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ALZHEIMER’S

DISEASE

Dana Bartlett, RN, BSN, MSN, MA

Dana Bartlett is a professional nurse and author. His clinical experience includes 16

years of ICU and ER experience and over 20 years of as a poison control center

information specialist. Dana has published numerous CE and journal articles, written NCLEX material and textbook chapters, and

done editing and reviewing for publishers such as Elsevier, Lippincott, and Thieme. He has written widely on the

subject of toxicology and was recently named a contributing editor, toxicology section, for Critical Care Nurse journal. He is currently employed at the Connecticut Poison Control Center and is actively involved in lecturing

and mentoring nurses, emergency medical residents and pharmacy students.

ABSTRACT

Alzheimer’s disease is a chronic, progressive neurological disorder that

causes profound cognitive and behavioral impairments. Alzheimer’s

disease is the most common cause of dementia in older adults,

afflicting approximately 5 million Americans. A person’s genetics, life

style, and environment play a part in the development of the disease

but the cause of Alzheimer’s is not known. Alzheimer’s is a progressive

disease for all patients but there can be distinct differences between

patients in terms of how they progress. Changes occur slowly and

incrementally with some patients experiencing periods called

“plateaus,” in which they are stable. Early-onset Alzheimer’s disease

takes a more rapidly progressive course. There is no cure for

Alzheimer’s disease and attempts at finding easily applied preventative

measures have not been successful. The treatment for Alzheimer’s

disease at this point focuses on symptomatic relief.

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Continuing Nursing Education Course Planners

William A. Cook, PhD, Director, Douglas Lawrence, MA, Webmaster,

Susan DePasquale, MSN, FPMHNP-BC, Lead Nurse Planner

Policy Statement

This activity has been planned and implemented in accordance with

the policies of NurseCe4Less.com and the continuing nursing education

requirements of the American Nurses Credentialing Center's

Commission on Accreditation for registered nurses. It is the policy of

NurseCe4Less.com to ensure objectivity, transparency, and best

practice in clinical education for all continuing nursing education (CNE)

activities.

Continuing Education Credit Designation

This educational activity is credited for 1.5 hours. Nurses may only

claim credit commensurate with the credit awarded for completion of

this course activity.

Pharmacology content is .5 hour (30 minutes).

Statement of Learning Need

Available evidence clearly shows that Alzheimer’s Disease is a very

common, serious, and growing public health care problem. A need

exists for high-quality education for nurses and caregivers.

Course Purpose

Provide current information on the epidemiology, etiology, clinical

presentation, diagnosis, and treatments for Alzheimer’s disease.

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Target Audience

Advanced Practice Registered Nurses and Registered Nurses

(Interdisciplinary Health Team Members, including Vocational Nurses

and Medical Assistants may obtain a Certificate of Completion)

Course Author & Planning Team Conflict of Interest Disclosures

Dana Bartlett, RN, BSN, MSN, MA, William S. Cook, PhD,

Douglas Lawrence, MA, Susan DePasquale, MSN, FPMHNP-BC - all

have no disclosures.

Acknowledgement of Commercial Support

There is no commercial support for this course.

Activity Review Information

Reviewed by Susan DePasquale, MSN, FPMHNP-BC.

Release Date: 1/1/2016 Termination Date: 6/29/2018

Please take time to complete a self-assessment of knowledge,

on page 4, sample questions before reading the article.

Opportunity to complete a self-assessment of knowledge

learned will be provided at the end of the course.

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1. Alzheimer’s disease primarily affects:

a. the elderly.

b. men.

c. the young.

d. people between 40 and 60.

2. True or false: Environmental risk factors are a proven cause

of Alzheimer’s.

a. True.

b. False.

3. A family history of Alzheimer’s disease:

a. has no influence on the risk for Alzheimer’s disease.

b. only affects women in terms of risk for Alzheimer’s disease.

c. only increases the risk if the patient has diabetes and

hypertension.

d. significantly increases the risk for Alzheimer’s disease.

4. Which of the following are risk factors for Alzheimer’s

disease?

a. Chronic obstructive pulmonary disease and hepatitis.

b. Acute kidney disease and anticoagulation with warfarin

c. Hypertension and diabetes.

d. Atrial fibrillation and long-term use of anti-depressants.

5. Alzheimer’s disease is characterized by:

a. cerebral emboli and hyper-coaguability.

b. vasospasm and Lewy bodies.

c. cerebral edema and amyloid plaques.

d. amyloid plaques and neurofibrillary tangles.

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Introduction

Alzheimer’s disease is a chronic, progressive neurological disorder that

causes profound cognitive and behavioral impairments. Alzheimer’s

disease is the most common cause of dementia in older adults,

afflicting approximately 5 million Americans. Genetic, life style, and

environmental risk factors for the development of the disease have

been identified but the cause of Alzheimer’s is not known.

