Alzheimer’s Disease

Alzheimer’s Disease is an irreversible, progressive brain disease that slowly destroys memory, cognition, and the ability to carry out the simplest tasks. The symptoms usually appear after 60 years old. It is also the most common cause of dementia, which is the loss of cognitive functioning such as thinking, remembering, and reasoning, interfering with one’s daily life and activities. 

Nursing Diagnoses 

Disturbed Thought Process

May be related to

• Alzheimer’s Disease
• Changes in cognitive abilities
• Impaired memory
• Disorientation
• Chemical imbalances in the brain
• Dementia
• Neuronal destruction in the brain

Possibly evidenced by

• Disorientation to time, place, person, and circumstance
• Decreased ability to reason or conceptualize
• Inability to reason
• Inability to calculate
• Memory loss
• Decreased attention span
• Easy distractibility
• Inability to follow simple or complex commands
• Deterioration in personal care and appearance
• Dysarthria
• Dysphagia
• Convulsions
• Inappropriate social behavior
• Paranoia
• Combativeness
• Inability to cooperate
• Wandering
• Disturbance in judgement and abstract thoughts
• Explosive behavior
• Illusions, delusions, hallucinations
• Deterioration of intellect
• Loss of sexual drive and desire, reduced control of sexual behavior
• Inappropriate behavior
• Lack of inhibitions
• Hypervigilance or hypovigilance
• Alteration in sleep pattern
• Lethargy
• Egocentricity

Desired Outcomes

• Patients will have appropriate maintenance of mental and psychological function as long as possible, and reversal of behaviors when possible.
• Family members will be able to exhibit understanding of required care and will demonstrate appropriate coping skills and ability to utilize community resources.
• Patient will achieve functional ability at his optimum level with modifications and alterations within his environment to compensate for deficits.
• Patients will have improved thought processing or will be maintained at a baseline level.
• Patients will be aware and oriented if possible, and reality will be maintained at an optimal level.
• Patients will have behavioral problems identified and controlled.
• Patient’s family will be able to access community resources and make informed choices regarding the patient’s care, both currently and for future care.

