Alzheimer, Alois

Etiology

In most cases of Alzheimer disease, a number of factors seem to interact to cause the disease, and there are certain heritable risk factors. The central biochemical problem in the disease appears to be a defect in the metabolism of alpha-amyloid precursor protein.

Symptoms

The disease begins with a mild memory loss (Stage I), which then progresses to deterioration of intellectual functions, personality changes, and speech and language problems (Stage II). In the terminal stage (Stage III), patients depend on others for activities of daily living. Seizures, hallucinations, delusions, paranoia, or depression can occur in either Stage II or III. Persons with Alzheimer disease will eventually develop macular degeneration See: table

Diagnosis

The diagnosis is usually made by ruling out other causes of cognitive dysfunction although a variety of laboratory tests are also employed in some settings.

Pathophysiology

Characteristic pathophysiological changes in the brain include neuritic plaques, neurofibrillary tangles, and marked cerebral atrophy. In addition to structural changes, abnormalities in cranial neurotransmitters may occur. Acetylcholine, for example, may be reduced by as much as 75%, contributing to cognitive impairment.

Treatment

The treatment of Alzheimer disease includes environmental structuring and drug therapy. Environmental structuring means provision of a safe, stimulating milieu that offers consistency and comfort for the patient. Drug therapy is to improve memory rather than cure the disease. Several cholinergic drugs, e.g., donepezil HCl (Aricept), are used to slow the decline in cognitive function. Antidepressants and psychotropic medications are used to treat patients who have secondary diagnoses such as depression and hallucinations.

Patient care

Reality orientation is helpful for patients in early stages of the disease. Validation therapy is most appropriate for patients in Stage II or III.

In collaboration with the physical and occupational therapists, the nurse assesses the patient's need for assistance with activities of daily living. Self-care, exercise, and other activities are encouraged as much as possible. If sleep disturbances occur, the patient should rest between daytime activities, but sleeping during daytime hours is to be discouraged. Neurological function, including mental and emotional states and motor capabilities, is monitored for further deterioration. Vital signs and respiratory status are assessed for pneumonia and other infections. The patient is evaluated for gastrointestinal or urinary problems (anorexia, dysphagia, and urinary or fecal incontinence); fluid and food intake is monitored to detect imbalances. The nurse or assistive nursing personnel takes the patient to the bathroom or bedside commode before and after meals and every 2 hr in between. Skin is inspected for evidence of trauma. The occupational therapist, home health nurse, or case manager assesses the patient's living environment to eliminate hazards and teaches the family to monitor the patient's activity to prevent falls, burns, and other injuries. Expectations should not exceed the patient's ability to perform tasks. Because the patient may misperceive the environment, health professionals should speak softly and calmly and allow sufficient time for answers because of the patient's slowed thought processes and impaired ability to speak. The case manager or nurse evaluates the caregiver's ability to manage the patient at home and makes the appropriate referrals to available local resources such as counseling, support groups, and respite care.

Loneliness, helplessness, and boredom, all associated with institutionalization, can be reduced by incorporating into the environment plants, pets, aviaries, and children as well as opportunities to handle objects having different tactile surfaces. A decor similar to the patient's familiar surroundings may provide comfort. Music therapy may enhance emotional and physical well-being, cognitive skills, ability to communicate, and social functioning. Activity therapy should include the patient’s known earlier interests and preferences. Such activities benefit the patient by encouraging interaction with others and by providing intellectual stimulation.

If mild cognitive impairment or early stage Alzheimer disease is suspected, the person should be evaluated by his physician or referred to a neurologist or gerontologist for evaluation. Early diagnosis allows family members to plan and prepare for the future. The physical and emotional health of the primary caregiver is an additional concern for the health team. Support groups can be a great help to family members by discussing care issues and exchanging information and by considering the caregivers’ feelings and coping skills in an accepting atmosphere. Caregivers experience grief and loss during and after the illness and need help in expressing their grief and pain. Some male caregivers may face unique challenges in taking over many of the tasks traditionally done by an ill wife or mother. All caregivers share the struggle with the common elements of acceptance: accepting the diagnosis, the devastating changes, the limited understanding of others, the progression of the disease, and the need for placement in a nursing home if this becomes necessary. Support groups can help with this process. Respite care can give life-sustaining relief to both partners. Friends who want to help may not even know what to offer, and caregivers must learn how to ask for help with specific tasks.

The local chapter of the Alzheimer's Disease and Related Disorders Association (ADRDA), sometimes simply referred to as the Alzheimer's Association, is an excellent resource. A list of local chapters can be found through the national ADRDA at 919 N. Michigan Avenue, Suite 1000, Chicago, IL 60611-1676 or at their web site at www.alz.org.