The available treatments cannot modify the course of the disease or

provide a cure, they can only provide symptomatic relief, and the

prognosis for someone who has Alzheimer’s disease is grim; the

average life span after diagnosis is 8-10 years. The cost of caring for

patients who have Alzheimer’s is very high and as the number of

people who develop Alzheimer’s increases in the next few decades the

monetary strain will be significant.

Epidemiology

As with any disease, the incidence and prevalence statistics of

Alzheimer’s disease are always retrospective, but available evidence

clearly shows that it is a very common, very serious, and growing

public health care problem. The Centers for Disease Control and

Prevention (CDC) estimated that in 2013, five million Americans had

Alzheimer’s disease.1 Alzheimer’s disease is the 6th leading cause of

death in the United States among all American adults1, and it is the

most common cause of dementia, accounting for approximately 60%-

80% of all cases of dementia.2

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Alzheimer’s is a disease that primarily afflicts older people. Most cases

of Alzheimer’s are diagnosed in people who are 60 years or older, and

the prevalence of the disease increases with each decade of life,

growing to 20%-40% of the population by age 85.3 Female gender,

even given the greater longevity of women, is a risk factor for the

development and progression of Alzheimer’s disease,3-5 and

Alzheimer’s disease is more common in the African American

population.6

Etiology And Pathophysiology Of Alzheimer’s Disease

Exposure to environmental contaminants, specific lifestyle factors and

coupled with chronic medical conditions, and genetics are considered

to be the three categories of risk factors that contribute to the

development of Alzheimer’s disease. How and in whom they come

together to cause the disease and their relative importance are not

known. Age is considered to be the biggest risk factor for Alzheimer’s

disease.

Environmental Contaminants

Exposure to environmental contaminants such as air pollution,

industrial chemicals, metals, and pesticides has been associated with

an increased risk for the development of Alzheimer’s disease,7 and

many of these are well-known neurotoxins. However, at this time

there is no definitive evidence of a cause and effect relationship

between exposure to an environmental contaminant and Alzheimer’s

disease.7

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Lifestyle and Medical Conditions

Diabetes, hypertension, obesity, sedentary lifestyle, smoking, and

many other diseases and lifestyle factors have been identified as

possible risk factors for the development of Alzheimer’s disease.8-12

Traumatic brain injury (TBI) is strongly associated with Alzheimer’s

disease.13

Genetics

It is often noted that Alzheimer’s has a strong genetic component.14 In

the development of Alzheimer’s disease there are genetic causes and

genetic risk factors.

The number of Alzheimer’s cases that have a clear genetic cause, with

little to no environmental influence, is a very small number of the

total. Most but not all of these cases are early onset familial

Alzheimer’s.

A family history of Alzheimer’s disease is a significant risk factor for

developing the disease. An individual who has a first-degree relative

(i.e., sibling or parent) with Alzheimer’s disease has double the risk for

Alzheimer’s, and the importance of this inherited risk increases as we

age the person ages.14

Late-onset Alzheimer’s is the most common form of the disease.

Although genetic risk factors for late-onset Alzheimer’s have been

identified, how they increase risk is not understood.14 Genetic risk

factors are not present in all patients who have Alzheimer’s.

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Alzheimer’s disease causes two distinct pathophysiological changes in

the brain: the formation of amyloid plaques and neurofibrillary

tangles.14 These pathological changes cause permanent damage to

neurons and synapses and affect three primary ways that neurons

maintain their normal functioning and health: communication,

metabolism, and repair.15 The amyloid plaques are essentially

comprised of clumps of amyloid-β peptides, protein constituents which

are produced by abnormal processing of amyloid precursor protein

(APP); APP is part of the cell membrane of neurons but its exact

function is not known.

The amyloid plaques damage neuronal synapses, interfere with normal

synaptic transmission, and may cause or contribute to inflammation

and oxidative damage in the brain. The neurofibrillary tangles are

intracellular support structures in the neurons called microtubules that

have had a breakdown in a specific protein called tau. The tau protein

is essential for maintaining the integrity of the microtubules - and thus

the structural soundness of neurons - and when tau is damaged the

microtubules are damaged, and the neuron cannot function and will

eventually die.15

The formation of amyloid plaques and neurofibrillary tangles is the

hallmark of Alzheimer’s disease, but it is not completely clear how

these pathological changes can cause the clinical characteristics and

the cognitive decline associated with the disease. In addition, these

lesions are found in the brains of people who do not have Alzheimer’s

disease,15 although the areas of the brain that are affected and the

total number of the pathological lesions are different.3

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Clinical Features Of Alzheimer’s Disease

The clinical features of Alzheimer’s disease are varied and complex.

