Alzheimer's Disease

Course Objectives

1.  Describe the criteria necessary for diagnosing alzheimer's disease.

2.  Describe the medications used to treat the symptoms of alzheimer's disease.

4   Identify co-occurring disorder.

5.  Describe the social skills and behaviors of alzheimer's patients..

 

A new environment filled with strange sights, odors and sounds, a change in the daily routine, medications and tests, and the disease process itself can all be factors that increase confusion, anxiety and agitation in a hospitalized individual with Alzheimer's disease. This will help you to meet the needs of these patients. You will find facts about Alzheimer's disease, communication tips, personal care techniques, suggestions for working with behaviors and environmental factors to consider in the ER and in the hospital room.

When hospitalization occurs, the best option for the individual with Alzheimer's disease is the constant presence of a family member or a trusted friend. Because this may not always be possible, this can serve as a guide in helping you understand and practice the many facets of care for your patient with memory disorder.

Remember, family members are your most valuable resource for information about the individual and the caregiving techniques that work best.

Alzheimer's Disease: Just the Facts

  • Alzheimer's disease attacks the brain and causes problems with memory, thinking and behavior.
  • Most people diagnosed with Alzheimer's are over age 65, but it can occur in people in their 40s and 50s.
  • Symptoms include gradual memory loss, decreased ability to perform routine tasks, disorientation, problems with language skills, poor judgment and personality changes.
  • The time from the beginning of symptoms until death ranges from 3 to 20 years; the average is 8 years.
  • There is no single test to identify Alzheimer's disease. A complete medical evaluation for diagnosis is essential.
  • A thorough evaluation will provide a correct diagnosis of possible or probable Alzheimer's 90-percent of the time.
  • There is no cure for Alzheimer's disease at present. There are FDA-approved drug treatments, designed specifically for memory symptoms occurring in mild to moderate stages of Alzheimer's disease.
  • The causes of Alzheimer's disease are not known. Suspected causes include genes and environmental exposure.

More Than Just Words: Effective Communication Techniques

Communicating with an Alzheimer's patient can be challenging, but remember, decreased verbal communication does not mean decreased awareness. Most patients are very aware and feel a great deal of distress about their increased loss of ability.

General Rules of Thumb:

Reality orientation does not work. Instead, use memory aids such as labeling objects (i.e. closet, bathroom). Be aware that as Alzheimer's disease progresses, an individual's ability to name objects and use words decreases.

Simplify the environment for Alzheimer's patients. Eliminate distracting noises such as the radio or TV, or loud conversation.

Do not use the in-room intercom to communicate. The patient may be frightened or confused by hearing a voice only.

Communication Tips

  • Always begin by identifying yourself and calling the patient's name.
  • Always approach from the front.
  • Maintain good eye contact.
  • Use short, simple sentences.
  • Speak slowly.
  • Be specific. Use the name of the person or object instead of "this" or "they."
  • Keep tone of voice low and pleasant.
  • Keep facial expression warm and friendly.
  • Use non-verbal cues: a reassuring touch, a smile, a demonstration stating the emotion.
  • Give the person plenty of time to respond to your question (20 seconds).
  • Always repeat your question exactly the same way.
  • Use concrete language.
  • State in positive terms. Constant use of "no" or commands increases resistance.
  • Don't test the patient's memory. Erase the words, "Don't you remember?" from your vocabulary
  • Give directions simply and one at a time.
  • When helping with personal care, tell the patient what you are doing each step of the way. Add occasional social or reassuring comments to avoid "task-focused talk" only.
  • Do not appear rushed or tense. The patient will become tense and agitated.
  • Listen to the patient. Try to find the key thought and take note of the feeling or emotion being expressed along with the spoken word.
  • Reassure through words. Remind the patient who you are and that you will take care of him.
  • Sometimes asking a "Why" question can get to the reason behind a repetitive question and decrease its occurrence. (i.e. "Why are you concerned about what time it is?")

In the Emergency Room: Assessment Tips

  • Do not leave the patient alone. A family member, trusted caregiver or friend should be present at all times.
  • Continuous cueing to the environment (place) and activity may be necessary. A family member can assist with this and offer reassurance as well.
  • Obtain patient's history from a close relative or caregiver.
  • Pay close attention to the caregiver's description of the patient's usual level of consciousness. Increased dementia or the onset of delirium can be a sign of acute physical illness or metabolic distress.
  • Perform a complete head to toe assessment. The patient may not be able to automatically identify painful or affected areas to you.
  • Before every communication with the patient, make sure you have his attention by calling his name and making direct eye contact with him. Your eyes should be level with the patient's eyes.
  • Ask simple "yes" and "no" questions. Allow ample response time (at least 20 seconds).
  • Watch for non-verbal communication of pain or discomfort such as grimacing, guarding or anger.
  • Apologize each time you cause pain and avoid repeating painful exams.
  • In short, simple statements, tell the patient what you are doing, why and that you will be finished soon. Repeat this throughout the examination.
  • Never talk about the patient to others as if he is not in the room.

My Patient Has Alzheimer's: General Guidelines

For an Alzheimer's patient, the trauma or ailment that preceded hospitalization, the strange new environment, the disrupted daily routine and the influence of medications can all be factors for increased confusion and decreased ability.