Nursing interventions

INTERVENTION	RATIONALE
Assess the patient’s ability for thought processing every shift. Observe patients for cognitive functioning, memory changes, disorientation, difficulty with communication, or changes in thinking patterns.	Changes in status may indicate progression of deterioration or improvement in condition.
Assess the level of cognitive disorders such as change to orientation to people, places and times, range, attention, thinking skills.	Provide the basis for the evaluation or comparison that will come, and influence the choice of intervention.
Assess level of confusion and disorientation.	Confusion may range from slight disorientation to agitation and may develop over a short period of time or slowly over several months. May indicate effectiveness of treatment or decline in condition.
Assess the patient’s ability to cope with events, interests in surroundings and activity, motivation, and changes in memory pattern.	The elderly may have a decrease in memory for more recent events and more active memory for past events and more active memory for past events and reminisce about the pleasant ones. Patients may exhibit assertiveness or aggressiveness to compensate for feelings of insecurity, or develop more narrowed interests and have difficulty accepting changes in lifestyle.
Orient the patient to the environment as needed, if the patient’s short term memory is intact. The use of calendars, radio, newspapers, television and so forth, are also appropriate.	Reality orientation techniques help improve patient’s awareness of self and environment only for patients with confusion related to delirium or with depression. Depending on the stage of AD, it may be reassuring for patients in the very early states who are aware that they are losing their sense of reality, but it does not work when dementia becomes irreversible because the patient can no longer understand reality. Television and radio programs may be overstimulating and may increase agitation, and can be disorientating to patients who cannot make a distinction between reality and fantasy or what they may view on television.
Assess patients for sensory deprivation, concurrent use of CNS drugs, poor nutrition, dehydration, infection, or other concomitant disease processes.	May cause confusion and change in mental status.
Maintain a regular daily schedule routine to prevent problems that may result from thirst, hunger, lack of sleep, or inadequate exercise.	If the needs of a patient with AD are not met, it may cause the patient to become agitated and anxious. Predictable behavior is less threatening to the patient and does not tax limited ability to function with ADLs.
Allow patients the freedom to sit in a chair near the window, utilize books and magazines as desired.	Validates the patient’s sense of reality and assists the patient in differentiating between day and night. Respect for the patient’s personal space allows the patient to exert some control.
Label drawers, use written reminders notes, pictures, or color-coding articles to assist patients.	Assists patient’s memory by using reminders of what to do and location of articles.
Allow hoarding and wandering in a controlled environment, as appropriate or within acceptable limitations.	Increases patient’s security and decreases hostility and agitation by permitting behaviors that are difficult to prevent, to be allowed within the confines of a safe supervised environment.
Provide positive reinforcement and feedback for positive behaviors.	Promotes patient confidence and reinforces progress.
Limit decisions that a patient makes. Be supportive and convey warmth and concern when communicating with the patient.	Patients may be unable to make even the simplest choice decisions and this will result in frustration and distraction. By avoiding this, the patient has an increased feeling of security. Patients frequently have feelings of loneliness, isolation and depression, and they respond positively to a smile, friendly voice, and gentle touch.
Provide opportunity for social interaction, but do not force interaction.	Helps prevent isolation. Forcing interaction usually results in confusion, agitation, and hostility.
Inform patients of care to be done, with one instruction at a time.	Patients with AD require extended time for processing information. Removal of decision making may facilitate improved compliance and feelings of security.
Maintain a nice quiet neighborhood.	Noise, crowds, the crowds are usually the excessive sensory neurons and can increase interference.
Instruct family in methods to use with communication with patients: listen carefully, listen to stories even if they’ve heard them many times previously, and to avoid asking questions that the patient may not be able to answer.	Comments from the patients may involve reliving experiences from previous years and may be totally appropriate within that context. In early stages of AD, questions may cause embarrassment and frustration when the patient is presented with another reminder that abilities are decreasing.
Instruct family members in the disease process, what can be expected, and assist with providing a list of community resources for support.	Once diagnosis of AD is made, the family should be prepared to make long-term plans in order to discuss problems before they arise. Choices for resuscitation, legal competency and guardianship including financial responsibility needed to be addressed. The care of a person with AD is expensive and time-consuming, as well as energy-draining and emotionally devastating for the family. Community resources can help delay the need for placement in a long-term care facility and may help defray some costs.
Face-to-face when talking with patients.	Cause concern, especially in people with perceptual disorders.
Call the patient by name.	The name is a form of self-identity and lead to recognition of reality and the individual.
Use a rather low voice and speak slowly to patients.	Increasing the possibility of understanding.
Assess the degree of impaired ability of competence, emergence of impulsive behavior, and a decrease in visual perception.	Impairment of visual perception increases the risk of falling. Identify potential risks in the environment and heighten awareness so that caregivers are more aware of the danger.
Help the people closest to identify the risk of hazards that may arise.	An impaired cognitive and perceptual disorders are beginning to experience the trauma as a result of the inability to take responsibility for basic security capabilities, or evaluating a particular situation.
Eliminate or minimize sources of hazards in the environment	Maintain security by avoiding a confrontation that could improve the behavior or increase the risk for injury.
Divert attention to a client when agitated or dangerous behaviors like getting out of bed by climbing the fence bed.	To promote safety and prevent risk for injury.

Chronic Confusion

May be related to

• Alzheimer’s disease
• Dementia

Possibly evidenced by

• Decreased ability to interpret one’s environment
• Decreased capacity for thought
• Memory impairment
• Disorientation
• Behavioral changes
• Personality changes
• Altered interpretation
• Response to stimuli

Desired Outcomes

• Patients will have minimal confusion, cognitive impairment, and other dementia manifestations.
• Patients will have a stable, safe environment with routine scheduling of activities to decrease anxiety and confusion.
• Patients will exhibit minimal or reduced confusion, memory loss, and cognitive disturbances, depending upon stage of AD.
• Patients will be able to tolerate stimuli when introduced slowly in a nonthreatening manner, with one item at a time.
• Patients will be able to be distracted or use other techniques to avoid stressful situations that may cause aggressive, hostile behaviors or frustration.
• Family will be able to utilize information effectively in dealing with patients with confusion with regard to limitations of simulation and validation of patient’s thoughts.
• Families will be able to utilize information to begin making decisions for long-term plans for patients.