Although Alzheimer’s is a progressive disease for all patients, there

can be distinct differences between patients in terms of how they

progress. The changes can occur slowly and incrementally but some

patients may have periods - plateaus - in which they are stable. Early-

onset Alzheimer’s disease takes a more rapidly progressive course.

However, all patients will eventually be unable to socialize or perform

self-care. The presentation or progression of Alzheimer’s disease is

often described as having four stages: pre-clinical, mild, moderate,

and severe.15

Cognitive impairments are the most prominent clinical feature in

patients who have Alzheimer’s disease, but physical impairments,

language, speech, and visuospatial impairments, and significant

behavioral and emotional disorders are also common. These can be

very disabling in the later stages of the disease and all of them, the

cognitive and physical impairments, visuospatial impairments,

language/speech disorders, and the behavioral and emotional

disorders, profoundly affect quality of life.

Cognitive Impairments

Cognitive impairments are perhaps the most striking feature of

Alzheimer’s disease. They typically follow a characteristic pattern and

begin with memory problems, and memory disorders are one of the

most prominent features of Alzheimer’s disease.3 The patient will

forget a conversation that she or he recently had. Names and dates

and the location of familiar items cannot be recalled. Initially the

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memory problems of Alzheimer’s disease can be relatively mild and

ascribed to aging, but eventually it becomes clear to family, friends,

and occasionally the patient that this forgetfulness is serious and

indicates the presence of a disease process.

The memory impairments of Alzheimer’s disease are not like the

memory lapses that are associated with aging: they are progressive,

they interfere with the activities of daily living, and their presence can

be confirmed using a standardized memory test.3,15 If the patient’s

memory capabilities are below a certain point on standardized memory

tests, the patient is said to have mild cognitive impairment, a

precursor to Alzheimer’s disease.

Learning Break:

The term mild cognitive impairment seems at first reading to be

imprecise and vague, but there is a diagnostic procedure that is used

to define and detect mild cognitive impairment, and this pathology

has important prognostic significance. Mild cognitive impairment is

considered to represent an early stage in the progression from

normal mental status to Alzheimer’s disease,16 and approximately

50% of patients who have mild cognitive impairment will develop

Alzheimer’s disease within four years.3

Difficulties with what are often called higher intellectual functions are

also common.3 The patient with Alzheimer’s cannot reason, or at least

reason effectively; the patient has difficulty concentrating; abstract

thinking and the ability to plan and organize are seriously diminished;

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and, simple tasks that require judgement - or any of the other skills

that were mentioned - cannot be performed. The physical impairments

of Alzheimer’s disease are usually the most pronounced in the later

stages. Patients can be incontinent of feces and urine. They are often

immobile, and the complications of immobility such as pneumonia,

aspiration, infections, or complications of pressure ulcers are the usual

causes of death from Alzheimer’s disease.

Language difficulties are quite common in the early stages of

Alzheimer’s disease, affecting 40%-50% of all patients.17 Patients have

difficulty finding the right word to say, their speech content is

rambling, and they may have a condition called paraphasia in which

unintended sounds, syllables, and words are spoken. Aphasia, a

communication disorder, develops in Alzheimer’s patients. In the later

stages of the disease patients can develop expressive aphasia, global

aphasia, and receptive aphasia. Visuospatial abilities - roughly defined

as perceiving spatial relations between objects - deteriorate as the

disease progresses, presenting another challenge for this patient

population.18

Ordinary day-to-day, self-care activities such as dressing, driving,

using eating utensils, reading, locating something in the environment,

navigating distances or finding one’s way from one place to another

are affected. A patient may lose the ability to distinguish colors.

Almost anything that requires coordination of the visual field with

motor activities can be difficult or impossible to perform.3,17

The behavioral and emotional disturbances and personality changes

that are associated with Alzheimer’s disease can be devastating for the

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patient and for family members. They also present significant

management challenges because they are intimately and inextricably

linked to cognitive, physical, language impairments of the disease that

are organic in nature and cannot be changed; they are often resistant

to treatment; and, they are numerous and complex.

The following list highlights behavioral and emotional disturbances that

are common to Alzheimer’s disease; however, this list could easily be

expanded.

BEHAVIORAL AND EMOTIONAL DISTURBANCES

Agitation

Confusion

Delusions

Depression

Mood swings

Physical and verbal aggression

Psychosis

Sleep disturbances

Social withdrawal

Wandering

The diagnosis of Alzheimer’s disease is made by taking a careful

history, a physical exam, targeted laboratory tests and imaging

studies, and neuropsychiatric testing. Much of the diagnostic

procedure is used to rule out the presence of other illnesses because

Alzheimer’s disease is a clinical diagnosis; it cannot be confirmed by

laboratory testing or imaging.

