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Alzheimer’s disease: Management

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Alzheimer’s disease: Management

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Alzheimer’s disease: Management

  1. 1. Alzheimer’s Disease<br />
  2. 2. Overview<br />
  3. 3. Alzheimer's disease<br />A progressive degenerative disorder of the cerebral cortex (especially the frontal lobe)<br /> Most common form of dementia<br />5% of people older than age 65 have a severe form of this disease<br />12% suffer from mild to moderate dementia<br />
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  5. 5. Alzheimer's disease<br />Characterized by:<br />Progressive impairment in memory, cognitive function, language, judgment, and ADL<br />Ultimately, patients cannot perform self-care activities and become dependent on caregivers<br />Prognosis: poor<br />
  6. 6. Pathophysiology and Etiology<br />
  7. 7. Gross pathophysiologic changes:<br />cortical atrophy<br />enlarged ventricles<br />basal ganglia wasting<br />Microscopically:<br />Changes in the proteins of the nerve cells of the cerebral cortex<br />accumulation of neurofibrillary tangles and neuritic plaques (deposits of protein and altered cell structures on the interneuronal junctions) <br />granulovascular degeneration<br />loss of cholinergic nerve cells (important in memory, function, cognition)<br />
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  11. 11. Biochemically:<br />neurotransmitter systems are impaired<br />Cause: unknown<br />Risk factors:<br />genetics and female gender<br />Viruses, environmental toxins, silent brain infarcts, and previous head injury may also play a role<br />
  12. 12. Clinical manifestations<br />
  13. 13. Disease onset: subtle and insidious<br />Initially, a gradual decline of cognitive function from a previously higher level<br />Short-term memory impairment is commonly the first characteristic in earliest stages of the disease<br />Forgetful and difficulty learning and retaining new information<br />Difficulty planning meals, managing finances, using a telephone, or driving without getting lost<br />
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  15. 15. Functional deficits:<br />Language disturbance (word-finding difficulty)<br />Visual-processing difficulty<br />Inability to perform skilled motor activities<br />Poor abstract reasoning and concentration<br />Personality changes:<br />Irritability<br />Suspiciousness<br />Personal neglect of appearance<br />Disorientation to time and space<br />
  16. 16. Middle stage:<br />Repetitive actions (perseveration)<br />Nocturnal restlessness<br />Apraxia (impaired ability to perform purposeful activity)<br />Aphasia (inability to speak)<br />Agraphia (inability to write)<br />Signs of frontal lobe dysfunction:<br />Loss of social inhibitions<br />Loss of spontaneity<br />
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  18. 18. Middle and late stages:<br />Delusions<br />Hallucinations<br />Aggression<br />Wandering behavior<br />Patients in the advanced stage of Alzheimer's disease require total care<br />Urinary and fecal incontinence<br />Emaciation<br />Increased irritability<br />Unresponsiveness or coma<br />
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  21. 21. complications<br />
  22. 22. Increased incidence of functional decline<br />Injury due to lack of insight, hallucinations, confusion, wandering, own violent bahavior<br />Pneumonia and other infections, especially if the patient doesn't get enough exercise<br />Malnutrition and dehydration due to inattention to mealtime and hunger or lack of ability to prepare meals<br />Aspiration<br />
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  25. 25. Diagnostic evaluation<br />
  26. 26. Detailed patient history with corroboration by an informed source<br />to determine cognitive and behavioral changes, their duration, and symptoms that may be indicative of other medical or psychiatric illnesses<br />Noncontrast computed tomography (CT) scan, Magnetic resonance imaging (MRI), single-photon emission computed tomography (SPECT) <br />to rule out other neurologic conditions<br /><ul><li>Neuropsychological evaluation (mental status assessment)</li></ul>to identify specific areas of impaired mental functioning in contrast to areas of intact functioning<br />
