline in cognitioncognition

• Controlling undesirable behavioral Controlling undesirable behavioral manifestations manifestations

• No cure No cure • Collaborative management aimed atCollaborative management aimed at

• Improving or controlling decline in Improving or controlling decline in cognitioncognition

• Controlling undesirable behavioral Controlling undesirable behavioral manifestations manifestations


Alzheimer’s DiseaseAlzheimer’s DiseaseDrug TherapyDrug Therapy

• Cholinesterase inhibitorsCholinesterase inhibitors• Used to treat mild and moderate Used to treat mild and moderate

dementiadementia• Block cholinesterase, enzyme Block cholinesterase, enzyme

responsible for breaking down responsible for breaking down acetylcholineacetylcholine

• Improves or stabilizes cognitive decline Improves or stabilizes cognitive decline but does not cure or reverse but does not cure or reverse

• Cholinesterase inhibitorsCholinesterase inhibitors• Used to treat mild and moderate Used to treat mild and moderate

dementiadementia• Block cholinesterase, enzyme Block cholinesterase, enzyme

responsible for breaking down responsible for breaking down acetylcholineacetylcholine

• Improves or stabilizes cognitive decline Improves or stabilizes cognitive decline but does not cure or reverse but does not cure or reverse



Fig. 60-5Fig. 60-5



• Often used for management of Often used for management of behavioral problemsbehavioral problems

• Conventional antipsychotic drugsConventional antipsychotic drugs• Acute episodes of agitationAcute episodes of agitation• Aggressive behaviorAggressive behavior• Psychosis Psychosis • Side effectsSide effects

• Often used for management of Often used for management of behavioral problemsbehavioral problems

• Conventional antipsychotic drugsConventional antipsychotic drugs• Acute episodes of agitationAcute episodes of agitation• Aggressive behaviorAggressive behavior• Psychosis Psychosis • Side effectsSide effects



• Depression often treated with Depression often treated with selective serotonin reuptake selective serotonin reuptake inhibitors inhibitors • May help with sleep problemsMay help with sleep problems

• Antiseizure drugsAntiseizure drugs• Manage behavioral problemsManage behavioral problems• Stabilize moodStabilize mood

• Depression often treated with Depression often treated with selective serotonin reuptake selective serotonin reuptake inhibitors inhibitors • May help with sleep problemsMay help with sleep problems

• Antiseizure drugsAntiseizure drugs• Manage behavioral problemsManage behavioral problems• Stabilize moodStabilize mood



• Ginkgo biloba Ginkgo biloba • Hormone replacement therapyHormone replacement therapy• Nonsteroidal antiinflammatory drugs Nonsteroidal antiinflammatory drugs

(NSAIDs) (NSAIDs) • Cholesterol-lowering drugsCholesterol-lowering drugs• AntioxidantsAntioxidants• Folic acidFolic acid

• Ginkgo biloba Ginkgo biloba • Hormone replacement therapyHormone replacement therapy• Nonsteroidal antiinflammatory drugs Nonsteroidal antiinflammatory drugs

(NSAIDs) (NSAIDs) • Cholesterol-lowering drugsCholesterol-lowering drugs• AntioxidantsAntioxidants• Folic acidFolic acid


Alzheimer’s DiseaseAlzheimer’s DiseaseNursing AssessmentNursing Assessment

• Subjective dataSubjective data• Past health historyPast health history• MedicationsMedications• Health perception Health perception • Nutritional state Nutritional state • Eliminating properly—incontinence Eliminating properly—incontinence

• Subjective dataSubjective data• Past health historyPast health history• MedicationsMedications• Health perception Health perception • Nutritional state Nutritional state • Eliminating properly—incontinence Eliminating properly—incontinence



• Subjective data (cont’d)Subjective data (cont’d)• Activity-exercise habits and stateActivity-exercise habits and state• Sleep-rest patternSleep-rest pattern• Cognitive-perceptual stateCognitive-perceptual state

• Subjective data (cont’d)Subjective data (cont’d)• Activity-exercise habits and stateActivity-exercise habits and state• Sleep-rest patternSleep-rest pattern• Cognitive-perceptual stateCognitive-perceptual state



