Geriatric Syndrome

Running head: ALZHEIMER'S DEMENTIA 1

Alzheimer's Dementia

Elizabeth Ping – T-012

Sue Ryno

Spring Arbor University

April 6, 2010

ALZHEIMER'S DEMENTIA

Alzheimer's Dementia

Senile dementia of the Alzheimer's type or SDAT represents a growing concern for

health care professionals and is the most common type of dementia in the elderly (Dharmarajan

& Gunturu, 2009, p. 39). The manifestations of Alzheimer's dementia such as progressive

cognitive deterioration and behavioral disturbances presents difficulties in managing the care

with those who have the disease. The following will discuss the prevalence of Alzheimer's

dementia in the United States, the pathophysiology of the disease process, the clinical

presentations of Alzheimer's disease, complications Alzheimer's disease, assessment tools for

Alzheimer's disease, and three nursing diagnoses that address the complications of Alzheimer's

disease.

Prevalence and Demographics

The Alzheimer's Association (2010) publishes statistics annually of the prevalence and

demographics of dementia in America ("Alzheimer's Disease Facts", pp. 1-74). It is estimated

that one in eight people who are 65 and older has Alzheimer's dementia. This number accounts

for approximately 5.3 million Americans who may have the disease. Specifically in Michigan,

there are 180,000 residents who have been diagnosed with Alzheimer's dementia with 42 %

representing those with moderate to severe cognitive impairments ("Michigan Alzheimer's",

2010, p. 1). The mortality rate of those aged 65 and older accounts for the 5th leading cause of

death in America and the 7th leading cause of death of for those of all ages ("Alzheimer's

Disease Facts", pp. 1-74). Moreover, it is assumed that since more Americans are living to a

greater age, there will be more elderly diagnosed with Alzheimer's dementia. Accordingly, it is

estimated that by the year 2050, there will be 19 million Americans identified with dementia.

Alzheimer's disease tends to have certain risk factors related to gender, ethnicity, level of

education, age, and geographical location ("Alzheimer's Disease Facts", 2010, pp. 1-74). Those

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who are female, African-American or Hispanic, less educated, older, and live in the South,

Midwest and West have a higher degree of incidence than those who are male, Caucasian, more

educated, younger, and live in the Northeast. Additionally, it has been noted by Dharmarajan

and Gunturu (2009), that those who have poorer physical status, smoke tobacco, been diagnosed

with depression, and have a lower household income have a greater incidence of Alzheimer's

dementia (p. 40).

Pathophysiology

Pathology relating to Alzheimer's dementia is demonstrated by the formation of amyloid

neuritic plaques seen throughout the neocortex and neurofibrillary tangles throughout the

amygdala, hippocampus, and thalamus (Dharmarajan & Gunturu, 2009, p. 40). These resultant

plaques produce inflammation and loss of neurons in all involved areas. There are multiple

theories concerning the risk factors of Alzheimer's dementia. According to Meiner and

Lueckenotte (2006), research has mainly focused on genetic, viral, environmental, and

nutritional factors (pp. 664-5). Currently there is no single cause of the disorder for everyone

who has Alzheimer's, and the disease is largely considered to be caused by multiple factors.

Meiner and Lueckonotte (2006) described genetic predisposition and exposure to viruses

as possible risk factors for Alzheimer's dementia (p. 664). A family history of Alzheimer's

dementia increases a person's risk for developing the disease, as does identification of certain

genes such as E-e4 (APOE-e4) and mutations in chromosomes 14 and 21. Furthermore,

researchers are studying how exposure to viral illness such as viral encephalitis, herpes zoster,

and herpes simplex are related to the damaging deposit of amyloid plaques in the brain.

Dharmarajan and Gunturu (2009) described other risk factors of Alzheimer's dementia

such as environmental and nutritional factors (p. 40). Environmental factors related to

Alzheimer's dementia include the exposure to certain substances such as smoking and physical

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strains such as head trauma or having postoperative delirium. Meiner and Lueckonotte (2006)

described nutritional factors that increase the risk for developing Alzheimer's dementia such as

folic acid or vitamin B12 deficiency (p. 665). Other related factors include having an elevated

homocysteine level, hyperlipidemia, hypertension, diabetes mellitus, low thyroid stimulating

hormone, and elevated C-reactive protein (Dharmarajan & Gunturu, 2009, p.40).

Clinical Presentations

The clinical features of Alzheimer's dementia are commonly classified into stages of

cognitive and functional decline. The Alzheimer's Association (2010) separated each phase of

the disease into seven sections with stage one representing no physical or mental impairments to

stage seven representing severe decline of physical and mental state ("Stages", pp. 1-5). Other

classification systems demarcate the clinical presentations into three stages including mild

dementia, moderate dementia, and severe dementia (Dharmarajan & Gunturu, 2009, p. 41).