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The initial presentation of many patients who have Alzheimer’s can

feature many of the signs and symptoms that were previously

discussed. But approximately 20%-40% of all patients who have

Alzheimer’s disease have an atypical presentation,3 and Alzheimer’s

disease can be misdiagnosed as depression, stroke, or many other

medical or psychiatric disorders. Alzheimer’s disease then is a

progressive disorder and as patients move through the pre-clinical,

mild, moderate, and severe stages the various impairments associated

with the disease gradually worsen.

Activities of daily living become increasingly difficult and eventually,

impossible. The patient cannot work, cannot socialize appropriately,

cannot provide self-care, and the patient’s behavioral and emotional

problems become unmanageable.

Table 1: Signs, Symptoms and the Stages of Alzheimer’s15

PRECLINICAL

Development of the amyloid plaques and neurofibrillary tangles.

The patient has no signs or symptoms of Alzheimer’s disease.

MILD ALZHEIMER’S DISEASE

Confusion

Delays in accomplishing simple tasks

Difficulty with simple tasks, i.e., handling money, following

directions

Memory loss

Mood changes

Poor judgment

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MODERATE ALZHEIMER’S DISEASE

Aggressive behavior

Coping problems

Delusions, hallucinations

Difficulty with thinking logically

Difficulty recognizing family and friends

Impulsive behavior

Inability to learn new tasks

Increasing confusion and memory loss

Increased emotional lability

Paranoid behavior and thinking

Problems with reading, speaking and writing

Problems recognizing friends and family members

Shortened attention span

Wandering

SEVERE ALZHEIMER’S DISEASE

Inability to communicate

Inability to perform self-care

Eventually physical impairments become so significant that the patient

requires constant care. Patients typically succumb to immobility-

related illnesses such as aspiration, infections, or pneumonia, usually

within 8-10 years from the time of diagnosis.

It was mentioned previously that Alzheimer’s disease is the most

common cause of dementia. Dementia is a commonly used and often

misunderstood term and should be explained here. Dementia is a

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syndrome, not a disease itself, and Alzheimer’s disease and dementia

are not synonymous.

There are many causes of dementia, and the signs of dementia are an

important part of the clinical picture of Alzheimer’s disease. Kane et

al., (2013) define dementia as “. . . a clinical syndrome involving a

sustained loss of intellectual functions and memory of sufficient

severity to cause dysfunction in daily living,”19 while Seeley and Miller

(2015) write that dementia “. . . is an acquired deterioration in

cognitive abilities that impairs the successful performance of activities

of daily living.”3 These definitions emphasize key points about

dementia and Alzheimer’s disease.

First, an important distinguishing aspect of dementia is an inability to

successfully perform the activities of daily living, caused by impaired

cognitive and intellectual capacity. Second, dementia is a syndrome

because there is a multitude of etiologies of dementia. The Diagnostic

and Statistical Manual of Mental Disorders V (DSM-V) criteria for

dementia are:20

1. Evidence of significant cognitive decline from a previous level

of performance in one or more cognitive domains:

Complex attention

Executive function

Language

Learning and memory

Perceptual-motor ability

Social cognition

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2. The cognitive effects interfere with independence in everyday

activities. At a minimum, assistance should be required with

complex activities of daily living such as managing

medications or paying bills.

3. The cognitive effects do not occur extensively in the context

of delirium.

4. The cognitive deficits are not better explained by another

mental disorder (i.e., major depressive disorder,

schizophrenia).

Early Onset Alzheimer’s Disease

Most cases of Alzheimer’s disease happen to the elderly, but early-

onset Alzheimer’s disease accounts for approximately 5.5% - 7% of all

cases of the disease.21,22 Early-onset Alzheimer’s disease is typically

described as evidence of the disease in people who are under the age

of 65, but there is no universally accepted definition for an age cut-off

point.23 Approximately one-half of all cases of early-onset Alzheimer’s

disease can be considered as inherited.24 However, although the

genetics of this form of the disease is well understood, it is a

dominantly inherited disease but not a fully penetrant disease.25

As mentioned above, the early-onset form of Alzheimer’s disease has a

more rapidly progressive course, and it appears to affect different

areas of the brain than late-onset Alzheimer’s disease.20 The risk

factors and the pathophysiological mechanisms may be distinct in the

two forms, as well, and patients who have the early-onset form have

been found to have a greater number of amyloid plaques and

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neurofibrillary tangles.25 Despite these differences, and the general