• Objective dataObjective data• Disheveled appearanceDisheveled appearance• Neurologic Neurologic

• Early, middle, lateEarly, middle, late

• Objective dataObjective data• Disheveled appearanceDisheveled appearance• Neurologic Neurologic

• Early, middle, lateEarly, middle, late


Alzheimer’s DiseaseAlzheimer’s DiseaseNursing DiagnosisNursing Diagnosis

• Disturbed thought processDisturbed thought process• Self-care deficitSelf-care deficit• Risk for injuriesRisk for injuries

• Fall preventionFall prevention

• GriefGrief• WanderingWandering

• Disturbed thought processDisturbed thought process• Self-care deficitSelf-care deficit• Risk for injuriesRisk for injuries

• Fall preventionFall prevention

• GriefGrief• WanderingWandering


Alzheimer’s DiseaseAlzheimer’s DiseasePlanningPlanning

• Overall goals for patientOverall goals for patient• Maintain functional ability as long as Maintain functional ability as long as

possiblepossible• Maintain safe environmentMaintain safe environment• Personal care needs metPersonal care needs met• Dignity maintainedDignity maintained

• Overall goals for patientOverall goals for patient• Maintain functional ability as long as Maintain functional ability as long as

possiblepossible• Maintain safe environmentMaintain safe environment• Personal care needs metPersonal care needs met• Dignity maintainedDignity maintained


Alzheimer’s DiseaseAlzheimer’s DiseasePlanningPlanning

• Overall goals for caregiver of a Overall goals for caregiver of a patientpatient• Reduce caregiver stressReduce caregiver stress• Maintain personal, emotional, and Maintain personal, emotional, and

physical healthphysical health• Cope with long-term effects associated Cope with long-term effects associated

with caregivingwith caregiving

• Overall goals for caregiver of a Overall goals for caregiver of a patientpatient• Reduce caregiver stressReduce caregiver stress• Maintain personal, emotional, and Maintain personal, emotional, and

physical healthphysical health• Cope with long-term effects associated Cope with long-term effects associated

with caregivingwith caregiving


Alzheimer’s DiseaseAlzheimer’s DiseaseNursing ImplementationNursing Implementation

• No known method to reduce risk of ADNo known method to reduce risk of AD• Antioxidants may be of benefitAntioxidants may be of benefit• Promote safety in physical activities and Promote safety in physical activities and

drivingdriving• Recognize and treat depressionRecognize and treat depression• Genetic testing not performed on regular Genetic testing not performed on regular

basisbasis

• No known method to reduce risk of ADNo known method to reduce risk of AD• Antioxidants may be of benefitAntioxidants may be of benefit• Promote safety in physical activities and Promote safety in physical activities and

drivingdriving• Recognize and treat depressionRecognize and treat depression• Genetic testing not performed on regular Genetic testing not performed on regular

basisbasis


Alzheimer’s DiseaseAlzheimer’s DiseaseNursing ImplementationNursing Implementation

• Early recognition and treatment Early recognition and treatment important important

• Nurse should inform patients and Nurse should inform patients and family regarding early warning signs family regarding early warning signs

• Early recognition and treatment Early recognition and treatment important important

• Nurse should inform patients and Nurse should inform patients and family regarding early warning signs family regarding early warning signs


Alzheimer’s DiseaseAlzheimer’s DiseaseAcute InterventionAcute Intervention

• Diagnosis traumatic for patient and Diagnosis traumatic for patient and familyfamily

• Patient often responds withPatient often responds with• DepressionDepression• DenialDenial• Anxiety and fearAnxiety and fear• IsolationIsolation

• Diagnosis traumatic for patient and Diagnosis traumatic for patient and familyfamily

• Patient often responds withPatient often responds with• DepressionDepression• DenialDenial• Anxiety and fearAnxiety and fear• IsolationIsolation



• Nurse should assess for depression Nurse should assess for depression and suicidal ideationand suicidal ideation

• Counseling and antidepressants may Counseling and antidepressants may be indicatedbe indicated

• Family members may be in denial, Family members may be in denial, delaying critical early caredelaying critical early care