Nursing interventions

INTERVENTION	RATIONALE
Assess patients for reversible or irreversible dementia, causes, ability to interpret environment, intellectual thought processes, memory loss, disturbances with orientation, behavior, and socialization.	Determines type and extent of dementia to establish a plan of care to enhance cognition and emotional functioning at optimal levels.
Utilize cognitive function testing.	Identifies current levels of dementia.
Maintain consistent scheduling with allowances for patient’s specific needs, and avoid frustrating situations and overstimulation.	Prevents patient agitation, erratic behaviors, and combative reactions. Scheduling may need revision to show respect for the patient’s sense of worth and to facilitate completion of tasks.
Avoid or terminate emotionally charged situations or conversations. Avoid anger and expectation of the patient to remember or follow instructions. Do not expect more than the patient is capable of doing.	Catastrophic emotional responses are prompted by task failure when the patient feels expected to perform beyond ability and becomes frustrated and angry. Responding calmly to the patient validates feelings and causes less stress.
Provide time for reminiscing if the patient so desires.	Allows for memory of past pleasant events. Patients may be reliving events in the past and the caregiver should identify this behavior and respect it.
Limit sensory stimuli and independent decision-making.	Decreases frustration and distractions from the environment. Decreasing stress of making a choice helps to promote security.
Assist with establishing cues and reminders for patient’s assistance.	Assists patients with early AD to remember location of articles and facilitates some orientation.
Identify family members and/or support systems for the patient.	Helps to determine appropriate people to notify for changes, to assist with care, and someone familiar to the patient to help deal with his confusion.
Ask family members about their ability to provide care for patients.	Identifies family’s need for assistance.
Instruct families and provide them with information regarding community services and long-term health care facilities.	Patients may require ongoing skilled nursing care that the patient’s family is unable or unwilling to provide.
Instruct family regarding avoidance of arguing with patients about what he thinks, sees, or hears.	Patients may have delusions and hallucinations that are real to the patient, and no amount of persuasion will convince him or her otherwise. The patient may become agitated or violent if contradicted.
Instruct family to consider if what the patient believes has some basis in reality.	Sometimes portions of conversations can be heard and misinterpreted by the patient.
Instruct family to consider if what the patient believes has some basis in reality from previous years ago.	Patients may be reliving times in the past and the reality may be decades ago.
Instruct family to avoid having patients watch violent TV shows.	Patient cannot make a distinction of reality from fiction, and witnessing violent acts on the screen may be frightening to the patient.
Instruct family to utilize distraction techniques, such as soothing music, going for a walk, or looking at picture albums if a patient has delusions.	Distraction may be effective to calm patients if stressful situations occur.

Impaired Verbal Communication

May be related to

• Alzheimer’s disease
• Dementia
• Psychological barriers
• Psychosis
• Decreased circulation to brain
• Age-related factors
• Lack of stimuli

Possibly evidenced by

• Confusion, anxiety, restlessness, disorientation to person, place, time and circumstance, agitation, flight of ideas
• Repetitive speech, inability to speak [properly], stuttering, slurring, impaired articulation, difficulty with phonation, inability to name words, inability to identify objects, difficulty comprehending communication, difficulty forming words or sentences
• Aphonia, dyslalia, dysarthria, inappropriate verbalizations, aphasia, dysphasia, apraxia, dyslexia.

Desired Outcomes

• Patient will be able to have effective speech and understanding of communication, or will be able to use another method of communication and make needs known.