observation that the clinical characteristics of early-onset and late-

onset are separate, Palasí et al., (2015) noted that when early-onset

and late-onset Alzheimer’s disease are closely examined “ … there is

no current consensus about which cognitive domains are more

impaired in each group.”26

Diagnosis Of Alzheimer’s Disease

The diagnosis of Alzheimer’s disease, as previously mentioned, is a

clinical diagnosis, based on a physical examination, taking a careful

health history, targeted laboratory tests and imaging studies, and

neuropsychiatric testing. Because Alzheimer’s disease is a clinical

diagnosis there can be some disagreement about what diagnostic

criteria are applicable. The following criteria are from Kane, et al.,

(2013).19

Memory impairment and one or more of the following: Aphasia,

apraxia, agnosia, and executive functioning deficits.

Cognitive deficits that severely impair social and occupational

functioning and are a major change from the previous level of

functioning.

The course of the cognitive deficits is gradual in onset and it

continuously declines.

The cognitive deficits do not occur during a period of delirium.

The patient’s clinical condition is not accounted for by an axis 1

disorder such as major depression or schizophrenia, a systemic

illness, or another progressive neurological disease such as a

brain tumor or Parkinson’s disease.

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Treatment Of Alzheimer’s Disease

Alzheimer’s disease cannot be cured, it can only be managed and

doing so is a big challenge. If the patient has no significant co-

morbidities, the patient will be relatively healthy in the physical sense

and will be ambulatory until late in the progression of the disease. But

for both patient and the patient’s caretakers, the cognitive deficits and

the behavioral and emotional issues associated with Alzheimer’s

disease - which in many instances are inextricably linked - can create

enormously frustrating situations.

It is impossible to improve a patient’s memory, executive function,

language difficulties; cognitive deficits cannot be reversed; the

patient’s condition always declines; and behavioral and emotional

problems will always occur. But with skillful application of

environmental and psychosocial interventions and targeted, judicious

use of medications, the patient who has Alzheimer’s disease can be

safely and effectively cared for.

Drug Therapy

Drug therapy for the treatment of Alzheimer’s disease is intended to:

1) provide symptomatic relief from the physical and psychological

complications; and, 2) slow the progression of the disease and/or alter

the pathophysiologic mechanisms of Alzheimer’s disease.

Drug therapy for the treatment of Alzheimer’s disease will not be

discussed in great detail. Medications can be helpful for providing

symptomatic relief, slowing the progression (somewhat) of the

disease, and addressing the pathophysiological mechanisms of these

disease, but drug therapy is considered to be second-line treatment:27

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the preferred approach is environmental and psychosocial

interventions.27 The generic names of drugs are listed first; trade

names are in parentheses.

Symptomatic Treatment

A wide variety of medications have been used to provide patients with

symptomatic relief from the emotional, physical, and psychological

complications associated with Alzheimer’s disease including, but not

limited to anti-depressants, anti-epileptic drugs, first and second-

generation anti-psychotics, anti-parkinsonian drugs, anxiolytics, beta-

blockers, calcium channel blockers, hypnotics or soporifics, and

tricyclic anti-depressants.28-32

While these drugs can and do provide some benefit, the evidence for

their effectiveness in treating agitation, depression, psychosis, sleep

disturbances, etc., in patients who have Alzheimer’s disease is modest

or lacking.27-30 And although all drugs have a risk-benefit ratio, for

some of the aforementioned medications such as the anti-psychotics

and the tricyclic anti-depressants, the risks can be significant and they

appear to greatly outweigh the benefits for this patient population.30

Disease Progression Slowing or Pathophysiology Alteration

The two types of drugs that are used for this purpose are memantine

(Namenda) and the acetylcholinesterase inhibitors donepezil (Aricept),

galantamine (Razadyne), and rivastigmine (Exelon®). (Note: Tacrine

[Cognex] is a cholinesterase inhibitor that was the first drug of this

class that was used to treat Alzheimer’s. It is no longer available as its

use caused severe gastrointestinal side effects and hepatotoxicity).

Memantine is classified as an N-methyl-D-aspartate (NMDA) receptor

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antagonist.33 This drug is a competitive antagonist of the NMDA type

of glutamate receptor.