• Nurse should assess for depression Nurse should assess for depression and suicidal ideationand suicidal ideation

• Counseling and antidepressants may Counseling and antidepressants may be indicatedbe indicated

• Family members may be in denial, Family members may be in denial, delaying critical early caredelaying critical early care



• Nurse should also assess family Nurse should also assess family members and their ability to cope members and their ability to cope and accept diagnosisand accept diagnosis

• Ongoing monitoring importantOngoing monitoring important• Work in collaboration with patient’s Work in collaboration with patient’s

caregivercaregiver• Teach caregiver how to manage careTeach caregiver how to manage care

• Nurse should also assess family Nurse should also assess family members and their ability to cope members and their ability to cope and accept diagnosisand accept diagnosis

• Ongoing monitoring importantOngoing monitoring important• Work in collaboration with patient’s Work in collaboration with patient’s

caregivercaregiver• Teach caregiver how to manage careTeach caregiver how to manage care



• AD patients subject to other health AD patients subject to other health care problemscare problems

• Inability to communicate symptoms Inability to communicate symptoms places responsibility on caregiver places responsibility on caregiver and health care professionalsand health care professionals

• Hospitalization can precipitate a Hospitalization can precipitate a worsening of disease or deliriumworsening of disease or delirium

• AD patients subject to other health AD patients subject to other health care problemscare problems

• Inability to communicate symptoms Inability to communicate symptoms places responsibility on caregiver places responsibility on caregiver and health care professionalsand health care professionals

• Hospitalization can precipitate a Hospitalization can precipitate a worsening of disease or deliriumworsening of disease or delirium


Alzheimer’s DiseaseAlzheimer’s DiseaseAmbulatory and Home CareAmbulatory and Home Care

• Family members and friends care for Family members and friends care for most AD patients in their homesmost AD patients in their homes

• Various facilities should be evaluatedVarious facilities should be evaluated• Consider stage of AD patient when Consider stage of AD patient when

choosingchoosing• Nursing care intensifies over timeNursing care intensifies over time

• Family members and friends care for Family members and friends care for most AD patients in their homesmost AD patients in their homes

• Various facilities should be evaluatedVarious facilities should be evaluated• Consider stage of AD patient when Consider stage of AD patient when

choosingchoosing• Nursing care intensifies over timeNursing care intensifies over time



• In early stages memory aids may In early stages memory aids may provide benefitprovide benefit

• Drugs must be taken regularlyDrugs must be taken regularly• Drug compliance can be challengingDrug compliance can be challenging

• Adult day care can provide Adult day care can provide • Caregiver respite Caregiver respite • Stimulation for AD patientStimulation for AD patient

• In early stages memory aids may In early stages memory aids may provide benefitprovide benefit

• Drugs must be taken regularlyDrugs must be taken regularly• Drug compliance can be challengingDrug compliance can be challenging

• Adult day care can provide Adult day care can provide • Caregiver respite Caregiver respite • Stimulation for AD patientStimulation for AD patient



• Demands on caregiver can exceed Demands on caregiver can exceed resources and total care is neededresources and total care is needed

• Person may need to be placed in a Person may need to be placed in a long-term care facility long-term care facility • Special units for AD patients are Special units for AD patients are

growing in long-term care facilities growing in long-term care facilities • Emphasis on safetyEmphasis on safety

• Demands on caregiver can exceed Demands on caregiver can exceed resources and total care is neededresources and total care is needed

• Person may need to be placed in a Person may need to be placed in a long-term care facility long-term care facility • Special units for AD patients are Special units for AD patients are

growing in long-term care facilities growing in long-term care facilities • Emphasis on safetyEmphasis on safety


Alzheimer’s DiseaseAlzheimer’s DiseaseBehavioral ProblemsBehavioral Problems

• Occur in 90% of AD patientsOccur in 90% of AD patients• These problems includeThese problems include

• Repetitiveness Repetitiveness • DelusionsDelusions• IllusionsIllusions• HallucinationsHallucinations

• Occur in 90% of AD patientsOccur in 90% of AD patients• These problems includeThese problems include

• Repetitiveness Repetitiveness • DelusionsDelusions• IllusionsIllusions• HallucinationsHallucinations



