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This course fulfills the continuing education requirement of Alzheimer’s Disease Training for the state of Rhode Island. Alzheimer’s disease is a destructive, progressive, and irreversible brain disorder that slowly destroys memory and thinking. Alzheimer’s is the most common cause of dementia in older adults (1). For most people who have Alzheimer’s disease, symptoms first appear in their mid 60‘s (1). Studies suggest more than 5.5 million Americans, most 65 or older, may have dementia caused by Alzheimer’s (1). It is currently listed as the sixth leading cause of death in the united states. It is important to understand the signs and symptoms of Alzheimer’s disease and how to manage the care of a patient, family member, or friend suffering from the disease. This course will cover Alzheimer’s nursing care and all of the major aspects of patient care related to Alzheimer’s disease.

Introduction

Alzheimer‘s disease is a destructive, progressive, and irreversible brain disorder that slowly destroys memory and thinking. Alzheimer‘s is the most common cause of dementia in older adults (1). For most people who have Alzheimer‘s disease, symptoms first appear in their mid 60‘s (1). Studies suggest more than 5.5 million Americans, most 65 or older, may have dementia caused by Alzheimer‘s (1). It is currently listed as the sixth leading cause of death in the united states. It is important to understand the signs and symptoms of Alzheimer’s dementia and how to manage the Alzheimer’s nursing care of a patient, family member, or friend suffering from the disease .

Dementia is the loss of cognitive functioning-thinking, remembering, and reasoning- and behavioral abilities to such extent that it interferes with activities of daily living (1). The severity of dementia ranges from mild to severe. In its mildest stage, it begins with forgetfulness, with its most severe stage consists of complete dependence on others for general activities of daily living (1).  

History of Alzheimer‘s Disease

Alzheimer‘s disease is named after Dr. Alois Alzheimer. In the early 1900’s,  Dr. Alzheimer noticed changes in the brain tissue of a patient who had died of an unknown mental illness. The patient’s symptoms included memory loss, language problems, and unpredictable behavior. After her death, her brain was examined, and was noted to have abnormal clumps known as amyloid plaques and tangled bundled fibers, known as neurofibrillary or tau tangles (1). These plaques and tangles within the brain are considered some of the main features of Alzheimer‘s disease. Another feature includes connections of neurons in the brain. Neurons are responsible for the transmissions of messages between different parts of the brain and from the brain to other parts of the body (1).  

Scientists are continuing to study the complex brain changes involved with the disease of Alzheimer‘s. It seems that the changes in the brain could begin ten years or more before cognitive problems start to surface. During this stage of the disease, the people affected seem to be symptom–free; however, toxin changes occur within the brain (1). Initial damage in the brain occurs within the hippocampus and entorhinal cortex, which are the parts of the brain that are necessary in memory formation. As the disease progresses, additional aspects of the brain become affected, and overall brain tissue shrinks significantly (1).  

As research of Alzheimer’s disease continues to progress, so does Alzheimer’s nursing care.

Signs and Symptoms & Diagnosis of Alzheimer‘s Disease  

Memory problems are typically among the first signs of cognitive impairment related to Alzheimer‘s disease. Some people with memory problems have a condition called Mild Cognitive Impairment (MCI) (4). In this condition, people have more memory problems than usual for their age; however, their symptoms do not interfere with their daily lives. Older people with MCI are at increased risk of developing Alzheimer‘s disease. The first symptoms of Alzheimer’s may vary from person to person. Many people display a decline in non-memory related aspects of cognition such as word-finding, visual issues, impaired judgment, or reasoning (4).  

Providers use several methods and tools to determine the diagnosis of Alzheimer‘s Dementia. To diagnose, they may conduct tests of memory, problem–solving, attention, counting, and language. They may perform brain scans, including CVT. MRI or PET to rule out other causes for symptoms. Various tests may be repeated to give doctors information about how memory and cognitive functions change over time. They can help diagnose other causes of memory problems such as stroke, tumor, Parkinson‘s disease, and vascular dementia. Alzheimer‘s disease can be diagnosed only after death by linking clinical measures with an examination of brain tissue in an autopsy (4).  

Stages of Disease  

Mild Alzheimer‘s  

As the disease progresses, people experience significant memory loss along with other cognitive problems. Most people are diagnosed in this stage (1). 

• Wandering/getting lost  
• Trouble handling money or paying bills  
• Repeating questions  
• Taking longer to complete basic daily tasks 
• Personality/behavioral changes (1) 

Moderate Alzheimer‘s  

In this stage, damage occurs in the area of the brain that controls language, reasoning, sensor processing, and conscious thought (1).  

• Memory and confusion worsen  
• Problems recognizing family and friends  
• Unable to learn new things  
• Trouble with multi-step tasks such as getting dressed  
• Trouble coping with situations 
• Hallucinations/delusions/paranoia (1) 

Severe Alzheimer‘s 

In this stage, plaques and tangles spread throughout the brain and brain tissue shrinks by a significant amount.

• Cannot communicate  
• Completely dependent on others for care  
• Bedridden– most often as the body shuts down  

Prevention  

As a person ages, many worry about developing Alzheimer‘s disease and dementia. Especially if they have had a family member who suffered from the disease, they may worry about genetic risk. Although there have been many studies on the prevention of the disease, and many are still ongoing, nothing has been proven to prevent or delay dementia caused by Alzheimer‘s disease (2).  

