Professional Documents
Culture Documents
Alzheimer's Dementia
Sue Ryno
April 6, 2010
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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
Alzheimer's disease, and three nursing diagnoses that address the complications of Alzheimer's
disease.
The Alzheimer's Association (2010) publishes statistics annually of the prevalence and
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 %
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
Pathophysiology
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
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.
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,
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 &
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
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
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
("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
Clock Drawing Test (CDT), Sydrome Kurtztest (SKT), Mattis Dementia Rating Scale,
(CERAD), New York University Computerized Test Battery (NYU Battery), Everyday Memory
Battery, Wechsler Adult Intelligence Scale, and Mini-Cog ("Conducting", 2010; Dharmarajan &
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
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
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
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."
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
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
dementia such as legal and ethical dilemmas and caregiver role strain, assessment tools can be
generated to help evaluate treatment modalities and develop better plans of care. Nursing
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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
http://www.alz.org/alzheimers_disease_facts_figures.asp?type=homepage
stresscheck/
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
Meiner, S. E. & Lueckenotte, A. G. (2006). Gerontologic nursing (3rd ed.). St. Louis, MO:
Mosby Inc.
/documents_custom/ALZ_FF_Michigan.pdf?type=interior_map
_disease_stages_of_alzheimers.asp