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  29. 29. Laboratory tests:<br />complete blood count, sedimentation rate, chemistry panel, thyroid-stimulating hormone, test for syphilis, urinalysis, serum B12, folate level, and test for HIV<br />to rule out infectious or metabolic disorders<br />Commercial assays for cerebrospinal fluid (CSF) tau protein and beta-amyloid<br />Genetic testing<br />In families with a history of Alzheimer's disease, test to confirm AD or to provide information to at-risk family members regarding their likelihood for development of AD<br />
  30. 30. management<br />
  31. 31. Primary goals of treatment for Alzheimer's disease:<br />To maximize functional abilities and improve quality of life by enhancing mood, cognition, and behavior<br />No curative treatment exists<br />Cholinesterase inhibitors <br />first treatment for cognitive impairment of AD<br />Improve cholinergic neurotransmission to help delay decline in function over time<br />
  32. 32. <ul><li>Donepezil (Aricept)</li></ul>Widely used in mild to moderate cases because it can be given once daily and is well tolerated<br />Starting at 5 mg hs and increased to 10 mg after 4 to 6 weeks<br /><ul><li>Galantamine (Reminyl) </li></ul>Given with food in dosage of 4 to 12 mg bid<br />Should be restarted at 4 mg bid if interrupted for several days<br />Dose should be reduced in cases of renal or hepatic impairment<br />
  33. 33. <ul><li>Rivastigmine (Exelon) </li></ul>Given 1.5 mg bid with meals and increased up to 6 to 12 mg per day<br /><ul><li>Memantine (Namenda)</li></ul>NMDA-receptor antagonist<br />The first of a new class approved for moderate to severe Alzheimer's<br />Dosage is 10 mg bid<br />Can be used with a cholinesterase inhibitor<br />
  34. 34. Patients with depressive symptoms should be considered for antidepressant therapy<br />Behavioral disturbances may require pharmacologic treatment<br />anxiolytics, antipsychotics, anticonvulsants<br />Nonpharmacologic treatments used to improve cognition:<br />Environmental manipulation that decreases stimulation<br />Pet therapy<br />Aromatherapy<br />Massage<br />Music therapy<br />Exercise<br />
  35. 35. Drug Alert<br />Cholinesterase inhibitors <br />initially aimed at improving memory and cognition<br />seem to have an important impact on the behavioral changes that occur in patients with cognitive impairment<br />improves the apathy, disinhibition, pacing, and hallucinations commonly noted in dementia<br />Be alert for drug interactions with NSAIDs, succinylcholine-type muscle relaxants, cholinergic and anticholinergic agents, drugs that slow the heart, and other drugs that are metabolized by the hepatic CYP2D6 or CYP3A4 pathways<br />
  36. 36. Nursing assessment<br />
  37. 37. Perform cognitive assessment:<br />orientation, insight, abstract thinking, concentration, memory, verbal ability<br />Assess for changes in behavior and ability to perform ADLs<br />Evaluate nutrition and hydration<br />check weight, skin turgor, meal habits<br />Assess motor ability, strength, muscle tone, flexibility<br />
  38. 38. Nursing diagnoses<br />
  39. 39. Bathing or hygiene self-care deficit<br />Constipation<br />Disabled family coping<br />Disturbed thought processes<br />Dressing or grooming self-care deficit<br />Feeding self-care deficit<br />Imbalanced nutrition: Less than body requirements<br />Impaired verbal communication<br />Ineffective coping<br />Interrupted family processes<br />Risk for infection<br />Risk for injury<br />Toileting self-care deficit<br />
  40. 40. Key outcomes<br />
  41. 41. The patient will<br />perform bathing and hygiene needs<br />maintain a regular bowel elimination pattern<br />(Family members will) use support systems and develop adequate coping behaviors<br />remain oriented to time, person, place, and situation to the fullest extent possible<br />perform dressing and grooming needs within the confines of the disease process<br />consume daily calorie requirements<br />
  42. 42. The patient will<br />show no signs of malnutrition<br />effectively communicate needs verbally or through the use of alternative means of communication<br />use support systems and develop adequate coping behaviors<br />(Family members will) discuss the impact of the patient's condition on the family unit<br />remain free from signs and symptoms of infection<br />(Family members will) identify strategies to make the patient's environment as safe as possible<br />perform toileting needs within the confines of the disease process<br />
  43. 43. Nursing interventions<br />
  44. 44.