Glutamate is the primary excitatory neurotransmitter.29,33 It is thought

that Alzheimer’s disease causes excessive stimulation of NMDA

receptors, and this continued and excessive stimulation may be a

cause of both cognitive impairments associated with Alzheimer’s

disease and neuronal damage.29 Memantine has been reported to be

effective at improving cognition, improving the a patient’s ability to

perform activities of daily living, and decreasing the level of agitation

in patients who have mild to moderate Alzheimer’s disease.29,34,35

Commonly seen side effects of memantine include confusion,

constipation, dizziness, and headache.33 Memanatine is usually dosed

once a day and it is available as an oral solution, regular release, and

extended release tablets. It is also available as a combination product

with donepezil and this combination of memantine and donepezil

(Namzaric) has been shown to be helpful.29

The acetycholinesterase inhibitors function by reversibly inhibiting

acetylcholinesterase, the enzyme that is responsible for enzymatic

degradation of the neurotransmitter acetylcholine.36 Alzheimer’s

disease damages cholinergic neurons thus decreasing the production

of acetylcholine, and this process is thought to be in part responsible

for some of the clinical signs of Alzheimer’s disease. The

acetylcholinesterase inhibitors have been reported to provide a mild to

moderate level of improvement in cognition and global functioning.37,38

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There is no evidence that one of these drugs is superior to the other.37

Commonly seen side effects of therapy with the acetylcholinesterase

inhibitors include diarrhea, nausea, and vomiting.38 These drugs are

usually dosed once a day and are available as regular release tablets,

transdermal patches, or disintegrating tablets.

Many other medications and supplements have been used to try and

alter the course of Alzheimer’s disease. Oxidative stress and

inflammation are part of the pathological process of Alzheimer’s

disease. There is evidence that antioxidants such as vitamin E can

slow the decline of the functional abilities of patients who have mild to

moderate Alzheimer’s disease,39 but non-steroidal anti-inflammatories

have not been shown to have any significant benefit for these

patients.29,40

Agitation, aggressive behavior, and psychosis are very common in

patients who have Alzheimer’s disease. Atypical and conventional anti-

psychotics would seem to be the most intuitive choice in these

situations, and these drugs are often used to treat these behaviors in

patients who have Alzheimer’s disease.41 However, the antipsychotics -

both atypical and conventional - can have significant side effects, i.e.,

antipyramidal effects, arrhythmias, hypotension, sedation, and an

increased risk for mortality in elderly patients (possibly); the evidence

for the effectiveness of these drugs in this clinical situation is modest,

at best; and, they may be especially dangerous for elderly patients

who have Alzheimer’s disease.42,43

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Environmental and Psychosocial Interventions

It is recommended that behavioral and environmental approaches

should be used to treat neuropsychiatric behavior problems and

emotional issues in patients who have Alzheimer’s disease.27 The

commonly used psychotropic medications do not have Food and Drug

Administration (FDA) approval for this purpose, and psychotropic

medications should only be used for treating neuropsychiatric behavior

problems and emotional issues in patients who have Alzheimer’s

disease if: 27

non-pharmacologic interventions have failed;

the patient has major depression with or without suicidal

ideation;

the patient has a psychosis that is causing great harm or has the

potential to do so;

the patient is very aggressive and may harm him/herself or

others.

It is often assumed that the neuropsychiatric behavior problems and

the emotional issues that are so distressing and difficult are simply

inevitable for patients who have Alzheimer’s disease. These problems

do occur quite often and Alzheimer’s disease is their root cause, but

the precipitating cause of agitation, aggression, inappropriate actions

and speech, wandering etc., is almost always internal and/or external

stimuli that are not obvious to family members, caregivers, and health

care professionals.27,44

The patient who has Alzheimer’s disease has cognitive deficits that

affect the patient’s ability to cope, communicate, understand the

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environment, and to provide self-care. These cognitive deficits and

language impairments also mean that the patient with Alzheimer’s

disease cannot express his or her needs or frustrations, and cannot

organize an appropriate response to them. These issues combine to

place the patient in a tremendous amount of stress, and the patient

reacts.

The behavior and the language of someone who has Alzheimer’s

disease may be difficult and inappropriate, but the patient is usually

reacting to an identifiable stressor. Considering neuropsychiatric

behavior problems and emotional outbursts as normal for a patient

who has Alzheimer’s dementia is in one sense treating the patient as

less than whole.

Learning Break:

Treatment and management of neuropsychiatric behavior problems

and emotional problems in patients who have Alzheimer’s disease is

an important part of their care. However, ensuring and attending to

the patient’s comfort and safety is equally as important. It can be

easy to focus on the aspects of Alzheimer’s care that is the most

dramatic, i.e., managing psychotic behavior, but basic patient needs

should not be neglected and doing so is likely to greatly attenuate the

issues that are the most challenging to cope with.

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The DICE Method

The optimal approach to neuropsychiatric behavior problems and

emotional difficulties can be summarized very simply: make every

effort to understand the situation from the patient’s point of view.