• Problems (cont’d)Problems (cont’d)• AgitationAgitation• AggressionAggression• Altered sleep patternsAltered sleep patterns• WanderingWandering• Resisting careResisting care

• Problems (cont’d)Problems (cont’d)• AgitationAgitation• AggressionAggression• Altered sleep patternsAltered sleep patterns• WanderingWandering• Resisting careResisting care



• Behavior is unpredictable Behavior is unpredictable • Can be challenging for caregiverCan be challenging for caregiver• Behaviors are not intentional and Behaviors are not intentional and

difficult to controldifficult to control• Often lead to placement in Often lead to placement in

institutional settingsinstitutional settings

• Behavior is unpredictable Behavior is unpredictable • Can be challenging for caregiverCan be challenging for caregiver• Behaviors are not intentional and Behaviors are not intentional and

difficult to controldifficult to control• Often lead to placement in Often lead to placement in

institutional settingsinstitutional settings



• Are a patient’s way of responding to Are a patient’s way of responding to precipitating factorprecipitating factor• PainPain• FrustrationFrustration• Temperature extremesTemperature extremes• AnxietyAnxiety

• Are a patient’s way of responding to Are a patient’s way of responding to precipitating factorprecipitating factor• PainPain• FrustrationFrustration• Temperature extremesTemperature extremes• AnxietyAnxiety



• Assess patient’s Assess patient’s • Physical statusPhysical status• EnvironmentEnvironment

• Reassure patient about his or her Reassure patient about his or her safetysafety

• Assess patient’s Assess patient’s • Physical statusPhysical status• EnvironmentEnvironment

• Reassure patient about his or her Reassure patient about his or her safetysafety



• Nursing strategies to address difficult Nursing strategies to address difficult behaviorsbehaviors• RedirectionRedirection• DistractionDistraction• ReassuranceReassurance

• Do not threaten or restrain patient if Do not threaten or restrain patient if frustrated frustrated

• Nursing strategies to address difficult Nursing strategies to address difficult behaviorsbehaviors• RedirectionRedirection• DistractionDistraction• ReassuranceReassurance

• Do not threaten or restrain patient if Do not threaten or restrain patient if frustrated frustrated



• AD patients can experience AD patients can experience sundowningsundowning• Specific type of agitationSpecific type of agitation• Patient becomes more confused and Patient becomes more confused and

agitated in late afternoon or eveningagitated in late afternoon or evening• Cause is unclearCause is unclear• Remain calm and avoid confrontationRemain calm and avoid confrontation

• AD patients can experience AD patients can experience sundowningsundowning• Specific type of agitationSpecific type of agitation• Patient becomes more confused and Patient becomes more confused and

agitated in late afternoon or eveningagitated in late afternoon or evening• Cause is unclearCause is unclear• Remain calm and avoid confrontationRemain calm and avoid confrontation



• Nursing interventions: SundowningNursing interventions: Sundowning• Create a quiet, calm environmentCreate a quiet, calm environment• Maximize exposure to daylightMaximize exposure to daylight• Evaluate medicationsEvaluate medications• Limit naps and caffeineLimit naps and caffeine• Consult health care provider on drug Consult health care provider on drug

therapytherapy

• Nursing interventions: SundowningNursing interventions: Sundowning• Create a quiet, calm environmentCreate a quiet, calm environment• Maximize exposure to daylightMaximize exposure to daylight• Evaluate medicationsEvaluate medications• Limit naps and caffeineLimit naps and caffeine• Consult health care provider on drug Consult health care provider on drug

therapytherapy


Alzheimer’s DiseaseAlzheimer’s DiseaseSafetySafety

• RisksRisks• Injury from fallsInjury from falls• Ingesting dangerous substancesIngesting dangerous substances• WanderingWandering• Injury to others and self Injury to others and self • Fire or burnsFire or burns• Inability to respond to crisisInability to respond to crisis

• RisksRisks• Injury from fallsInjury from falls• Ingesting dangerous substancesIngesting dangerous substances• WanderingWandering• Injury to others and self Injury to others and self • Fire or burnsFire or burns• Inability to respond to crisisInability to respond to crisis