In mild dementia, patients demonstrate a loss of memory for recent events and

personality changes start to develop (Dharmarajan & Gunturu, 2009, p. 41). At this stage,

patients are still able to independently manage their activities of daily living because behavioral

and motor changes have not occurred. Moderate dementia represents a worsening of memory for

recent, remote and recalled events, significant cognitive impairment, and increasing personality

changes. In this stage, behavior changes are evident and may be expressed as agitation,

aggressive behavior, anxiety, and depression. A patient at this phase can no longer manage all

activities of daily living with competence and safety and must be partially dependent on others.

In severe dementia, patients demonstrate advanced deterioration of memory, language, and

cognition. Patients with severe dementia may only be able to speak a few words and have

echolalia and palilalia, frequently wander, may be unable to feed self or even swallow, and are

incontinent of urine and stool. Behavior traits worsen and include those present in moderate

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dementia with the addition of psychosis (Mohs, 2000, p. 2). Activities of daily living can no

longer be completed by the patient safely and must be managed by an outside caregiver.

Complications

Complications arising from Alzheimer's dementia are numerous and are often associated

with the different stages of the disease's advancement. The most obvious complication is the

decline in mental functioning. Worsening cognition ultimately can lead to short-term memory

loss, chronic confusion, sleep disturbances, wandering, increase number of injuries, falling,

behavior problems (i.e., agitation, hallucinations, depression, anxiety, aggression, apathy,

hallucinations, and delusions), inability to speak, inability to safely swallow food, inability to

care for activities of daily living safely, and incontinence of urine and stool (Dharmarajan &

Gunturu, 2009, p. 43).

Care giver role strain is another complication of Alzheimer's dementia because of the

heavy dependence on others that patients with the disease require to maintain normal functioning

with activities of daily living. It is estimated by Dharmarajan and Gunturu (2009) that 70 % of

the population with Alzheimer’s dementia can be categorized as needing assistance from their

community (p. 45). Care often is delegated to female members of the family such as daughters

who have families of their own. Those who feel burdened often suffer from increased rates of

depression, musculoskeletal disorders, and hypertension. Care giver role strain can worsen as

the person with Alzheimer's dementia needs 24-hour assistance, when the economic cost of care

becomes too great, and the care giver receives little time away from the individual.

Ethical dilemmas related to Alzheimer's dementia occur as the patient progresses to the

stage of severe dementia. At the advanced stage of dementia, even simple acts of eating become

too difficult, and the patient cannot make decisions regarding desired health care wishes

(Dharmarajan & Gunturu, 2009, p. 43). It must then be determined whether the individual with

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Alzheimer's dementia should have a percutaneous endoscopic gastrostomy (PEG ) tube inserted

for alternative nutrition and/or whether advanced life support measures should be initiated when

the patient goes into respiratory and cardiac failure. This presents difficult decisions for family

members and health care providers if the patient had made their desires concerning therapies that

they want and do not want such as through the creation of living wills and appointment of

durable power of attorney.

Placement concerns for the Alzheimer's patient presents multiple problems. As

Dharmarajan and Gunturu (2009) have noted, Alzheimer's disease eventually progresses to a

state of profound behavioral changes (p. 41). These behavioral changes can make it more

challenging for a person with Alzheimer's dementia to qualify financially and appropriately for

nursing home placement because of the extra burden and specialized care that those with the

disease require for optimal quality of life and treatment.

Assessment Approaches

Evaluation of dementia relies on tools that assess cognitive abilities, functional abilities,

behavior, general physical health, and the quality of life of the individual ("Conducting", 2010,

par. 1-9). If a patient is at the early stages of dementia, these tools can be used by the patient with

minimal assistance. Alternatively, if a patient is at the late stages of dementia, these tools can be

used by the patient's caregiver. Furthermore, as many assessment tools for evaluating

Alzheimer's disease that are feasible for a given patient should be used to gain a better

understanding of assessing baseline functioning and treatment efficacy.

Cognitive decline represents one of the main symptoms of Alzheimer's dementia

("Conducting", 2010, par. 1-9). As such, diversified assessments concentrating on the cognitive

ability of the individual have been created. These assessments devices include the Alzheimer's

Disease Assessment Scale (ADAS-cog), Blessed Information-Concentration Test (BIMC),

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Clinical Dementia Rating Scale (CDR), and the Mini-Mental State Examination (MMSE), Clock

Drawing Test (CDT), Sydrome Kurtztest (SKT), Mattis Dementia Rating Scale,

Neuropsycholgical Battery of the Consortium to Establish a Registry for Alzheimer's Disease

(CERAD), New York University Computerized Test Battery (NYU Battery), Everyday Memory

Battery, Wechsler Adult Intelligence Scale, and Mini-Cog ("Conducting", 2010; Dharmarajan &

Gunturu, 2009; Mohs, 2000).

