Alzheimer’s Disease
Jill C. Cash and Karen M. Kress
Definition
A.Alzheimer’s disease (AD) is a permanent, progressive neurocognitive disorder that is characterized by deficits in several dimensions of cognitive functioning, including memory disturbance, that severely interfere with the person’s everyday living but produces no decrease in level of consciousness (LOC). Insidious onset, gradually progressive decline in intellectual functioning, and absence of other specific causes of dementia are also present.
B.Alzheimers.net notes that AD has seven distinct stages. See the following website for full descriptions of What Are the 7 Stages of Alzheimer’s Disease?
at www.alzheimers.net/stages-of-alzheimers-disease.
1.Stage 1: No impairment.
2.Stage 2: Very mild decline (losing keys; forgetting familiar names).
3.Stage 3: Mild decline (memory and concentration problems).
4.Stage 4: Moderate decline (difficulty planning dinner or paying bills on time).
5.Stage 5: Moderately severe decline (unable to recall events or remember important dates like birthdays, anniversaries, etc.).
6.Stage 6: Severe decline (needs help getting dressed; personality begins to change).
7.Stage 7: Very severe decline (late-stage AD includes trouble eating, swallowing, speaking, and all motor function).
Incidence
A.AD is the most commonly occurring neurocognitive disorder, affecting more that 44 million people throughout the world in 2015 and expected to double by the year 2050. Among the elderly, approximately 40% of those older than 85 years of age are affected. Of all types of dementias, Alzheimer’s dementia includes 70% of those affected, with the other 30% affected by atypical dementia. AD is the sixth leading cause of death in the United States.
B.Early-onset AD occurs between a person’s 30s to mid-60s. Early-onset AD only affects about 10% of all people who have AD.
C.Many people with Down syndrome develop AD as they age. By age 40, almost all people with Down syndrome have plaque from amyloid precursor protein (APP) and protein deposits called tau tangles, which increases the risk of developing AD. People with Down syndrome begin to show symptoms of AD in their 50s or 60s.
Pathogenesis
A.The disease is a degenerative process involving cell loss from the basal forebrain, cerebral cortex, and other areas in which plaques and tangles build up and block the cell processes that are needed to survive, thereby destroying the nerve cells. Cortical atrophy is most prominent in the temporal and hippocampal regions of the brain. Death of the nerve cells causes memory loss, changes in personality, and other signs and symptoms of AD. The Apo E epsilon 4 allele of chromosome 19 has been associated with familial and late onset AD.
B.People with Down syndrome are born with an extra copy of chromosome 21, which carries the APP gene. This gene produces a specific protein called APP. APP protein leads to a buildup of protein clumps called beta-amyloid plaques in the brain.
C.Obesity has been identified to increase the risk of AD because it increases the adipokine dysregulation, which causes a release in the proinflammatory adipokines and decreases anti-inflammatory adipokines.
Predisposing Factors
A.Definite risks:
1.Advanced age older than 50 years.
2.Atrial fibrillation (AFib).
3.Depression.
4.Abnormal genetic makeup, such as Down syndrome.
5.Positive family history of AD.
6.Gender (females have a higher incidence; Alzheimer’s is two-thirds more common in females than in males).
7.Obesity.
B.Possible risks:
1.Delirium.
2.Head trauma.
3.Heavy smoking
4.Hypertension (HTN).
5.Hyperlipidemia.
6.Low educational level.
7.Postmenopausal hormone therapy (HT).
Common Complaints
A.Significant memory loss or change in behavior as reported by the patient, family, or caregiver.
B.Typical changes that occur with aging compared to the 10 Alzheimer’s warning signs
are noted in Table 23.1.
TABLE 23.1 10 Alzheimer’s Warning Signs
| Issue | Common Symptoms of Early Stage Alzheimer’s Disease | Typical for Aging |
| Memory Loss | Forgetting new information and asking for the same information over and over | Forgetting names or appointments occasionally and remembering them later |
| Difficulty performing familiar task | Difficulty planning or completing everyday tasks. Losing track of steps involved in activities from preparing a meal to making a phone call | Occasionally forgetting why you came into a room or what you were planning to say |
| New problems with writing or speaking | Forgetting simple words or substituting unusual words, making speech or writing hard to understand | Sometimes having trouble finding the right word |
| Confusion with time and place | Getting lost in familiar places, forgetting where they are and how they got there, and how to get back home | Forgetting the day of the week or where you are going |
| Poor or decreased judgment | Dressing inappropriately for the weather, giving away large sums of money to telemarketers | Making a questionable or debatable decision from time to time |
| Problems with abstract thinking | Unusual difficulty performing complex mental tasks especially relating to numbers | Finding it challenging to balance a checkbook |
| Misplacing things and losing the ability to retrace steps | Putting things in unusual, inappropriate places | Misplacing keys or a wallet, but being able to retrace steps to find it later |
| Changes in mood or behavior | Rapid mood swings, extreme confusion, anxiety, suspiciousness, dependent on a family member | Occasionally feeling sad or moody |
| Trouble understanding visual images and spatial relationships | Change in visual processing; difficulty reading, judging distance, and determining color or contrast, which may cause problems with driving | Vision changes related to cataracts |
| Withdrawing from social activities | Avoiding being social because of the changes they have experienced. Becoming passive, sitting in front of the TV for hours, sleeping more than usual, or not wanting to perform activities of daily living | Sometimes feeling weary of work or social obligations |
Source: aPlaceforMom. (2015). 10 Alzheimer’s warning signs. Retrieved from https://www.aplaceformom.com/planning-and-advice/articles/alzheimers-warning-signs. Reprinted with permission from aPlaceforMom: Connecting Families to Senior Living. (Copyright © 2018).