Nursing interventions

INTERVENTION	RATIONALE
Assess the patient’s ability to speak, language deficit, cognitive or sensory impairment, presence of aphasia, dysarthria, aphonia, dyslalia, or apraxia. Presence of psychosis, and/or other neurologic disorders affecting speech.	Identifies problem areas and speech patterns to help establish a plan of care.
Assess effects of communication deficit.	Communication becomes progressively impaired as AD advances. The left side cerebral functions consisting of language reasoning, and calculation are decreased. Receptive and expressive aphasia are major symptoms of AD and affects speaking, reading, writing, and math.The mechanics of speech production is usually intact until the last stages of AD but the patient has difficulty concentrating on what has been said, understanding and processing what was said, and then preparing a response. In the first stage of AD, vocabulary skill decreases and the patient has trouble finding the correct word to use, resulting in word substitution. The patient can usually understand most messages but forgets them because of memory deficits. As the disease evolves, the ability to comprehend written and spoken language is decreased. False details about past events may be invented to try to camouflage the inability to remember. Ultimately the patient will become mute.
Monitor the patient for nonverbal communication, such as facial grimacing, smiling, pointing, crying, and so forth; encourage use of speech when possible.	Indicates that feelings or needs are being expressed when speech is impaired. Excessive mumbling, striking out, or non verbalization clues may b e the only method left for the patient to express discomfort.
Attempt to anticipate a patient’s needs.	Helps to prevent frustration and anxiety.
When communicating with a patient, face patient and maintain eye contact, speaking slowly and enunciating clearly in a moderate or low-pitched tone.	Clarity, brevity, and time provided for responses promotes the opportunity for successful speech by allowing patient time to receive and process the information.
Remove competing stimuli, and provide a calm, unhurried atmosphere for communication.	Reduces unnecessary noise and distraction and allows patient time to decrease frustration.
Use simple, direct questions requiring one-word answers. Repeat and reword questions if misunderstanding occurs.	Promotes self-confidence of the patient who is able to achieve some degree of speech or communication.
Utilize pencil and paper to write messages.	Provides an alternative method of communication if fine motor function is not impaired; use of magic slate is also suitable.
Assess patients for hearing deficits, and use of appropriate adaptive devices if needed. Minimizes glare in the room, speaks normally, but distinctly, and uses short phrases with speech attempts.	If a patient is deaf or requires hearing aids, make sure the battery is working and the aid is correctly placed to enhance hearing ability. Shouting usually increases the pitch of the voice and does not help with hearing. Glare makes it more difficult for patients to read your lips.
Encourage the patient to breath prior to speaking, pause between words, and use tongue, lips, and jaw to speak.	Promotes coordinated speech breathing.
Encourage patients to control the length and rate of phrases, over articulate words, and separate syllables, emphasizing consonants.	Helps to promote speech in the presence of dysarthria.
Avoid rushing the patient when struggling to express feelings and thoughts.	Impaired verbal communication results in a patient’s feeling of isolation, despair, depression, and frustration. Compassion helps to foster a therapeutic relationship and sense of trust and is important for continuing communication.
Encourage patients to take part in social activities.	Helps reduce feelings of isolation, which then result in further depression and unwillingness to communicate, even if the patient is physically able to do so.
Instruct patient and/or SO regarding need to use glasses, hearing aids, dentures	Helps promote communication with sensory or other deficits.
Provide consultation with speech therapists, as appropriate.	Helps facilitate speech ability and provides potential alternatives for communication needs.
Instruct patient and/or SO in the performance of facial muscle exercises, such as smiling, frowning, sticking tongue out, moving tongue from side to side and up and down.	Promotes facial expressions used to communicate by increasing muscle coordination and tone.

Nursing Notes

Causes

The cause of AD is unknown but knowledge about the hereditary links is growing. Patients with Down syndrome eventually develop DAT if they live long enough. There is a higher-than-normal concentration of aluminum in the brain of a person with DAT, but the effect is unknown. A distinct protein, AZ 50, has been identified at autopsy in the brains of DAT patients. This protein has been isolated from neurons that were not yet damaged, suggesting that its presence early in the degenerative process might cause the neuronal damage. The life expectancy of a DAT patient is reduced 30% to 60%.

Characteristics/ Signs and Symptoms

The disease course is divided into four stages, with progressive patterns of cognitive and functional impairments.

 

Pre-dementia

Stage 1 is characterized by recent memory loss, increased irritability, impaired judgment, loss of interest in life, decline of problem-solving ability, and reduction in abstract thinking. Remote memory and neurological exam remain unchanged from baseline.

 

Early

Stage 2 lasts 2 to 4 years and reveals a decline in the patient’s ability to manage personal and business affairs, an inability to remember shapes of objects, continued repetition of a meaningless word or phrase (perseveration), wandering or circular speech patterns (circumlocution dysphasia), wandering at night, restlessness, depression, anxiety, and intensification of cognitive and emotional changes of stage 1.

 

Moderate

Stage 3 is characterized by impaired ability to speak (aphasia), inability to recognize familiar objects (agnosia), inability to use objects properly (apraxia), inattention, distractibility, involuntary emotional outbursts, urinary or fecal incontinence, lint-picking motion, and chewing movements. Progression through stages 2 and 3 varies from 2 to 12 years.

