Alzheimer's Disease

Alzheimer’s

Alzheimer’s disease is an age-expressed, irreversible, progressive disease in which the brain undergoes specific changes. The neurons that transmit information in the brain become tangled and coated in plaque so that information is not accurately processed. The beginning of the disease (sometimes called insidious onset) is not apparent. This subtle progression makes it difficult to determine when the condition began. Many people are able to cover the symptoms well in the early stages, particularly if they are highly intelligent or have a spouse or partner to compensate for their losses.

The average survival time following the onset symptoms ranges from 2 to 16 years. Life expectancy for people with Alzheimer’s is lower on average than the general population (Walsh, Welch, & Larson, 1990). Higher rates of mortality in persons with Alzheimer’s disease result from loss of muscle control (and, with it, the ability to swallow), dehydration, malnutrition, pneumonia, and other infection. Recent research indicates that artificial nutrition, which refers to various methods of feeding patients when eating orally, does not extend or improve the lives of individuals with late-stage dementia. Therefore, inserting a feeding tube in the late stages of Alzheimer’s disease is considered by many to be a futile treatment (Finucane, 2003). Some religious and legal groups contest this conclusion. Nonetheless, many medical patient advocates strongly discourage the surgical insertion of feeding tubes for late-stage dementia patients. This is one issue to consider when discussing advance directives with clients.

Alzheimer’s disease is recognizable. There are ways to differentiate early Alzheimer’s disease from normal aging. The Alzheimer’s Association (2004) has developed a list of 10 warning signs that help identify the disease. Persons who exhibit several of these symptoms should see a physician for a complete examination.

  • Memory loss that affects job skills
  • Difficulty performing familiar tasks
  • Problems with language
  • Disorientation to time and place (getting lost)
  • Poor or decreased judgment
  • Problems with abstract thinking
  • Changes in mood or behavior
  • Misplacing things
  • Changes in personality
  • Loss of initiative

Symptoms of Alzheimer’s disease typically progress through three stages. Staging is somewhat arbitrary, as there is variability within each stage and movement between stages. Alzheimer’s disease is not always diagnosed in its early stage. A physician’s evaluation as soon as early symptoms of Alzheimer’s disease are noted.

In the beginning stage, most people with AD maintain the ability to make health care decisions for themselves, but they will lose this capacity over the course of the illness. If a diagnosis of Alzheimer’s disease is made, it’s very important that the affected individual identify in writing a health care agent to make future health care decisions. Designation of a health care agent facilitates optimal health care in later stages of the disease.

Early-Stage Alzheimer’s Disease

Symptoms of early-stage Alzheimer’s disease generally present themselves over a two- or four-year period. People with early-stage AD begin experiencing short-term memory deficits, difficulty in decision-making, problems in performing routine tasks, personality change, and mood changes. Examples of early symptoms of Alzheimer’s disease include misplacing jewelry, wallets, and other personal items. Routine paperwork such as writing checks becomes difficult and frustrating. At this early stage, most individuals still function independently, although many benefit from assistance. Many people who have the illness (as well as their family members) may overlook symptoms because the individual speaks fluently and recalls things from the past. Some families believe that if an older relative can remember the name of a first grade teacher, he or she must be fine. They may not realize, however, that she can’t remember the name of the person she met just five minutes ago, or whether or not she took her mediation that morning.

Common Symptoms of Early Stage Alzheimer’s Disease

  • Progressive memory loss – poor memory for new information; remote memories are generally lost
  • Mild difficulty finding words with maintenance of rhythm and smoothness of speech
  • Misplacement of things; disorganization
  • Mild problems with judgment and abstraction
  • Sleep difficulty
  • Loss of spontaneity and initiative
  • Social withdrawal because of loss of initiative, embarrassment about others witnessing deficits, or other reasons
  • Delusions – most commonly, these involve belief that others are trying to hut to steal from the individual
  • Depressive symptoms – approximately 25 percent of individuals with AD develop depressive symptoms in response to awareness of deficits and decline or brain changes associated with the disease; major depression is rare (Becker, Boller, Lopez, Saton, & McGonigle, 1994; Weiner, Doody, Sairam, Foster, & Liao, 2002).

Middle-Stage Alzheimer’s Disease

The middle stage of Alzheimer’s disease can last from 2 to 10 years or more after diagnosis. Memory loss often worsens during this stage. Communication skills, reasoning, and attention to personal care needs and hygiene may diminish. During this stage, people with Alzheimer’s disease often grow to need full-time care and supervision.

