Alzheimer’s Disease is the form of dementia you will see the most often, and is the leading cause of significant cognitive decline in the elderly.
The three forms of Alzheimer’s are:
- nonhereditary sporadic or Late-Onset (70-90% of cases)
- early onset familial AD
- early-onset AD (very rare)
The pathologic changes in the brain of someone with Alzheimer’s ultimately cause memory loss and progressive cognitive decline:
- Accumulation of and inability to clear abnormal amyloid beta and tau proteins, which build up, leading to the development of plaques. These plaques prevent normal neurotransmission and cause neurons to die. Amyloid also gets deposited in the cerebral arteries as well, causing reduced blood flow to the brain.
- The presence of neurofibrillary tangles made up of tau proteins, which lead to cell death.
- Degeneration of cholinergic neurons leading to a loss of acetylcholine
- Immune responses are triggered by the presence of these abnormal proteins…and this leads to neuroinflammation and oxidative stress.
- The brain atrophies, the ventricles widen, and there are changes to the basal ganglia (a group of nuclei in the brain responsible for motor control, executive functions and emotions).
LATTE Method for Alzheimer’s Disease
L: How does the patient LOOK?
Alzheimer’s can be divided into 5 stages, ranging from mild cognitive impairment to end stage disease. It starts with mild short-term memory deficits that can easily be overlooked or explained away as forgetfulness or stress. Over the years, the memory loss progresses to culminate in a total loss of all executive function and cognition.
In addition to experiencing memory loss, the individual may also show difficulty with word-finding, have visual-processing difficulty and exhibit poor concentration. As the condition worsens, memory loss increases and it becomes difficult for the individual to concentrate and they become disoriented and confused. They will have increased difficulty with motor skills and eventually be confined to bed.
Individuals with Alzheimer’s lose the ability to perform problem solving, including math calculations. They are unable to think in an abstract manner and suffer lapses in judgment. Eventually they lose the ability to communicate and suffer from mood swings, hallucinations, aggression and/or depression.
Additionally, many patients undergo personality changes. They may withdraw from social situations, becoming irritable or suspicious, and show a lack of attention to their personal hygiene. Many Alzheimer’s patients will be especially restless at night and may start to wander, which can be a significant patient safety issue.
If the frontal lobe is involved, the individual may have changes in motor control exhibited as rigidity or flexion. Many patients with Alzheimers suffer from dyspraxia, which is an impaired ability to initiate purposeful activity, or could also exhibit repetitive motions (this is called preservation).
At the culmination of the disease, the individual is often emaciated due to lack of nutrition, incontinent to urine and feces, and unresponsive or even in a coma.
A: How do we ASSESS the patient with Alzheimer’s?
- Assess for orientation to person, place, time and situation
- Assess ability to perform ADLs
- Assess for changes in behavior or personality
- Assess muscle strength, motor ability with an eye toward keeping the patient safe and maximizing mobility as able
- Administer the MMSE (Mini Mental State Exam LINK: https://www.dementiacarecentral.com/mini-mental-state-exam)
- Administer the “clock test” which involves asking the individual to draw a clock showing that it is ten minutes past eleven. If the clock has the features in the correct place (and the time is correct) this is considered a normal result. Any deviation warrants referral to the individual’s primary care physician.
T: What TESTS will be ordered?
Unfortunately, there’s no gold standard diagnostic test for the presence of Alzheimer’s. The diagnosis is conducted based on assessment of the patient’s cognitive function and by utilizing imaging and blood work to rule out potential other causes such as a thyroid disorder, Vit B-12 deficiency or a brain tumor.
New diagnostics utilize PET scans to detect the amyloid lesions and tau proteins.
CSF testing can tell us if biomarkers for tau or beta-amyloid are present, which is supportive of a diagnosis but not used on their own as a diagnostic tool.
T: What TREATMENTS will be provided?
Treatments for Alzheimer’s focus on promoting safety, maximizing functional ability and slowing progression as much as possible.
Pharmacologic interventions are aimed at preventing the breakdown of acetylcholine and preventing the binding of glutamate. Recall that acetylcholine is an essential component in neurotransmission, so by preventing acetylcholinesterase from breaking it down, we help improve cholinergic function in patients with Alzheimer’s Disease. We are essentially making MORE acetylcholine available. Common cholinesterase inhibitors are donepezil, galantamine and rivastigmine.
We can also prevent the binding of glutamate with the combination drug of donepezil and memantine. Memantine binds to NMDA receptor sites, so it prevents the binding of glutamate, which is an excitatory neurotransmitter. Patients with AD have damaged nerve cells and too much glutamate is produced. Memantine prevents the binding of glutamate and protects the nerve cells from its excitatory effects. This decreases abnormal brain activity in patients with Alzheimer’s Disease.
Nurse-driven interventions include:
- Avoiding falls. Start by identifying and mitigating any fall risks. Remove rugs and clutter from the environment, provide non-slip shoes/slippers, promote the use of handrails, walkers, and other assistive devices.
- Ensure the room has adequate lighting.
- Place the patient in a room near the nurse’s station for high visibility.
- Promote activity as tolerated.
- Assist with ADLs, while encouraging independence.
- Promote a healthy sleeping environment.
- Provide support to caregivers who may be enduring an enormous amount of stress and fatigue. Support groups for caregivers are a wonderful resource.
E: How will you EDUCATE the caregiver/family?
- To prevent wandering: Add door locks (especially where paint can’t reach or isn’t likely to notice such as up high), cover door handles so they’re not easily visible, use alarms that sound when doors are opened
- Medic Alert ID
- Avoid stimulants such as caffeine
- Maximize nutrition with the patient’s favorite foods that are easy to eat
- Minimize distractions while eating
- Promote physical activity, which helps promote better sleep
- Don’t argue with the agitated or hostile patient; remain calm and avoid escalating the behavior
- The importance of developing a plan to manage finances and other legal issues such as DPOA and Advance Directives
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Alzheimer’s Association. (n.d.). Medical Tests for Diagnosing Alzheimer’s. Alzheimer’s Association. https://www.alz.org/alzheimers-dementia/diagnosis/medical_tests
Alzheimer’s Society. (n.d.). How do drugs for Alzheimer’s disease work? | Alzheimer’s Society. Alzheimer’s Society. https://www.alzheimers.org.uk/about-dementia/treatments/drugs/how-do-drugs-alzheimers-disease-work
Houston Methodist. (n.d.). Patient education | alzeimer’s disease. Houston Methodist. https://www.houstonmethodist.org/neurology/for-patients/patient-education/alzheimers/
Lanciego, J. L., Luquin, N., & Obeso, J. A. (2012). Functional neuroanatomy of the basal ganglia. Cold Spring Harbor Perspectives in Medicine, 2(12). https://doi.org/10.1101/cshperspect.a009621
Mayo Clinic. (2019, April 19). Learn how Alzheimer’s is diagnosed. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/alzheimers-disease/in-depth/alzheimers/art-20048075
MedlinePlus. (2016, April 15). Memantine: Medlineplus drug information. MedlinePlus. https://medlineplus.gov/druginfo/meds/a604006.html
Wolk, MD, D. A., & Dickerson, MD, B. C. (2020, December 11). Clinical features and diagnosis of Alzheimer disease. UpToDate. https://www.uptodate.com/contents/clinical-features-and-diagnosis-of-alzheimer-disease?search=alzheimers%20diagnosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H406204628