• Special attention to home Special attention to home environment to decrease riskenvironment to decrease risk

• Supervision is neededSupervision is needed

• Special attention to home Special attention to home environment to decrease riskenvironment to decrease risk

• Supervision is neededSupervision is needed



• Over time patient has difficulty Over time patient has difficulty navigating physical spacesnavigating physical spaces

• Nurse can help caregiver assessing Nurse can help caregiver assessing home environment for safety riskshome environment for safety risks

• Wandering is major concernWandering is major concern• AD patient can register with Safe AD patient can register with Safe

ReturnReturn

• Over time patient has difficulty Over time patient has difficulty navigating physical spacesnavigating physical spaces

• Nurse can help caregiver assessing Nurse can help caregiver assessing home environment for safety riskshome environment for safety risks

• Wandering is major concernWandering is major concern• AD patient can register with Safe AD patient can register with Safe

ReturnReturn


Alzheimer’s DiseaseAlzheimer’s DiseasePain ManagementPain Management

• Pain should be recognized and Pain should be recognized and treated promptlytreated promptly• Monitor patient’s responseMonitor patient’s response• Patients can have difficulty Patients can have difficulty

communicating complaintscommunicating complaints• May exhibit changes in behaviorMay exhibit changes in behavior

• Pain should be recognized and Pain should be recognized and treated promptlytreated promptly• Monitor patient’s responseMonitor patient’s response• Patients can have difficulty Patients can have difficulty

communicating complaintscommunicating complaints• May exhibit changes in behaviorMay exhibit changes in behavior


Alzheimer’s DiseaseAlzheimer’s DiseaseEating and Swallowing DifficultiesEating and Swallowing Difficulties

• Undernutrition problem in middle Undernutrition problem in middle and late stagesand late stages• Loss of interest in foodLoss of interest in food• Decreased ability to self-feedDecreased ability to self-feed• Comorbid conditionsComorbid conditions

• Undernutrition problem in middle Undernutrition problem in middle and late stagesand late stages• Loss of interest in foodLoss of interest in food• Decreased ability to self-feedDecreased ability to self-feed• Comorbid conditionsComorbid conditions



• When chewing and swallowing When chewing and swallowing become difficult usebecome difficult use• Pureed foodPureed food• Thickening liquidsThickening liquids• Nutritional supplementsNutritional supplements

• Quiet and unhurried environmentQuiet and unhurried environment• Easy-grip utensilsEasy-grip utensils

• When chewing and swallowing When chewing and swallowing become difficult usebecome difficult use• Pureed foodPureed food• Thickening liquidsThickening liquids• Nutritional supplementsNutritional supplements

• Quiet and unhurried environmentQuiet and unhurried environment• Easy-grip utensilsEasy-grip utensils



• Offer liquids frequentlyOffer liquids frequently• Finger foods may allow self-feedingFinger foods may allow self-feeding• Short-term possibilitiesShort-term possibilities

• Nasogastric (NG) feedingsNasogastric (NG) feedings• Percutaneous endoscopic gastrostomy Percutaneous endoscopic gastrostomy

(PEG) tube(PEG) tube

• Offer liquids frequentlyOffer liquids frequently• Finger foods may allow self-feedingFinger foods may allow self-feeding• Short-term possibilitiesShort-term possibilities

• Nasogastric (NG) feedingsNasogastric (NG) feedings• Percutaneous endoscopic gastrostomy Percutaneous endoscopic gastrostomy

(PEG) tube(PEG) tube


Alzheimer’s DiseaseAlzheimer’s DiseaseOral CareOral Care

• In late stages patient will be unable In late stages patient will be unable to perform oral self-careto perform oral self-care

• Dental problems likely to occurDental problems likely to occur• Patient may pocket food, adding to Patient may pocket food, adding to

potential tooth decaypotential tooth decay• Inspect mouth regularly, and mouth Inspect mouth regularly, and mouth

care should be provided care should be provided

• In late stages patient will be unable In late stages patient will be unable to perform oral self-careto perform oral self-care