Kales et al., (2014) note that the ideal approach is “… to conceptualize

behaviors as stemming from unmet needs, environmental overload,

and interactions of individual, caregiver, and environmental factors.”27

A useful approach that has been developed is called the DICE

approach: Describe, Investigate, Create, and Evaluate.35

The DICE approach is a systematic way of identifying and treating

neuropsychiatric behavior problems. It begins with and operates under

the assumption that such difficult management issues with patients

who Alzheimer’s disease are caused by a stressor that can be

identified and corrected, and that these issues can be solved with

creativity and patience. The steps in the DICE method are explained

below. In the example below, we review a patient exhibiting agitation

but the DICE approach can be used for any problem that may arise

between an Alzheimer’s patient and caregiver. In addition, the DICE

approach can be used while an event is happening or retrospectively.

Describe

The staff, family member, or the caretaker reports that the patient has

become agitated and aggressive and this behavior is new. In the first

step of the DICE approach the clinician, caretaker, or family member

should clearly describe the situation; simply reporting that the patient

has become agitated and aggressive is not helpful without context.

This step is not complicated, but an organized approach works best, so

focus on who, when, what, and where.

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Who is there when the patient is agitated? The same person and

only that person or can it be anyone?

When does this behavior happen? Is it only at a specific time of

the day, does it happen throughout the day, is it periodic in

nature, or is it continuous?

What is happening when the behavior occurs? This is probably

the most important variable. Does the behavior happen during

meals, when the patient is going to sleep, during bathing, or

when a new person enters the room? Was the patient recently

prescribed a new medication or does the behavior begin shortly

after a dose of medication is given? Is the patient in a situation

that could be described as frightening or threatening? The

questions to ask can be nearly endless, but it is often obvious

what the precipitating situation involves.

Where relates to whether there are environmental conditions

that may be precipitating the behavior? Is there a lot of

background noise, a lot of people in the area (or too few), or a

lot of new activity happening?

Additionally, has the patient been asked why she/he is upset and/or

behaving in a certain way? Asking someone who has Alzheimer’s

disease to explain feelings and motivations may not always be fruitful,

but it should be done. It is important to listen to the patient. Is the

patient making a specific complaint? What is the patient saying when

the events(s) occur?

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Investigate

The investigation stage of DICE is closely linked with the description

stage, but one of the areas to focus on in the investigation stage is

basic needs, i.e., comfort, hunger, presence of pain, etc. In addition, it

is important to remember that many people who have dementia are

elderly and have chronic medical problems. Neuropsychiatric

behavioral problems are often caused by emotional or psychological

stress, but the possibility of an acute illness or exacerbation of an

existing one should always be considered.

Check the patient’s temperature, blood pressure, pulse, and

respiratory rate, if needed. Has the patient’s vision or hearing

changed? Could the patient have developed a new medical

issue?

Is the patient incontinent of stool or urine?

Could the patient be too cold or warm?

Could the patient be hungry or thirsty?

Is the patient’s position uncomfortable?

Does the patient have an injury? The patient may have suffered

an injury but is unable to tell anyone.

Was the patient recently prescribed a new medication or does

the behavior begin shortly after a dose of medication is given?

Was the patient supposed to receive a dose of medication but

the dose was not given?

Could the patient be in pain?

Has the patient’s daily activity schedule been changed or the

patient’s sleep pattern disrupted?

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Is there anything about the physical and emotional interaction

between the patient caretakers, family members, or staff that

may be contributing?

Create

Creating a treatment plan should be a collaborative effort between

nurses, other healthcare professionals and if they are involved in day-

to-day care, the family members. The clinician needs to focus on the

behavior that is problematic at the time, but also on root causes and

prevention. Strategies for the two can be different. The patient who is

agitated may need to be in a place that is quiet and away from others

- an immediate solution - but underlying causes such as over-

stimulation and pain need to be addressed. Specific problems that are

easily identifiable such as a fever or incontinence can easily be

treated. Finding creative solutions that address less obvious

precipitating factors or ones not easily changed can be difficult.

Evaluate

In this final step, the creative solution is evaluated for its

effectiveness, its negative and positive consequences, and how easy it

was to apply. The interventions should also be routinely assessed to

ensure they were successful, and if successful, that they are being

done correctly.

Can Alzheimer’s Disease Be Prevented?

Alzheimer’s disease is devastating and there is no cure, so prevention

of the disease is an area of intensely focused research. Han et al.,

(2014) note that disease prevention can be primary, secondary, or

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tertiary.45 Primary prevention of Alzheimer’s disease focuses on

modifiable risk factors and targeting the pathophysiological processes

of the disease; secondary prevention focuses on early detection of the

disease before clinical signs and symptoms begin; and, tertiary

prevention focuses on changing the course of the disease to make it

easier to live with and prevent complications.

