Running head: ALZHEIMERS DISEASE

An Overview of Alzheimers Disease

AN OVERVIEW OF ALZHEIMERS DISEASE An Overview of Alzheimers Disease In a November 5, 1994 letter announcing his diagnosis of Alzheimers disease (AD), the late, former President of the United States, Ronald Reagan said; I now begin the journey that will lead me into the sunset of my life (Wetzstein, 2011). For so many, AD forever alters the course of their life. This paper focuses on the technical aspects of this devastating disease, however we cannot forget the people who are personally affected. Originally discovered by Alois Alzheimer in 1906 (Cummings, 2008), AD has surfaced as the most common type of dementia and the sixth leading cause of death in the elderly today (Alzheimers Association, 2013a). An estimated 5.2 million Americans of all ages have AD (Alzheimers Association, 2013a). The

number will soar rapidly in coming years as the baby boom generation ages. In the United States, the cost of caring for patients with AD has been estimated to be $148 billion annually (Cummings, 2008). In recent years, research studies have made major advances in our understanding of the pathophysiology, signs and symptoms, risk factors, and treatment options for this disparaging disease. This

AN OVERVIEW OF ALZHEIMERS DISEASE report outlines that understanding, along with associated nursing diagnoses, planning outcomes, and recommended interventions for Alzheimers care. Pathophysiology and Diagnostic Studies The common neuropathologic findings in AD include amyloid plaques, neurofibrillary tangles, and synaptic and neuronal cell death. Amyloid plaques all

contain forms of Beta-amyloid protein (Lewis, 2011, p. 1523). B-amyloid protein is believed to interfere with neuronal activity because of its stimulatory effect on production of free radicals, resulting in oxidative stress and neuronal cell death. Neurofibrillary tangles are paired helical filaments composed of tau protein, which in normal cells is essential for axonal growth and development (Lewis, 2011, p. 1523). However, when hyper phosphorylated, the tau protein forms tangles that are deposited within neurons located in the hippocampus and medial temporal lobe, the parietal temporal region, and the frontal association cortices, leading to cell death (Poalelungi, & Popescu, 2013). Areas of neuronal cell death and synapse loss greatly affect neurotransmitter pathways. The death of cholinergic neurons leads to a deficit in acetylcholine (Ach), a major neurotransmitter believed to be involved with memory. In addition, loss of

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serotoninergic neurons leads to deficits in serotonin and norepinephrine (Poalelungi, & Popescu, 2013). Glutamate is found in excess in AD and causes damage to brain cells. Familial early onset AD is associated with Genetic mutations in chromosomes 21, 14, and 1. These chromosomal mutations account for less than 5% of all cases and result in the overproduction and deposit of B-amyloid protein (Cummings 2008). Although a conclusive diagnosis of AD requires an autopsy to examine brain tissue for neurofibrillary tangles and neuritic plaques, diagnosis can be made through the process of exclusion, ruling out other disorders (Lewis, 2011, p. 1525). Cognitive impairment is one of the early signs, which can be caused by a variety of conditions, some treatable. Once other possible conditions are ruled out, a comprehensive patient evaluation includes a complete health history, physical examination, neurologic and mental status assessments, and laboratory tests (Lewis, 2011, p.1525). To detect early changes in the brain and create a baseline, Lewis (2011, p. 1525) indicates that magnetic resonance spectroscopy (MRS), and positron emission tomography (PET) scans can be used. Additionally,

AN OVERVIEW OF ALZHEIMERS DISEASE Computed tomography (CT) and magnetic resonance imaging (MRI) may be used to identify later changes in the brain. Signs, Symptoms, and Risk Factors In his discovery of the disease, Alois Alzheimer described the case of

Auguste D., a patient who had profound memory loss, unfounded suspicions about her family, and other worsening psychological changes. During the autopsy of her brain, he saw dramatic shrinkage and abnormal deposits in and around nerve cells (Alzheimers Association, 2013b). As a result of his work, and the work of his predecessor, we now know that AD is a progressive dementia with memory loss as the major clinical manifestation. Another important feature is the disturbance of language. Initially, patients might search for words when naming objects or while engaged in a simple conversation. But with progression of the disease, the language difficulties evolve into an inability to communicate as the patient struggles with a distinctly limited vocabulary, nominal aphasia, and defects in verbal comprehension (Alzheimers Association, 2013b). Other signs and symptoms such as apraxia, and visual spatial dysfunction may become apparent over the course of the disease. With the development of