Subjective Data
Family members are a good resource for obtaining an accurate history.
A.Determine onset, course, and duration of symptoms.
B.Note loss of immediate, recent, or remote memory, such as trouble remembering appointments, difficulty recalling recent events, and inability to find personal belongings.
C.Determine the patient’s ability to make reasonable judgments, such as answering the phone when it rings, and so forth.
D.Is the patient able to carry on daily functions of living, including cooking meals and cleaning house?
E.Discuss the patient’s sleep–wake cycle.
F.Assess the patient for decreased appetite, lack of pleasure in usual activities, melancholy mood, or other symptoms associated with depression.
G.Note language difficulties and problems expressing self.
H.Note any recent physical illness.
I.Review the patient’s medication history, specifically those medications with anticholinergic side effects, including over-the-counter (OTC) products such as diphenhydramine.
J.Discuss alcohol intake and abuse factors.
K.Review past medical history of head trauma, HTN, cerebrovascular accident (CVA), cancer, metabolic problems, neurologic disease, infections, gastric surgery (vitamin B12 deficiency), and emotional or psychiatric problems.
L.Note any recent major life events such as the death of a spouse, a move to a new living environment, or loss of purpose following retirement.
Physical Examination
A.Check blood pressure (BP), pulse, respirations, and weight.
B.Inspect: Inspect overall appearance for hygiene and nutritional status.
C.Auscultate: Auscultate the heart, lungs, abdomen.
D.Neurologic exam: Perform a complete neurologic exam. Note facial asymmetry, distal weakness, and any focal neurologic findings.
E.Perform screening using standardized tools:
1.Perform the Standardized Mini-Mental State Examination (SMMSE) screening tool available at www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/cogimp-smmse.pdf
2.The clock-draw test (CDT) may also be administered and used as a screening tool. The CDT is available at www.rehabmeasures.org (see Section II: Procedure for Clock-Draw Test
).
Rule out other specific causes of dementia, including cerebrovascular disease.
F.Complete depression screening with instrument of choice:
1.Beck depression scale. Available at www.enhertsccg.nhs.uk/sites/default/files/pathways/Beck%27s%20Depression%20Inventory_0.docx
G.Assess functional status. May use a functional assessment tool such as the Physical Self-Maintenance Scale, Instrumental Activities of Daily Living (IADL) Scale, or Reisberg Functional Assessment Staging Scale (FAST). Available at www.pbm.va.gov/PBM/clinicalguidance/drugmonitoring/FunctionalAssessmentStagingFAST73108.doc
H.Palpate:
1.Neck and thyroid for goiter and lymphadenopathy.
Diagnostic Tests
A.Complete blood count (CBC).
B.Chemistry profile.
C.Thyroid function studies.
D.Folate and B12 levels.
E.Homocysteine.
F.Methylmalonic acid.
G.Vitamin D level.
H.Venereal disease research laboratory (VDRL) for syphilis.
I.CT scan of the brain.
Differential Diagnoses
A.AD.
B.Drug interactions.
C.Delirium.
D.Depression.
E.Cerebrovascular disease.
Plan
A.General interventions:
1.Identify the stage of impairment.
a.Preclinical-brain changes, including amyloid buildup and other nerve cell changes, may already be in progress, but significant clinical symptoms are not yet evident.
b.Mild cognitive impairment (MCI)—a stage marked by symptoms of memory and/or other thinking problems that are greater than normal for a person’s age and education, but that do not interfere with his or her independence. People with MCI may or may not progress to Alzheimer’s dementia:
i.Very mild decline—no symptoms of dementia, has memory lapses.
ii.Mild decline—difficulty in memory and concentration.
iii.Moderate decline—impairment with complex tasks, trouble with solving math problems, forgetting personal history.
c.Alzheimer’s dementia—the final stage of the disease in which symptoms of Alzheimer’s, such as memory loss, word-finding difficulties, and visual/spatial problems, are significant enough to impair a person’s ability to function independently:
i.Moderately severe decline—unable to remember phone number, address, confusion on the day of the week, difficulty with decisions on dressing self properly.
ii.Severe decline—difficulty with personal history, difficulty with naming family members, spouse, difficulty with dressing self, behavior changes, may wander and get lost.
iii.Very severe decline—unable to communicate appropriately with others, requires assistance with activities of daily living (ADLs), abnormal reflexes, difficulty swallowing.