  45. 45. Establish an effective communication system with the patient and his family<br />to help them adjust to the patient's altered cognitive abilities<br />Provide emotional support to the patient and his family<br />Encourage them to talk about their concerns<br />Listen carefully to them<br />Answer their questions honestly and completely<br />Use a soft tone and a slow, calm manner when speaking to him<br />Because the patient may misperceive his environment, <br />
  46. 46. Allow the patient sufficient time to answer your questions <br />his thought processes are slow, impairing his ability to communicate verbally<br />Administer ordered medications to the patient and note their effects<br />If the patient has trouble swallowing, check with a pharmacist to see if tablets can be crushed or capsules can be opened and mixed with a semi-soft food<br />Protect the patient from injury <br />Provide a safe, structured environment<br />Provide rest periods between activities because these patients tire easily<br />
  47. 47. Encourage the patient to exercise<br />to help maintain mobility<br />Encourage patient independence<br />allow ample time for the patient to perform tasks<br />Encourage sufficient fluid intake and adequate nutrition<br />Provide assistance with menu selection<br />allow the patient to feed himself as much as he can<br />Provide a well-balanced diet with adequate fiber<br />Avoid stimulants, such as coffee, tea, cola, and chocolate<br />
  48. 48. Give the patient semisolid foods if he has dysphagia<br />Insert and care for a nasogastric tube or a gastrostomy tube for feeding as ordered<br />Because the patient may be disoriented or neuromuscular functioning may be impaired, take the patient to the bathroom at least every 2 hours<br />Make sure he knows the location of the bathroom<br />Assist the patient with hygiene and dressing as necessary<br />Many patients with Alzheimer's disease are incapable of performing these tasks<br />
  49. 49. Patient teaching<br />
  50. 50. Teach the patient's family about the disease<br />Explain that the cause of the disease is unknown<br />Review the signs and symptoms of the disease<br />Be sure to explain that the disease progresses but at an unpredictable rate and that patients eventually suffer complete memory loss and total physical deterioration<br />Review the diagnostic tests that are to be performed and treatment the patient requires<br />Advise family members to provide the patient with exercise<br />Suggest physical activities, such as walking or light housework, that occupy and satisfy the patient<br />
  51. 51. Stress the importance of diet<br />Limit the number of foods on the patient's plate so he doesn't have to make decisions<br />If the patient has coordination problems, cut his food and to provide finger foods, such as fruit and sandwiches<br />Suggest using plates with rim guards, easy-grip utensils, and cups with lids and spouts<br />Allow the patient as much independence as possible while ensuring his and others' safety<br />Create a routine for all the patient's activities, which helps them avoid confusion<br />If the patient becomes belligerent, advise family members to remain calm and try to distract him<br />Refer family members to support groups<br />
  52. 52. Teaching patient about alzheimer’s disease<br />
  53. 53. Counsel family members to expect progressive deterioration in the patient with Alzheimer's disease<br />To help them plan future patient care, discuss the stages of this relentless neurodegenerative disease<br />Bear in mind that family members may refuse to believe that the disease is advancing<br />Be sensitive to their concerns and, if necessary, review the information again when they're more receptive<br />
  54. 54. Forgetfulness<br />The patient becomes forgetful, especially of recent events<br />He frequently loses everyday objects such as keys<br />Aware of his loss of function, he may compensate by relinquishing tasks that might reveal his forgetfulness<br />Because his behavior isn't disruptive and may be attributed to stress, fatigue, or normal aging, he usually doesn't consult a physician at this stage<br />
  55. 55. Confusion<br />The patient has increasing difficulty at activities that require planning, decision making, and judgment, such as managing personal finances, driving a car, and performing his job<br />He does retain skills such as personal grooming<br />Social withdrawal occurs when the patient feels overwhelmed by a changing environment and his inability to cope with multiple stimuli<br />Travel is difficult and tiring<br />As he becomes aware of his progressive loss of function, he may become severely depressed<br />Safety becomes a concern when the patient forgets to turn off appliances or recognize unsafe situations such as boiling water<br />At this point, the family may need to consider day care or a supervised residential facility<br />
  56. 56. Decline in activities of daily living<br />The patient at this stage loses his ability to perform such daily activities as eating or washing without direct supervision<br />Weight loss may occur<br />He withdraws from the family and increasingly depends on the primary caregiver<br />Communication becomes difficult as his understanding of written and spoken language declines<br />Agitation, wandering, pacing, and nighttime awakening are linked to his inability to cope with a multisensory environment<br />He may mistake his mirror image for a real person (pseudohallucination)<br />Caregivers must be constantly vigilant, which may lead to physical and emotional exhaustion<br />They may also be angry and feel a sense of loss.<br />
  57. 57. Total deterioration<br />In the final stage of Alzheimer's disease, the patient no longer recognizes himself, his body parts, or other family members<br />He becomes bedridden, and his activity consists of small, purposeless movements<br />Verbal communication stops, although he may scream spontaneously<br />Complications of immobility may include pressure ulcers, urinary tract infections, pneumonia, and contractures<br />
  58. 58. Learning activity<br />
  59. 59. True or False: Alzheimer’s disease is a memory-related disease that is reversible with medications.<br />
  60. 60. FALSE<br />Alzheimer’s disease is a progressive degenerative disorder of the brain that is irreversible<br />The exact cause is unknown; initial stages include recent memory loss and impaired judgment, inability to learn and retain new information, and difficulty finding words; later stages include decreased abilility to care for self, wandering, agitation and hostility, and possibly eventually inability to walk, incontinence, and no intelligible speech<br />Medications may help improve memory in early stages, but there is no cure<br />It is typically diagnosed when other dementia-producing conditions have been ruled out<br />
  61. 61. http://nurseRD.blogspot.com<br />www.authorstream.com/reynel89/Nursing<br />www.slideshare.net/reynel89/slideshows<br />THANK YOU!Have a nice day : )<br />- RDG<br />

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