AN OVERVIEW OF ALZHEIMERS DISEASE apraxia, patients lose the ability to carry out such simple tasks as combing their hair or turning on a water faucet. Visual spatial abnormalities can be seen as patients become disoriented with their body position in space (University of Maryland Medical Center, 2013). Behavioral problems emerge throughout the various stages of the disease. Mood disturbances such as depression, anxiety, or apathy may be present early on in AD, whereas delusions, hallucinations, and psychosis can be prominent in later stages (Poalelungi, & Popescu, 2013). In addition, aggression and inappropriate sexual behavior can be particularly problematic for the caregiver. Researchers continue to try to understand the signs and have begun to understand who may be at risk. Age is the primary risk factor for AD. The number of AD cases doubles every 5 years beyond age 65. While less common, AD can also affect younger people. More women than men develop AD. African Americans and Hispanics are at greater risk than whites. This may be in part because they have a higher prevalence of medical conditions such as high blood pressure, obesity, high cholesterol, and diabetes, which are also associated with an increased risk for

AN OVERVIEW OF ALZHEIMERS DISEASE Alzheimers. Although we understand more and more about AD, we are still no closure to a cure. Treatment Options Drug therapy aims to slow disease progression and treat associated symptoms (University of Maryland Medical Center, 2013). Used in mild to moderate AD, Cholinesterase inhibitors block cholinesterase, the enzyme responsible for the breakdown of Ach. Cholinesterase inhibitors include donepezil, rivastigmine, and galantamine. In late stage AD, N-methyl-D-aspartate (NMDA) receptor antagonists such as memantine may prevent cell destruction by blocking the action of glutamate, a different messenger chemical involved in learning and memory (Shan, 2013). Depression, anxiety, and irritability are often associated with early stages of AD and treatment may improve cognition. Treatment for depression may include selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, sertraline, and citalopram. Anxiolytics such as lorazapam are used for anxiety/restlessness. Hallucinations may accompany later stages of AD. Although used as a drug of last resort, due to their harmful side effects, treatment for

AN OVERVIEW OF ALZHEIMERS DISEASE hallucinations may include antipsychotic medications like risperidone (U.S. Department of Health and Human Services, 2013). Researchers have also found

promise in a non-psychoactive cannabinoid in cannabis. Study results indicate that cannabidiol exerts a combination of neuroprotective, anti-oxidative and antiapoptotic effects on the brain (Iuvone et al., 2004). Cacao, acai oil, Coconut Oil, and many other natural remedies have also been associated with reducing oxidative stress. Ginkgo Biloba, a unique species of tree is sometimes used to improve memory and circulation. The Nurse should consider the patients medical treatment plan, input from family/caregivers, and the patients wishes when developing a comprehensive care plan. Common Nursing Diagnosis, Expected Outcomes, and Interventions Care plans are developed based on the individual patient diagnoses and will differ based on the progression of the disease. AD is staged as mild, moderate, and severe. The mild stage may consist of memory deficits, irritability, and confusion. Individuals progress from mild Alzheimers disease to moderate and severe disease at different rates. Progression results in a decline of the individuals cognitive and functional abilities. In advanced Alzheimers, people need

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help with activities of daily living (ADLs). In the final stages individuals lose their ability to communicate, walk, and swallow. They fail to recognize loved ones, and become bed-bound, reliant on around the clock care. Nursing diagnoses and interventions should focus on the complications encountered at the differing stages of worsening cognitive and functional conditions. The Nurses Pocket Guide (Doenges, Moorhouse, & Murr, 2010) outlines possible diagnosis, outcomes, and interventions. A patient assessment, and family/caregiver interview should precede development of the care plan. For the purpose of this paper, we will focus on the following nursing diagnosis to outline a care plan: chronic confusion, caregiver role strain, and risk for injury, which may apply in all stages of AD. Chronic confusion, related to progressive degeneration of the cerebral cortex, causes an irreversible decline in mental ability and personality (pp. 215218). Cognitive deterioration is present and long-standing. One of the expected outcomes could be patient will remain safe and free from harm. Family or significant other will identify and participate in interventions to deal effectively with the situation is another expected outcome. Interventions may include: the nurse will assess patients cognitive impairment by conducting an Alzheimers

