Alzheimer's Disease Dwane June D.

Peola, RN

WHAT IS ALZHEIMER'S DISEASE?

Alzheimer's disease is a progressive, neurodegenerative disease that occurs when nerve cells in the brain die and often results in the following:

Impaired memory, thinking, and behavior Confusion Restlessness Personality and behavior changes Impaired judgment Impaired communication Inability to follow directions Language deterioration Impaired thought processes that involve visual and spatial awareness Emotional apathy

HISTORY

When Alzheimer's was first identified by German physician, Alois Alzheimer, in 1906, it was considered a rare disorder. Today Alzheimer's disease is recognized as the most common cause of dementia (a disorder in which mental functions deteriorate and break down). An estimated 5.3 million Americans have Alzheimer's disease. According to the Alzheimer's Association, this number includes 5.1 million people over the age of 65, as well as 200,000 to 500,000 people younger than 65 who have early-onset Alzheimer's and other types of dementias.

ASSESSMENT: HISTORY
Ask both the patient & a reliable informant about the patients: Current condition Medical history Current medications & medication history Patterns of alcohol use or abuse Living arrangements

ASSESSMENT: PHYSICAL
Examine: Neurologic status Mental status Functional status Neuropsychologic testing

ASSESSMENT: LABORATORY
Complete blood cell count Blood chemistries Liver function tests Serologic tests for: Syphilis, TSH, Vitamin B12 level

ASSESSMENT: BRAIN IMAGING

Use imaging when: Onset occurs at age < 65 years Symptoms have occurred for < 2 years Neurologic signs are asymmetric Clinical picture suggests normal-pressure hydrocephalus Consider: Noncontrast computed topography head scan Magnetic resonance imaging Positron emission tomography

HOW IS ALZHEIMER'S DIFFERENT FROM OTHER FORMS OF DEMENTIA?

Alzheimer's disease is distinguished from other forms of dementia by characteristic changes in the brain that are visible only upon microscopic examination during autopsy. Brains affected by Alzheimer's disease often show presence of the following: Fiber tangles within nerve cells (neurofibrillary tangles) Clusters of degenerating nerve endings (neuritic plaques) Another characteristic of Alzheimer's disease is the reduced production of certain brain chemicals necessary for communication between nerve cells, especially acetylcholine, as well as norepinephrine, serotonin, and somatostatin.

WHAT CAUSES ALZHEIMER'S DISEASE?

Although intense investigation has been underway for many years, the causes of Alzheimer's disease are not entirely known. Suspected causes often include the following: Age and family history Certain genes Abnormal protein deposits in the brain Other risk and environmental factors Immune system problems

WHAT ARE THE WARNING SIGNS OR SYMPTOMS OF ALZHEIMER'S DISEASE?

According to the Alzheimer's Association, the following are the most common symptoms of Alzheimer's disease. However, each individual may experience symptoms differently. Symptoms may include: Memory loss that affects job skills, especially short-term memory loss Difficulty performing familiar tasks Problems with language Disorientation to time and place Poor or decreased judgment Problems with abstract thinking Misplacing things Changes in mood or behavior Changes in personality Loss of initiative Loss of ability to recognize who people are, even people well known to the individual, such as his or her child or spouse, when the disease progresses to a severe stage

HOW IS ALZHEIMER'S DIAGNOSED?

There is not a single, comprehensive test for diagnosing Alzheimer's disease. By ruling out other conditions through a process of elimination, physicians, or other specialists, can obtain a diagnosis of probable Alzheimer's disease with approximately 90 percent accuracy. However, the only way to confirm a diagnosis of Alzheimer's disease is through autopsy. Examination and evaluation are essential in determining whether the dementia is the result of a treatable illness. In addition to a complete medical history and extensive neurological motor and sensory exam, diagnostic procedures for Alzheimer's disease may include the following:

Mental status test - this is a brief and simple test of memory and some other common cognitive or thinking skills; it is usually part of a complete neurological exam Neuropsychological testing Blood tests Lumbar puncture (spinal tap) - a procedure performed by inserting a hollow needle into the lower back (lumbar spine) Urinalysis - laboratory examination of urine for various cells and chemicals, such as red blood cells, white blood cells, infection, or excessive protein Chest x-ray - a diagnostic test which uses invisible electromagnetic energy beams to produce images of internal tissues, bones, and organs onto film

Electroencephalogram (EEG) - a procedure that records the brain's continuous electrical activity by means of electrodes attached to the scalp Computed tomography scan (also called a CT or CAT scan) - a diagnostic imaging procedure that uses a combination of x-rays and computer technology to produce cross-sectional images (often called slices), both horizontally and vertically, of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than general x-rays. Magnetic resonance imaging (MRI) - a diagnostic procedure that uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body Genetic testing - some genetic testing is available, especially in some research settings; Because there is no cure or effective treatment for Alzheimer's, the decision to undergo genetic testing is one that requires careful consideration and counseling with a specialist in genetics.