Common Symptoms of Middle Stage of Alzheimer’s Disease

  • Symptoms from early stage continue and worsen
  • Remote memory declines
  • Great difficulty finding words, repeating phrases
  • Visual-spatial problems such as difficulty copying figures and recognizing objects or people
  • Exacerbation of symptoms when routine or environment is disturbed or there is too much sensory input (e.g., in loud restaurants or shopping malls)
  • Problems calculating, dealing with money
  • Problems operating machinery, dressing, and grooming
  • Agitation, disinhibition (e.g., saying and doing things no one wouldn’t normally say or do in public)
  • Sleeping often; waking frequently at night, wandering
  • Difficulty writing
  • Verbal and physical aggression – particularly among those who have a troubled relationship with the caregiver before the onset of the illness, as well as for those with significant medical problems
  • Appetite changes (e.g., huge appetite for sugary, salty, high-fat foods); no memory for when the last meal was eaten; loss of interest in eating
  • Sundowning, a syndrome in which symptoms get worse in the evening
  • Social and interpersonal skills often look normal until the last stage

Late-Stage Alzheimer’s Disease

Late-stage Alzheimer’s disease reflects a further decrease in mental function and communication skills. During this stage, people with AD lose the ability to recognize family members, friends, and caregivers. Activities of daily living require full assistance. People in the final stage case to speak and eat, lose muscle control and swallow reflexes, slip into a coma, and eventually die. Due to the loss of muscle control and decreased immune functioning, many people with Alzheimer’s disease due from sepsis (a severe infection) due to pneumonia or urinary tract infection. This stage lasts from a few months to three years.

Common Symptoms of Late Stage Alzheimer’s Disease

  • Symptoms from middle stage continue and worsen
  • Remote memory gone
  • Communication changes; stops speaking or cries out incoherently
  • Failure to recognize family members, friends, or self in the mirror
  • Ambulation problems
  • Assistance required with all activity, including feeding
  • Incontinence

Treatment of Alzheimer’s Disease

At this time, there is no treatment that can reverse of cure the effects of Alzheimer’s disease. Although many medications have been studied, none has proven to have a lasting effect on the symptoms. Treatment of Alzheimer’s disease typically focuses on therapeutic and social interventions that help manage the disease process, with an emphasis on maximizing functional abilities and quality of life. However, establishing a diagnosis as early as possible and providing access to medications that slow cognitive deterioration may delay the onset of disability.

Medications

Pharmaceutical research in recent years has led to the development of sever medications that, if prescribed early in the disease process, may help to control symptoms and delay the progression of the illness. The medications do not cure the disease. Approximately 5 percent of patients benefit from these drugs, with effects lasting one to two years. Patients to benefit from the drugs sometimes see an abrupt decline in functioning if the medication is discontinued. Changes in medication should always be coordinated with a physician.

Currently, the Food and Drug Administration has approved two types of medications for treating the cognitive symptoms of dementia.

The first class of drugs was designed to prevent the decomposition of acetylcholine, a brain chemical associated with memory and other cognitive abilities. (Drugs are listed with their trademarked name first, followed by their generic name in parentheses).

  • Aricept (donepezil, approved in 1996)
  • Exelon (rivastigmine, approved in 2000)
  • Reminyl (galantamine hydrochloride, approved in 2001)
  • Cognex (tacrine, approved in 1993, but seldom prescribed today due to side effects, including possible liver damage)

The second type of drug, brand new in the United States, regulates glutamate, a brain chemical involved in learning and memory.

  • Naenda (memantine, approved 2003)

Nutritional supplements have also been suggested for the treatment and prevention of dementia. There has been evidence that vitamin E aids in the prevention of Alzheimer’s disease (Zandi et al., 2004) and slows the progression of symptoms of Alzheimer’s disease (Sano et al., 1997). Vitamin E is not recommended for people with cardiac illness or blood disorders unless prescribed by a physician. There is mixed evidence for the usefulness of estrogen and nonsteroidal anti-inflammatory drugs (NSAIDS, e.g., ibuprofen or aspirin) for prevention of AD. Because of possible side effects, their use is not currently recommended. Herbal remedies, such as gingko biloba, have no documented effect on dementia.