AN OVERVIEW OF ALZHEIMERS DISEASE Disease Assessment Scale and by talking with the patients significant others and/or caregivers to identify baseline behaviors and longevity of difficulties. Another intervention might be determining anxiety level in relation to situation and problem behaviors. Caregiver role strain, related to apprehension about the future and caregivers ability to provide care, is a critical concern in AD (pp. 163-166). Planning outcomes might include; caregiver will identify resources within self to deal with situation, and report improved general well being/ability to deal with situation. Interventions could involve; assess caregivers current state of functioning (e.g., sleep, nutrition, demeanor, personal appearance) and discuss strategies to coordinate caregiving tasks and other responsibilities. Additionally,

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determine the need for, and identify additional resources (e.g., respite care, legal, spiritual). Risk for injury, related to confusion, disorientation, impaired decision making, and inability to identify hazards in the environment is a genuine concern in AD (pp. 472-475). Expected outcomes should include patient is free of injury, and modify environment (as indicated) to enhance safety. Perform thorough

AN OVERVIEW OF ALZHEIMERS DISEASE assessments regarding safety issues for care receiver and caregiver. Provide information regarding the patients disease that may result in increased risk for injury. Identify interventions and safety devices to promote a safe physical environment. Conclusion

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During her August 13, 1996 speech at the Republican National Convention, Nancy Reagan poignantly talked about the terrible pain and loneliness that must be endured, as each day brings another reminder of this very long goodbye'' when talking about AD (Nagourney, 1996). Characteristic of the disease, Ronald Reagans sunset occurred ten years after his initial diagnosis. Thanks in part to the Reagans campaign to raise awareness; the world is more focused on changing the course of AD. This paper provides an overview of AD, outlining the pathophysiology; diagnostic studies, signs and symptoms, risk factors, treatment, and information outlining nursing care plan development. Nurses can use this paper to provide an overview of AD to caregivers/family members and to collaboratively develop plan that will enhance the patients life. By doing so, caregivers/family members will

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have a good foundation for understanding the disease itself, patient behavior, and care needs. The patient will benefit as a result of this understanding. While researching this paper, I found it astounding that one in eight people over the age of 65 will be struck by AD. My research taught me that we should be hopeful for a cure, hopeful for a good day of caring for and living with Alzheimers disease, and most of all I am hopeful that science makes a difference sooner than later!

AN OVERVIEW OF ALZHEIMERS DISEASE References: Alzheimers Association, (2013a). Alzheimers disease facts and figures,

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Alzheimers & Dementia, Volume 9, Issue 2.b

Alzheimers Association. (2013b). Major milestones in Alzheimers and brain

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http://www.alz.org/research/science/major_milestones_in_alzheimers.asp Cummings, J. L. (2008). Update on Alzheimers disease: One Hundred Years After Dr. Alois Alzheimer. Primary Psychiatry, 15 (Suppl.1), 4-6. Doenges, M., Moorhouse, M. F., & Murr, A. (2010). Nurses pocket guide:

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Iuvone, T., Esposito, G., Esposito, R., Santamaria, R., Di Rosa, M., & Izzo, A. A. (2004). Neuroprotective effect of cannabidiol, a non-psychoactive

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component from Cannabis sativa, on -amyloid-induced toxicity in PC12 cells.

Journal Of Neurochemistry, 89 (1), 134-141. doi:10.1111/j.14714159.2003.02327.x Nagourney, A. (August 1996). A bittersweet moment brings tears. The New

York Times. Retrieved from: http://www.nytimes.com/1996/08/13/us/abittersweet-moment-brings-tears.html?pagewanted=print&src=pm Poalelungi, A., & Popescu, B. O. (2013). Alzheimers disease Neurological or psychiatric disorder?. Romanian Journal of Neurology, 12(1), 5-14. http://moe.ic.highline.edu:2048/login?url=http:// Shan, Y. (July 2013). Treatment of Alzheimers disease. Primary Health Care [serial online]. 23(6):32-38. Available from: Academic Search Complete, Ipswich, MA. Accessed November 11, 2013. University of Maryland Medical Center, (September 2013). Alzheimers disease. Retrieved from: http://umm.edu/health/medical/reports/articles/alzheimersdisease

AN OVERVIEW OF ALZHEIMERS DISEASE U. S. Department of Health and Human Services (2013). National Plan to

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Address Alzheimers Disease. Retrieved from:

http://www.alzheimers.gov/fighting_alzheimers.html Wetzstein, C. (February 3, 2011). Alzheimers: Reagans long goodbye. The

Washington Times. Retrieved from:

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