PREVENTION OF ALZHEIMER'S
the cause of the disease is unknown, there are no prevention protocols to follow at this time. the controllable risk factors for Alzheimer's disease are unknown, it is not yet possible to reduce the chances of developing the disease.

TREATMENT FOR ALZHEIMER'S

Specific treatment for Alzheimer's disease will be determined by your physician based on: Your age, overall health, and medical history Extent of the disease Your tolerance for specific medications, procedures, or therapies Expectations for the course of the disease Your opinion or preference

At this time, there is no cure for Alzheimer's, no way of slowing down the progression of this disease, and no treatment available to reverse the deterioration of Alzheimer's disease. New research findings give reason for hope, and several drugs are being studied in clinical trials to determine if they can slow the progress of the disease or improve memory for a period of time. There are some medications available to assist in managing some of the most troubling symptoms of Alzheimer's disease, including the following: Depression Behavioral disturbance Sleeplessness

ALZHEIMER'S REHABILITATION

he rehabilitation program for persons with Alzheimer's differs depending upon the symptoms, expression, and progression of the disease, and the fact that making a diagnosis of Alzheimer's is so difficult. These variables determine the amount and type of assistance needed for the Alzheimer's individual and family. With Alzheimer's rehabilitation, it is important to remember that, although any skills lost will not be regained, the caregiving team must keep in mind the following considerations: In managing the disease, physical exercise and social activity are important, as are proper nutrition and health maintenance. Plan daily activities that help to provide structure, meaning, and accomplishment for the individual.

As functions are lost, adapt activities and routines to allow the individual to participate as much as possible. Keep activities familiar and satisfying. Allow the individual to complete as many things by himself/herself as possible. The caregiver may need to initiate an activity, but allow the individual to complete it as much as he/she can. Provide "cues" for desired behavior (i.e., label drawers/cabinets/closets according to their contents). Keep the individual out of harm's way by removing all safety risks (i.e., car keys, matches). As a caregiver (full-time or part-time), it is important to understand your own physical and emotional limitations.

WHAT ARE THE MAIN DRUGS USED?

There are two main types of medication used to treat Alzheimer's disease
cholinesterase

inhibitors and NMDA receptor antagonists - which work in different ways Cholinesterase inhibitors include donepezil hydrochloride (Aricept), rivastigmine (Exelon) and galantamine (Reminyl). The NMDA receptor antagonist is memantine (Ebixa).

HOW DO THEY WORK?

Donepezil (Aricept), rivastigmine (Exelon) and galantamine (Reminyl) Research has shown that the brains of people with Alzheimer's disease show a loss of nerve cells that use a chemical called acetylcholine as a chemical messenger. The loss of these nerve cells is related to the severity of symptoms that people experience. Donepezil, rivastigmine and galantamine prevent an enzyme known as acetylcholinesterase from breaking down acetylcholine in the brain. Increased concentrations of acetylcholine lead to increased communication between the nerve cells that use acetylcholine as a chemical messenger, which may in turn temporarily improve or stabilise the symptoms of Alzheimer's disease. All three cholinesterase inhibitors work in a similar way, but one might suit an individual better than another, particularly in terms of side-effects experienced. (Current guidance for NHS treatment is that the cheapest of these drugs is generally tried first, see 'NICE guidance' below.)

Memantine (Ebixa) -The action of memantine is quite different from, and more complex than, that of donepezil, rivastigmine and galantamine. Memantine blocks a messenger chemical known as glutamate. Glutamate is released in excessive amounts when brain cells are damaged by Alzheimer's disease and this causes the brain cells to be damaged further. Memantine can protect brain cells by blocking these effects of excess glutamate.

ARE THERE ANY SIDE-EFFECTS?

Generally, cholinesterase inhibitors and memantine can be taken without too many side-effects. Not everyone experiences the same side-effects, or has them for the same length of time, if they have them at all.

The most frequent side-effects of donepezil, rivastigmine and galantamine are loss of appetite, nausea, vomiting and diarrhea. Other side-effects include stomach cramps, headaches, dizziness, fatigue and insomnia. Side-effects can be less likely for people who start treatment by taking the lower prescribed dose for at least a month.

The side-effects of memantine are less common and less severe than for the cholinesterase inhibitors. They include dizziness, headaches, tiredness, increased blood pressure and constipation It is important to discuss any side-effects with the doctor and/or the dispensing pharmacist. None of these drugs are addictive.

HOW CAN THESE DRUGS BE OBTAINED?

these drugs can only be prescribed by a consultant. A GP will need to refer the person to a hospital for a specialist assessment. A consultant will carry out a series of tests to assess whether the person is suitable for treatment and will write the first prescription, if appropriate. Subsequent prescriptions may be written by the GP or the consultant.