• Dental problems likely to occurDental problems likely to occur• Patient may pocket food, adding to Patient may pocket food, adding to

potential tooth decaypotential tooth decay• Inspect mouth regularly, and mouth Inspect mouth regularly, and mouth

care should be provided care should be provided


Alzheimer’s DiseaseAlzheimer’s DiseaseInfection PreventionInfection Prevention

• CommonCommon• Urinary tract infectionUrinary tract infection• PneumoniaPneumonia• Ultimately cause of death in many AD Ultimately cause of death in many AD

patientspatients

• Manifestations need prompt Manifestations need prompt evaluation and treatmentevaluation and treatment

• CommonCommon• Urinary tract infectionUrinary tract infection• PneumoniaPneumonia• Ultimately cause of death in many AD Ultimately cause of death in many AD

patientspatients

• Manifestations need prompt Manifestations need prompt evaluation and treatmentevaluation and treatment


Alzheimer’s DiseaseAlzheimer’s DiseaseSkin CareSkin Care

• In late stages patient at risk for skin In late stages patient at risk for skin breakdown breakdown • Incontinence, immobility, and Incontinence, immobility, and

undernutritionundernutrition• Tend to rashes, areas of rednessTend to rashes, areas of redness• Keep skin dry and cleanKeep skin dry and clean• Change patient’s position regularlyChange patient’s position regularly

• In late stages patient at risk for skin In late stages patient at risk for skin breakdown breakdown • Incontinence, immobility, and Incontinence, immobility, and

undernutritionundernutrition• Tend to rashes, areas of rednessTend to rashes, areas of redness• Keep skin dry and cleanKeep skin dry and clean• Change patient’s position regularlyChange patient’s position regularly


Alzheimer’s DiseaseAlzheimer’s DiseaseElimination ProblemsElimination Problems

• Urinary and fecal incontinence Urinary and fecal incontinence during middle to late stagesduring middle to late stages

• Habit or behavioral retraining may Habit or behavioral retraining may ↓↓ episodes episodes

• Constipation may relate to Constipation may relate to immobility, dietary intake, immobility, dietary intake, ↓↓ fluids fluids

• Urinary and fecal incontinence Urinary and fecal incontinence during middle to late stagesduring middle to late stages

• Habit or behavioral retraining may Habit or behavioral retraining may ↓↓ episodes episodes

• Constipation may relate to Constipation may relate to immobility, dietary intake, immobility, dietary intake, ↓↓ fluids fluids


Alzheimer’s DiseaseAlzheimer’s DiseaseCaregiver SupportCaregiver Support

• AD disrupts all aspects of personal AD disrupts all aspects of personal and family lifeand family life

• Very stressfulVery stressful• Caregivers also exhibit adverse Caregivers also exhibit adverse

consequencesconsequences

• AD disrupts all aspects of personal AD disrupts all aspects of personal and family lifeand family life

• Very stressfulVery stressful• Caregivers also exhibit adverse Caregivers also exhibit adverse

consequencesconsequences


Alzheimer’s DiseaseAlzheimer’s DiseaseCaregiver SupportCaregiver Support

• Work with caregiver to Work with caregiver to • Assess stressors Assess stressors • Identify coping strategies Identify coping strategies • Find a support group Find a support group

• Local Alzheimer Association chapterLocal Alzheimer Association chapter

• Work with caregiver to Work with caregiver to • Assess stressors Assess stressors • Identify coping strategies Identify coping strategies • Find a support group Find a support group

• Local Alzheimer Association chapterLocal Alzheimer Association chapter


Alzheimer’s DiseaseAlzheimer’s DiseaseEvaluationEvaluation

• Patient goalsPatient goals• Functions at highest level of cognitive Functions at highest level of cognitive

abilityability• Performs self-care, bathing, dressing, Performs self-care, bathing, dressing,

and toileting with assistance as neededand toileting with assistance as needed• Experiences no injuryExperiences no injury• Uses assistive devices appropriately for Uses assistive devices appropriately for

ambulation supportambulation support

• Patient goalsPatient goals• Functions at highest level of cognitive Functions at highest level of cognitive

abilityability• Performs self-care, bathing, dressing, Performs self-care, bathing, dressing,