Medications are often useful in managing the behavioral symptoms of dementia. Selective serotonin re-uptake inhibitors (SSRIs e.g., Zoloft, Prozac, or Celexa) can be effective in treating the mood-related symptoms of dementia. Benzodazapines (e.g., Xanax or Ativan) have been used to treat agitation and sleep disorder, but caution must be taken in prescribing these medications due to possible side effects and risk of addiction. Antipychotic medications (e.g., Risperdal or Haldol) are frequently used to treat psychotic symptoms associated with dementia. Generally these medications have not been found to improve wandering, pacing, or rummaging behavior (Weiner, 2003). All psychiatric medication should be managed for seniors by a geriatric psychiatrist or a psychiatrist experienced in prescribing medication for persons with dementia.

Some research indicates that intellectual activity, such as reading, learning new information, and problem solving, may slow the progression of symptoms and even decrease the risk of getting Alzheimer’s disease. People both with and without dementia should be encouraged to engage in as much intellectually simulating activity as is enjoyable for them.

Psychotherapy and Behavioral Intervention

Psychotherapy may be helpful for individuals coping with the impact of losses associated with Alzheimer’s disease. Processing the emotional issues tied to coping with dementia has been shown to be effective in reducing symptoms of depression, improving self-esteem, and preparing for future losses. Both individual and group psychotherapy may be helpful (Cheston, Jones, & Gilliard, 2003; James, Postma, & MacKenzie, 2003).

Many family and professional caregivers become frustrated with inappropriate behaviors sometime shown by persons with Alzheimer’s disease. The inappropriate behavior may be the result of difficulty expressing feelings, controlling impulsive reactions, and solving problems.

Mrs. Jackson had been doing very well during the first six months after she moved into a nursing home. Her family had found a place for her there after her advanced Alzheimer’s dementia became too much for them to manage at home. Suddenly, Mrs. Jackson began refusing showers. She became very agitated and screamed when her aide tried to coax her into the bathroom. It wasn’t until her daughter came to visit during shower time that the reason for her behavior was discerned. Because of a change in the aide’s schedule, she reduced the amount of time she could devote to bathe Mrs. Jackson. To save time, the aide now undressed Mrs. Jackson fully before beginning to wash her, in contrast to her previous procedure, in which she uncovered only the parts she was washing. Her daughter explained that Mrs. Jackson had always been an extremely private, modest person, and sitting naked in the shower chair was terrifying for her. Returning to the prior shower regimen resulted in a significant reduction in Mrs. Jackson’s agitated behavior.

Management of Other Health Concerns

The unfortunate reality is that medical conditions that could be improved may be overlooked in people with dementia. This is especially true when a cognitively impaired person can no longer communicate that something is wrong. Even a concerned caregiver may inadvertently overlook treatable problems. Proper medical evaluation and treatment can help ensure that an individual with Alzheimer’s disease will be able to function at a high level while avoiding pain or other complications that can be caused by a treatable condition.

In addition to treating acute illness, it is important for caregivers to persons with dementia to make sure that chronic health conditions, including visual and hearing impairments, are treated. Sensory impairments can exacerbate cognitive problems of individuals with dementia, and simply wearing glasses or hearing aids may greatly enhance functional abilities. Encouraging use of assistive devices such as glasses and hearing aids should start in the earlier stages of dementia. Testing and teaching people with dementia to use new assistive devices becomes more difficult as cognitive abilities deteriorate.

Just as incontinence (loss of bladder or bowel control) is not a normal part of aging, it is not an inevitable part of dementia until the very end of the disease process. When incontinence becomes an issue in the earlier stages, caregivers should look into interventions that can lesson its impact. Incontinence interventions may involve identifying when the accidents happen and what may be triggering them. Possible causes of incontinence include physical conditions (change in bladder or bowel habits, hormonal imbalances, medications), cognitive changes, depression, and chronic or acute disease. One simple strategy is to take a person with dementia to the toilet on a regular schedule. As with all interventions, it is important to maintain the dignity of the individual experiencing the problem. For example, announcing that is time to go to the bathroom to avoid an accident in the middle of a crowded restaurant is inappropriate.

Maintaining good overall health during the course of dementia-related illness is very important but may be very difficult. Seemingly simple factors, such as good nutrition, proper hygiene, and appropriate dental care, can become enormous challenges in caring for cognitively impaired individuals. Proper nutrition is necessary not only to maintain energy and stamina, but to promote resistance to infection and aid in would healing. As discussed earlier, however, artificial nutrition in late-stage AD does not improve quality of life or extend life (Finucane, 2003).

The above information was provided by the Society of Certified Senior Advisors (SCSA).