Functional assessment tools evaluating an individual's decline in the ability to fulfill

activities of daily living include the Functional Assessment Questionnaire (FAQ), Instrumental

Activities of Daily Living (IADL), Physical Self-Maintenance Scale (PSMS), and the

progressive Deterioration Scale (PDS) ("Conducting", 2010, par. 1-9). Global assessment tools

include the Clinical Impression of Change (CGIC), Clinical Interview-Based Impression (CIBI),

and Global Deterioration Scale (GDS). Neuropschological instruments for the evaluation of

psychiatric disorders include the Hamilton Depression Rating Scale, Cohen-Mansfield scale,

NIMH Scale for Depression in Dementia, and the Brief Psychiatric Rating Scale (Mohs, 2000, p.

4). Additionally, caregivers of Alzheimer's patients can take the Caregiver Stress Check Quiz

offered by the Alzheimer's Association to evaluate whether they may be experience caregiver

role strain ("Caregiver Stress", 2010 p. 1).

Nursing Interventions

Nursing diagnoses and interventions for the patient with Alzheimer's dementia should

focus on the complications that are encountered at the different stages of worsening cognitive

and functional conditions. Carpenito-Moyet (2005) suggested that potential nursing diagnoses

for the patient with dementia should include "chronic confusion", "caregiver role strain", "risk

for injury", "decisional conflict", "interrupted family process", "impaired home maintenance",

and "wandering" (p. 568). For the purpose of this paper, the nursing diagnosis of "chronic

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confusion" and "caregiver role strain" were outlined and an educational flyer on the nursing

diagnosis "risk for injury" was created for teaching purposes.

Chronic confusion. Carpenito-Moyet (2008) noted that chronic confusion occurs when a

person reaches the state when there is an irreversible decline in mental ability and personality

(pp. 169-174). The nursing diagnosis of chronic confusion related to progressive degeneration of

the cerebral cortex secondary to Alzheimer's disease can be applied to any stage of the

Alzheimer's disease process where cognitive deterioration is present and long-standing. Figure 1

represents the care plan for "chronic confusion."

Date Initiated

Plan and Outcome Nursing Intervention

4/6/2010 Patient will remain safe and free from harm by 5/1/2010.

Family or significant other will verbalize understanding of disease process/prognosis and patient’s needs, identify and participate in interventions to deal effectively with situation, and provide for maximal independence while meeting safety needs of patient by 5/1/2010.

The nurse will by 5/1/2010:

1. Assess patient's cognitive impairment by conducting an Alzheimer's Disease Assessment Scale, Blessed Information-Memory-Concentration Test, Clinical Dementia Rating Scale, and/or Mini-Mental State Examination.

2. Evaluate by talking with patient's significant others and caregivers the patient's baseline behaviors and how long that the patient has had dementia and memory difficulties.

3. Evaluate by talking to patient's significant others and caregivers the receptiveness to maintaining safety for the patient.

4. Evaluate the patient's anxiety level and establish trust with the patient.

5. Provide a calm environment by reducing noises, smells, and bright lights and maintain objects such as clocks, calendars, personal items, and seasonal decorations in the house or room that can assist in reorienting the patient.

6. Avoid challenging patients illogical thinking that would not result in safety concerns.

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7. Reorient patient to environment when needed and encourage participation in re-socialization groups.

8. Encourage patient to explain what is known by reminiscing when appropriate.

9. Encourage safety measures such as having the patient wear an identification bracelet, keeping the medication locked up, lowering the temperature on the hot water tank and providing closer supervision of the patient by caregivers.

10. Identify appropriate community resources such as the Alzheimer's Association, respite care services, and support groups.

11. Provide written information for the patient's caregivers about Alzheimer's Dementia.

12. Refer patient to respite care, home care agencies, and Meals on Wheels as appropriate.

Figure 1. Chronic Confusion. (Carpenito-Moyet, 2008, pp. 169-174).

Caregiver role strain. Carpenito-Moyet (2008) noted that care giver role strain occurs

when a person reaches the state physical, emotional, and/or financial burden while caring for

another person (pp. 108-116). The nursing diagnosis of caregiver role strain related to multiple

care needs and insufficient resources can be applied to any relationship where caring for another

has been transformed into a stressful process. Figure 2 represents the care plan for "care giver

role strain."

Date Initiated Plan and Outcome Nursing Intervention

4/6/2010 Caregiver will demonstrate competence and confidence in meeting the patient's physical and mental needs by 5/1/2010.

Caregiver will express


1. Assess patient's caregiver's amount of stress by having caregiver take the caregiver role strain assessment.

2. Assess caregiver's communication patterns, health, resources, support systems, and finances.

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ALZHEIMER'S DEMENTIAsatisfaction with the role as caregiver by 5/1/2010.