A review led by experts from the National Academies of Sciences, Engineering, and Medicine, found encouraging yet inconclusive evidence for three types of interventions related to ways to prevent or delay Alzheimer‘s Dementia or age-related cognitive decline (2):  

• Increased physical activity  
• Blood pressure control  
• Cognitive training  

Treatment of the Disease  

Alzheimer‘s disease is complex and is continuously being studied. Current treatment approaches focus on helping people maintain their mental function, manage behavioral symptoms, and low the symptoms of the disease. The FDA has approved several prescription drugs to treat those diagnosed with Alzheimer‘s (3). Treating symptoms of Alzheimer‘s can provide patients diagnosed with comfort, dignity, and independence for a greater amount of time, simultaneously assisting their caregivers. The approved medications are most beneficial in the early or middle stages of the disease (3). 

Cholinesterase inhibitors are prescribed for mild to moderate Alzheimer‘s disease; they may help to reduce symptoms. Medications include Rzadyne®, Exelon ®, and Aricept ® (3).  Scientists do not fully understand how cholinesterase inhibitors work to treat the disease; however, research indicates that they prevent acetylcholine breakdown. Acetylcholine is a brain chemical believed to help memory and thinking (3). 

For those suffering from moderate to severe Alzheimer‘s disease, a medication known as Namenda®, which is an N-methyl D-asparate (NMDA) antagonist, is prescribed. This drug helps to decrease symptoms, allowing some people to maintain certain essential daily functions slightly longer than they would without medication (3). For example, this medication could help a person in the later stage of the disease maintain their ability to use the bathroom independently for several more months, benefiting the patient and the caregiver (3).  This drug works by regulating glutamate, which is an important chemical in the brain. When it is produced in large amounts, glutamate may lead to brain cell death. Because NMDA antagonists work differently from cholinesterase inhibitors, these rugs can be prescribed in combination (3).  

Medications that may be Contraindicated in Alzheimer‘s  

Some medications such as sleep aids, anxiety medications, anticonvulsants, and antipsychotics should only be taken by a patient diagnosed with Alzheimer‘s after the prescriber has explained the risk and side-effects of the medications (3).  

Sleep aids: They are used to help people get to sleep and stay asleep. People with Alzheimer‘s should not take these drugs regularly because they could make the person more confused and at a higher risk for falls.  

Anti-anxiety: These are used to treat agitation and can cause sleepiness, dizziness, falls, and confusion (3).  

Antipsychotics: they are used to treat paranoia, hallucinations, agitation, and aggression. Side effects can include the risk of death in older people with dementia. They would only be given when the provider agrees the symptoms are severe enough to justify the risk (3).   

Care-giving: A Major Component in Alzheimer’s Nursing Care

Coping with Agitation and Aggression  

People with Alzheimer‘s disease may become agitated or aggressive as the disease progresses. Agitation causes restlessness and causes someone to be unable to settle down. It may also cause pacing, sleeplessness, or aggression (5). As a caregiver, it is important to remember that agitation and aggression are usually happening for reasons such as pain, depression, stress, lack of sleep, constipation, soiled underwear, a sudden change in routine, loneliness, and the interaction of medications (5). Look for the signs of aggression and agitation. It is helpful to be able to prevent the problems before they happen.  

Coping with agitation and aggression (5):  

• Reassure the person. Speak calmly. Listen to concerns and frustrations.  
• Allow the person to keep as much control as possible  
• Build in quiet times along with activities 
• Keep a routine 
• Try gently touching, soothing music, reading, or walks 
• Reduce noise and clutter  
• Distract with snacks, objects, or activities

Common Medical Problems

In addition to the symptoms of Alzheimer‘s disease, a person with Alzheimer‘s may have other medical problems over time. These problems can cause confusion and behavior changes. The person may be unable to communicate with you as to what is wrong. As a caregiver, it is important to watch for various signs of illness and know when to seek medical attention for the person being cared for.  

Fever: Fever could be a sign of potential infection, dehydration, heatstroke, or constipation (4).  

Flu and Pneumonia: These are easily transmissible. Patients 65 years or older should get the flu and Pneumonia shot each year. Flu and Pneumonia may cause fever, chills, aches, vomiting, coughing, or trouble breathing (4).  

Falls: As the disease progresses, the person may have trouble with balance and ambulation. They may also have changes in depth perception. To reduce the chance of falls, clean up clutter, remove throw rugs use armchairs, and use good lighting inside (4). 

Dehydration: It is important to remember to ensure the person gets enough fluid. Signs of dehydration include dry mouth, dizziness, hallucinations, and rapid heart rate (4).  

Wandering  

Many people with Alzheimer‘s disease wander away from their homes or caregiver. As the caregiver, it is important to know how to limit wandering and prevent the person from becoming lost (5).  

Steps to Follow Before a Person Wanders (5) 

• Make sure the person carries a form of ID or wears a medical bracelet  
• Consider enrolling the person in the Medic Alert® + Alzheimer‘s Association Safe Return Program® 
• Alert neighbors and local police that the person tends to wander and ask them to alert you immediately if they are seen alone  
• Place labels on garments to aid in identification 

Tips to Prevent Wandering (5) 

• Keep doors locked. Consider a key or deadbolt 
• Use loosely fitting doorknob covers or safety devices  
• Place STOP, DO NOT ENTER, or CLOSED signs on doors  
• Divert the attention of the person away from using the door  
• Install a door chime that will alert when the door is opened  
• Keep shoes, keys, suitcases, coats, and hats out of sight  
• Do not leave a person who has a history of wandering unattended  

Conclusion of Alzheimer’s Nursing Care 

Alzheimer‘s is a sad, debilitating, progressive disease that robs patients of their life and dignity. As research continues on the causes, treatment, and prevention of the disease, it is important for healthcare workers and caregivers to know the signs and symptoms of a patient with Alzheimer‘s disease and potential coping mechanisms and management strategies of the disease. More information on the disease is available through several various resources, including:  

Family Caregiver Alliance  

800-445-8106 

NIA Alzheimer‘s and related Dementias Education and Referral Center  

800-438-4380 

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