Pharmacological approaches to tertiary prevention have been

unsuccessful, early detection is still unreliable, and targeting the

pathophysiological processes of the disease have not worked. The

most promising approach to date is focusing on modifiable risk factors

such as cardiovascular disease, diabetes, diet, hypertension, metabolic

syndrome, physical activity, psychosocial issues such as depression

and isolation, and smoking.

Changing behaviors in relation to these risk factors has undoubted

health benefits. However, the evidence for the effectiveness of this

approach in preventing Alzheimer’s disease, i.e., increasing physical

activity directly decreasing the risk of developing Alzheimer’s disease,

is far from unequivocal.45-48 The literature often describes an

association between change in a specific behavior and change in the

risk for Alzheimer’s disease, but as Sindi, et al., note (2015), when the

evidence for preventive interventions is examined, it is considered

inadequate.47

Summary

Alzheimer’s is a chronic, progressive neurological disease that causes

devastating cognitive impairments. The pathophysiological processes

that are characteristic of Alzheimer’s disease, amyloid plaque deposits

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and neurofibrillary tangles in specific areas of the brain, develop many,

many years before the clinical signs and symptoms begin. Alzheimer’s

disease primarily affects people who are 60 or older: age is one of the

biggest risk factors for the development of the disease. The disease is

well described in the pathophysiological and clinical sense, and thought

to be caused by a confluence of environmental, genetic, and lifestyle

issues and disease states, but it is still not clear how and when these

interact to produce Alzheimer’s disease. Much about Alzheimer’s is still

unknown.

There is no cure for Alzheimer’s disease and attempts at finding easily

applied preventative measures have not been successful. The

treatment for Alzheimer’s disease at this point focuses on symptomatic

relief and to a lesser degree, altering or influencing several of the

pathophysiological processes that are thought to cause the cognitive

impairments. However, pharmacologic therapy has been relatively

disappointing in its effectiveness, and environmental and psychosocial

interventions are the preferred approach for care of the patient who

has Alzheimer’s disease.

Please take time to help NurseCe4Less.com course planners

evaluate the nursing knowledge needs met by completing the self-assessment of Knowledge Questions after reading the

article, and providing feedback in the online course evaluation.

Completing the study questions is optional and is NOT a course requirement.

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1. Alzheimer’s disease primarily affects:

a. the elderly.

b. men.

c. the young.

d. people between 40 and 60.

2. True or false: Environmental risk factors are a proven

cause of Alzheimer’s.

a. True.

b. False.

3. A family history of Alzheimer’s disease

a. has no influence on the risk for Alzheimer’s disease.

b. only affects women in terms of risk for Alzheimer’s disease.

c. only increases the risk if the patient has diabetes and

hypertension.

d. significantly increases the risk for Alzheimer’s disease.

4. Which of the following are risk factors for Alzheimer’s

disease?

a. Chronic obstructive pulmonary disease and hepatitis.

b. Acute kidney disease and anticoagulation with warfarin

c. Hypertension and diabetes.

d. Atrial fibrillation and long-term use of anti-depressants.

5. Alzheimer’s disease is characterized by:

a. cerebral emboli and hyper-coaguability.

b. vasospasm and Lewy bodies.

c. cerebral edema and amyloid plaques.

d. amyloid plaques and neurofibrillary tangles.

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6. The pathologic lesions of Alzheimer’s disease

a. begin many years before clinical signs begin.

b. differ significantly in nature from patient to patient.

c. begin after the clinical signs are evident.

d. can spread to the peripheral nerves.

7. One of the earliest and most prominent signs of

Alzheimer’s disease is:

a. Incontinence.

b. Memory loss.

c. Aphasia.

d. Inability to perform self-care.

8. True or false: Anti-psychotics are very safe and effective

treatment for Alzheimer’s disease.

a. True.

b. False.

9. Which of the following drugs are commonly used to treat

Alzheimer’s disease?

a. Beta blockers and benzodiazepines.

b. Antihistamines and MAO inhibitors

c. Memantine and acetylcholinesterase inhibitors.

d. Anti-depressants and calcium channel blockers.

10. Alzheimer’s disease can be definitively diagnosed with

laboratory tests.

a. True.

b. False.

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Correct Answers:

1. A 2. B

3. D 4. C

5. D 6. A

7. B 8. B

9. C 10. B

REFERENCE SECTION

The reference section of in-text citations include published works

intended as helpful material for further reading. Unpublished works

and personal communications are not included in this section, although

may appear within the study text.

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and Gerontology. 6th ed. New York, NY: McGraw-Hill;2009. Online

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26. Palasí A, Gutiérrez-Iglesias B, Alegret M, Pujadas F, Olabarrieta M,

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014-0218-y.

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