Caregiver will use outside resources as appropriate to facilitate in taking care of the patient 5/1/2010.

Caregiver will identify personal strengths and weakness of taking care of the patient by 5/1/2010.

3. Assess caregiver's level of understanding and willingness of responsibilities in taking care of the patient.

4. Assess patient for signs of neglect or abuse from the caregiver such as bruises or the patient showing fear around caregiver.

5. Establish a relationship with the caregiver by having open communication and gaining trust and acknowledge to the caregiver how difficult caring for another person is.

6. Encourage the caregiver to seek help and support from family member, community support groups, church groups, and be involved in political policy making.

7. Encourage the caregiver to utilize appropriate community resources such as Meals on Wheels, Companion Services, respite care, and home health care.

8. Encourage the caregiver to discuss feelings, concerns, and problems.

9. Encourage caregiver to take breaks as appropriate.

10. Refer caregiver to counseling services as needed.

11. Demonstrate to caregiver quicker, safer , and cheaper ways of taking care of patient as appropriate.

Figure 2. Caregiver Role Strain. (Carpenito-Moyet, 2008, pp. 108-116).

Risk for injury. Carpenito-Moyet (2008) noted that a risk for injury occurs when a person

is at risk for harming oneself due to a lack of awareness or possible perceptual deficiencies (pp.

358-373). The nursing diagnosis of "risk for injury" related to lack of awareness of

environmental hazards can be applied to any of the stages of dementia. Figure 3 represents the

care plan for "risk for injury."

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ALZHEIMER'S DEMENTIADate Initiated Plan and Outcome Nursing Intervention

4/6/2010 Patient will be free of injuries by 5/10/2010.


1. Assess patient's environment for safety hazards such as loose rugs, lack of lighting, lack of non-skid mats in bathtub, high water tank settings, stairs without rails, lack of smoke detectors and encourage caregiver to repair/remove hazards or install safety measures as appropriate.

2. Assess patient for current injuries related to falls, bumping into objects, and other mishaps related to being an unsafe environment.

3. Educating caregiver and patient on ways to reduce injuries from falls by giving them a brochure about falls (see Addendum 1).

3. Encourage patient and caregiver to keep bed set at the lowest level at during the night.

4. Encourage the use of a night light for the night time.

5. Encourage caregiver to reorient patient to new and current surroundings as needed.

6. Encourage patient to use an alert system in case of falls.

7. Encourage caregiver to install safety measures such as locks and rails as needed.

8. Encourage caregiver to keep medications in a safe place.

Figure 3. Risk for Injury. (Carpenito-Moyet, 2008, pp. 358-373).

As the prevalence of Alzheimer's dementia continues grow in the coming years, it will

become increasingly important for health care professionals to be aware of the risk factors

surrounding the disease and the clinical manifestations such as confusion and behavioral

disturbances. Furthermore, by understanding the numerous complications of Alzheimer's

dementia such as legal and ethical dilemmas and caregiver role strain, assessment tools can be

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generated to help evaluate treatment modalities and develop better plans of care. Nursing

diagnoses such as "chronic confusion," "caregiver role strain," and "risk for injury" with

interventions can then be utilized for the patient with ongoing Alzheimer's dementia.

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References

Alzheimer’s facts and figures (2010). Alzheimer’s Association. Retrieved from

http://www.alz.org/alzheimers_disease_facts_figures.asp?type=homepage

Caregiver stress check (2010). Alzheimer's Association. Retrieved from http://www.alz.org/

stresscheck/

Carpenito-Moyet L. J. (2005). Handbook of nursing diagnosis (11th ed.). Philadelphia, PA:

Lippincott Williams & Wilkins.

Carpenito-Moyet L. J. (2008). Nursing Diagnosis: Application to clinical practice (3th ed.).

Philadelphia, PA: Lippincott Williams & Wilkins.

Dharmarajan, T., & Gunturu, S. (2009). Alzheimer's disease: a healthcare burden of epidemic

proportion. American Health & Drug Benefits, 2(1), 39-47. Retrieved from CINAHL

Plus with Full Text database.

Meiner, S. E. & Lueckenotte, A. G. (2006). Gerontologic nursing (3rd ed.). St. Louis, MO:

Mosby Inc.

Michigan Alzheimer's statistics (2010). Alzheimer's Association. Retrieved from http://alz.org

/documents_custom/ALZ_FF_Michigan.pdf?type=interior_map

Mohs, R. C. (2000). Neuropsychological assessment of patients with Alzheimer's disease.

Retrieved from http://www.acnp.org/g4/GN401000133/CH130.html

Stages of Alzheimer's (2010). Alzheimer's Association. Retrieved from http://alz.org/alzheimers

_disease_stages_of_alzheimers.asp

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