 

Advanced

Stage 4, which lasts approximately 1 year, reveals a patient with a masklike facial expression, no communication, apathy, withdrawal, eventual immobility, assumed fetal position, no appetite, and emaciation.

Diagnostic Examination

• Alzheimer’s disease is usually diagnosed clinically from the patient history, collateral history from relatives, and clinical observations, based on the presence of characteristic neurological and neuropsychological features and the absence of alternative conditions.
• Advanced medical imaging with computed tomography (CT) or magnetic resonance imaging (MRI), and with single photon emission computed tomography (SPECT) or positron emission tomography (PET) can be used to help exclude other cerebral pathology or subtypes of dementia.Moreover, it may predict conversion from prodromal stages (mild cognitive impairment) to Alzheimer’s disease.
• Assessment of intellectual functioning including memory testing can further characterize the state of the disease.Medical organisations have created diagnostic criteria to ease and standardize the diagnostic process for practicing physicians. The diagnosis can be confirmed with very high accuracy post-mortem when brain material is available and can be examined histologically.

 

Primary Nursing Diagnosis

Self-care deficit related to impaired cognitive and motor function

• Outcomes. Self-care: Activities of daily living—Bathing, Hygiene, Eating, Toileting; Cognitive ability; Comfort level; Role performance; Social interaction skills; Hope
• Interventions. Self-care assistance: Bathing and Hygiene; Oral health management; Behavior management; Body image enhancement; Emotional support; Mutual goal setting; Exercise therapy; Discharge planning

 

Other Nursing Diagnosis

Risk for Injury related to:

• Unable to recognize / identify hazards in the environment.
• Disorientation, confusion, impaired decision making.
• Weakness, the muscles are not coordinated, the presence of seizure activity.

 

Medical Management

There is no cure for Alzheimer’s disease; available treatments offer relatively small symptomatic benefit but remain palliative in nature.

The initial management of the patient begins with education of the family and caregivers regarding the disease, the prognosis, and changes in lifestyle that are necessary as the disease progresses.

Basic collaborative principles include:

• Keep requests for the patient simple
• Avoid confrontation and requests that might lead to frustration
• Remain calm and supportive if the patient becomes upset
• Maintain a consistent environment
• Provide frequent cues and reminders to reorient the patient
• Adjust expectations for the patient as he or she declines in capacity

 

Pharmacologic Treatment

• Generally, therapy is focused on symptoms with an attempt to maintain cognition.
• Donepezil (cholinesterase inhibitor; elevates acetylcholine concentration in cerebral cortex by slowing degradation of acetylcholine released by intact neurons)which improves cognitive symptoms; improves cognitive function in the early stages of the disease only; drug effects diminish as the disease progresses
• Antidepressants (selective serotonin reuptake inhibitors; increases activity of serotonin in the brain) which treats depression, anxiety, and irritability
• Other Tests: Supporting tests include computed tomography (CT) scan; magnetic resonance imaging (MRI); positron emission tomography (PET). During the early stages of dementia, CT and MRI may be normal, but in later stages, an MRI may show a decrease in the size of the cerebral cortex or of the area of the brain responsible for memory, particularly the hippocampus. Genetic testing for the ApoE gene is available and the presence of the gene is a risk factor for AD. Genetic tests may be helpful in diagnosis, but further studies are needed to confirm their reliability.

 

Nursing Intervention

1. Establish an effective communication system with the patient and his family to help them adjust to the patient’s altered cognitive abilities.
2. Provide emotional support to the patient and his family.
3. The Administrator ordered medications and note their effects. If the patient has trouble swallowing, crush tablets and open capsules and mix them with a semi soft food.
4. Protect the patient from injury by providing a safe, structured environment.
5. Provide rest periods between activities because the patient tires easily.
6. Encourage the patient to exercise as ordered to help maintain mobility.
7. Encourage patient independence and allow ample time for him to perform tasks.
8. Encourage sufficient fluid intake and adequate nutrition.
9. Take the patient to the bathroom at least every 2 hours and make sure he knows the location of the bathroom.
10. Assist the patient with hygiene and dressing as necessary.
11. Frequently check the patient’s vital signs.
12. Monitor the patient’s fluid and food intake to detect imbalances.
13. Inspect the patient’s skin for evidence of trauma, such as bruises or skin breakdown.
14. Encourage the family to allow the patient as much independence as possible while ensuring safety to the patient and others.