and toileting with assistance as neededand toileting with assistance as needed• Experiences no injuryExperiences no injury• Uses assistive devices appropriately for Uses assistive devices appropriately for

ambulation supportambulation support


Alzheimer’s DiseaseAlzheimer’s DiseaseEvaluationEvaluation

• Patient goals (cont’d)Patient goals (cont’d)• Uses effective coping strategies to Uses effective coping strategies to

manage grief related to diagnosis of ADmanage grief related to diagnosis of AD• Verbalizes reality of health situationVerbalizes reality of health situation• Remains in restricted area during Remains in restricted area during

ambulation and activityambulation and activity

• Patient goals (cont’d)Patient goals (cont’d)• Uses effective coping strategies to Uses effective coping strategies to

manage grief related to diagnosis of ADmanage grief related to diagnosis of AD• Verbalizes reality of health situationVerbalizes reality of health situation• Remains in restricted area during Remains in restricted area during

ambulation and activityambulation and activity


Other Neurodegenerative Other Neurodegenerative DiseasesDiseases

• Lewy body dementia (LBD)Lewy body dementia (LBD)• Characterized by presence of Lewy Characterized by presence of Lewy

bodies in brainstem and cortexbodies in brainstem and cortex• Common cause of dementiaCommon cause of dementia• Often unrecognizedOften unrecognized

• Lewy body dementia (LBD)Lewy body dementia (LBD)• Characterized by presence of Lewy Characterized by presence of Lewy

bodies in brainstem and cortexbodies in brainstem and cortex• Common cause of dementiaCommon cause of dementia• Often unrecognizedOften unrecognized



• LBD (cont’d)LBD (cont’d)• Symptoms of Symptoms of

• ParkinsonismParkinsonism• HallucinationsHallucinations• Short-term memory lossShort-term memory loss• Unpredictable cognitive shiftsUnpredictable cognitive shifts• Sleep disturbances Sleep disturbances

• LBD (cont’d)LBD (cont’d)• Symptoms of Symptoms of

• ParkinsonismParkinsonism• HallucinationsHallucinations• Short-term memory lossShort-term memory loss• Unpredictable cognitive shiftsUnpredictable cognitive shifts• Sleep disturbances Sleep disturbances



• LBD (cont’d)LBD (cont’d)• Dementia plus two of the following Dementia plus two of the following

indicates a possible diagnosisindicates a possible diagnosis• Extrapyramidal signs such as Extrapyramidal signs such as

bradykinesia, rigidity, and postural bradykinesia, rigidity, and postural instability, but not always a tremorinstability, but not always a tremor

• Fluctuating cognitive abilityFluctuating cognitive ability• Hallucinations Hallucinations

• LBD (cont’d)LBD (cont’d)• Dementia plus two of the following Dementia plus two of the following

indicates a possible diagnosisindicates a possible diagnosis• Extrapyramidal signs such as Extrapyramidal signs such as

bradykinesia, rigidity, and postural bradykinesia, rigidity, and postural instability, but not always a tremorinstability, but not always a tremor

• Fluctuating cognitive abilityFluctuating cognitive ability• Hallucinations Hallucinations



• LBD (cont’d)LBD (cont’d)• Medications determined on an Medications determined on an

individual basisindividual basis• Standard treatment plan has not been Standard treatment plan has not been

determineddetermined• Nursing care for LBD patients relates Nursing care for LBD patients relates

to management of dementia to management of dementia

• LBD (cont’d)LBD (cont’d)• Medications determined on an Medications determined on an

individual basisindividual basis• Standard treatment plan has not been Standard treatment plan has not been

determineddetermined• Nursing care for LBD patients relates Nursing care for LBD patients relates

to management of dementia to management of dementia



• Creutzfeldt-Jakob disease (CJD)Creutzfeldt-Jakob disease (CJD)• Rare and fatal brain disorderRare and fatal brain disorder• Caused by a prion proteinCaused by a prion protein

• Creutzfeldt-Jakob disease (CJD)Creutzfeldt-Jakob disease (CJD)• Rare and fatal brain disorderRare and fatal brain disorder• Caused by a prion proteinCaused by a prion protein



• CJD (cont’d)CJD (cont’d)• Earliest symptomsEarliest symptoms

• Memory impairmentMemory impairment• Behavior changesBehavior changes

• CJD (cont’d)CJD (cont’d)• Earliest symptomsEarliest symptoms

• Memory impairmentMemory impairment• Behavior changesBehavior changes



• CJD (cont’d)CJD (cont’d)• Disease progresses rapidly Disease progresses rapidly

• Mental deterioration Mental deterioration • Involuntary movementsInvoluntary movements• Weaknesses in limbsWeaknesses in limbs• BlindnessBlindness• Eventual comaEventual coma

• No diagnosis or treatmentNo diagnosis or treatment

• CJD (cont’d)CJD (cont’d)• Disease progresses rapidly Disease progresses rapidly

• Mental deterioration Mental deterioration • Involuntary movementsInvoluntary movements• Weaknesses in limbsWeaknesses in limbs• BlindnessBlindness• Eventual comaEventual coma

• No diagnosis or treatmentNo diagnosis or treatment



• Pick’s diseasePick’s disease• Type of frontotemporal dementiaType of frontotemporal dementia• Rare brain disorderRare brain disorder• Characterized byCharacterized by

• Disturbances in behaviorDisturbances in behavior• Sleep Sleep • PersonalityPersonality• Eventual memory lossEventual memory loss

• Pick’s diseasePick’s disease• Type of frontotemporal dementiaType of frontotemporal dementia• Rare brain disorderRare brain disorder• Characterized byCharacterized by

• Disturbances in behaviorDisturbances in behavior• Sleep Sleep • PersonalityPersonality• Eventual memory lossEventual memory loss



• Pick’s disease (cont’d)Pick’s disease (cont’d)• Major distinguishing characteristic is Major distinguishing characteristic is

marked symmetric lobar atrophy of marked symmetric lobar atrophy of temporal and/or frontal lobestemporal and/or frontal lobes

• Relentless progressionRelentless progression

• Pick’s disease (cont’d)Pick’s disease (cont’d)• Major distinguishing characteristic is Major distinguishing characteristic is

marked symmetric lobar atrophy of marked symmetric lobar atrophy of temporal and/or frontal lobestemporal and/or frontal lobes

• Relentless progressionRelentless progression



• Normal-pressure hydrocephalusNormal-pressure hydrocephalus• Uncommon disorderUncommon disorder• Characterized by obstruction in the Characterized by obstruction in the

flow of CSF causing a buildup of fluid flow of CSF causing a buildup of fluid in brainin brain

• Normal-pressure hydrocephalusNormal-pressure hydrocephalus• Uncommon disorderUncommon disorder• Characterized by obstruction in the Characterized by obstruction in the

flow of CSF causing a buildup of fluid flow of CSF causing a buildup of fluid in brainin brain



• Normal-pressure hydrocephalus Normal-pressure hydrocephalus (cont’d)(cont’d)• SymptomsSymptoms

• DementiaDementia• Urinary incontinenceUrinary incontinence• Difficulty in walkingDifficulty in walking

• Meningitis, encephalitis, or head injury Meningitis, encephalitis, or head injury may cause condition may cause condition

• Normal-pressure hydrocephalus Normal-pressure hydrocephalus (cont’d)(cont’d)• SymptomsSymptoms

• DementiaDementia• Urinary incontinenceUrinary incontinence• Difficulty in walkingDifficulty in walking

• Meningitis, encephalitis, or head injury Meningitis, encephalitis, or head injury may cause condition may cause condition



• Normal-pressure hydrocephalus Normal-pressure hydrocephalus (cont’d)(cont’d)• If diagnosed early, disease is treatable If diagnosed early, disease is treatable

by surgeryby surgery• Shunt is inserted to divert fluid away Shunt is inserted to divert fluid away

from brainfrom brain

• Normal-pressure hydrocephalus Normal-pressure hydrocephalus (cont’d)(cont’d)• If diagnosed early, disease is treatable If diagnosed early, disease is treatable

by surgeryby surgery• Shunt is inserted to divert fluid away Shunt is inserted to divert fluid away

from brainfrom brain

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