There are a number of things you can do to reassure your patient. You should:

  • Provide a consistent, predictable routine. Ask the primary caregiver for the patient's usual routine and follow it as closely as possible.
  • Encourage the use of security objects from home (i.e., favorite pillow or quilt).
  • Provide care by the same nurses and nursing assistants as much as possible.
  • Avoid surrounding the patient with several doctors and medical students at one time.
  • Evaluate the patient for sources of potential pain and discomfort. Even though he may be experiencing pain, the patient will probably not verbally complain.
  • When possible, schedule tests at a time of day when the patient is at his best and not fatigued.
  • Discontinue asking orientation questions once the patient's level of comprehension is established.
  • Use good communication techniques. (See Communication Section).
  • Schedule at least two rest periods:  A half hour after morning care and an hour in early afternoon. Rest is important!
  • Post rest period times on the patient's door. Use a big "Resting" or "Do Not Disturb" sign during the actual rest period.
  • Limit visitors to one or two at a time.
  • Cue the patient for sleep by darkening and quieting the room.
  • Avoid using physical restraints. They do not prevent falls. Injuries from falls while the patient is restrained are often more serious.

Room Service: Assessing the Environment

  • Avoid numerous room changes. Change increases confusion and anxiety.
  • Avoid placing the patient in a room located in a high noise, high traffic area.
  • Keep the television off until the patient turns it on or requests it.
  • Remove artwork containing people or animals if the patient interprets them as real-life intruders.
  • Keep lighting as free of shadows and glare as possible.
  • Avoid clutter. It can increase confusion, agitation and the risk of falls.
  • If the patient can understand written words, then large, bold lettered signs can serve as cues to the bathroom, closet and personal items.

Providing the Essentials: Comfort and Safety

Comfort

  • Always communicate a sense of security, caring and respect.
  • Each staff/patient interaction should include: touch, eye contact, orienting information and an activity the patient can successfully perform.
  • Eyeglasses, dentures and hearing aids can enhance the patient's communication. Offer to assist the patient with placement of these devices. Be aware in some instances the patient is more comfortable without them.
  • If the patient has a comfort item, something that makes him feel secure, make sure it is within reach.

Safety

  • Provide a safe, structured environment.
  • Provide consistent staff to attend the patient.
  • Place the patient in a room that allows easy and careful observation.
  • Place bed in low position.
  • Don't leave anything at the bedside that might harm the patient.
  • Elopement precautions: Place the patient in a room where he has to pass the nursing station in order to reach an exit. Have a photo of the patient on file.

Positive Approaches to Personal Care: Activities of Daily Living

Eating

  • Do not ask the patient to fill out a menu. Ask the family about food preferences.
  • Simplify the food tray. Keep small, colored dishes on the unit to allow for smaller portions and the ability to offer one or two food items at a time. 
  • Smaller, more frequent meals may work better for the patient than the standard three large meals.
  • Cueing the patient to eat by using verbal reminders along with a light touch to the forearm increases food intake.
  • Finger foods, cups with lids and broad-handled utensils may make mealtime easier for the patient.
  • Late stage patients may chew, but need frequent reminders to swallow.
  • Plate guards and bibs with pockets catch spills and protect the patient's clothing.
  • Offer the patient fluids frequently throughout the day. Ask the caregiver what the patient prefers to drink and the type of drinking container used at home.

Oral Hygiene

  • Brush the patient's teeth at least twice a day.
  • For less impaired patients, apples and other fresh fruits aid with oral hygiene.

Bathing

  • Bathe the patient at his "best" time of day.
  • If possible, bathe the patient at the time he normally bathes at home.
  • Avoid using the shower. A hand-held showerhead provides better control of the water.
  • Allow the patient to do as much as possible. Break down the task into simple steps using verbal and visual cues.
  • When assisting the patient, give the bath slowly. To avoid agitation, tell the patient what you are going to do one step at a time.
  • Use soft music, talking or snacks as pleasant distractions.
  • Keep the patient warm! During a bed bath, cover body parts except the parts that are being washed.
  • Sounds amplify off tile walls. Running water can sound frightening.
  • Be flexible. A "bird bath" may be more acceptable to the patient.

Toileting

  • Clear a path to the toilet or commode.
  • Place bed in view of toilet.
  • To help cue the patient, place a picture of a toilet or a written sign on bathroom door.
  • Place your patient on a two-hour toileting schedule.
  • Use a nightlight to make it easier for the patient to find the toilet in the middle of the night.
  • Observe your patient for constipation. Ask questions about abdominal discomfort. Watch for non-verbal signs of discomfort such as grimacing or clutching. Do not ask the patient if he has had a bowel movement.

The Art of Camouflage: Protecting Tubes and Dressings

Reduce the number of tubes as quickly as possible while considering patient safety. Make remaining tubes as unobtrusive as possible.

  • Nasogastric Tubes (of small diameter): Tape to the side of the face, place tube behind patient's ear and fasten to shoulder area of the gown with a safety pin.
  • Central Venous Pressure lines: Can remain under the gown with a point of departure through the sleeve.
  • Peripheral Intravenous Line: 1. Can be wrapped in bandage gauze to prevent access or, 2. Can be place high on dominant arm. Dress patient in long sleeve gown with cuff (like an O.R. gown), run tubing up the arm and out the neck of the gown.
  • Foley Catheters: Should be run directly from the area of insertion to the end of the bed to prevent accidental pulling by the patient. Patient should wear undergarments to minimize access to the catheter.
  • Foley Catheter in Men: Should be taped to the abdomen.
  • Picks at Dressing: Consult with your occupational therapist to develop hand splints (like those used for patients with burns or rheumatoid arthritis) that maintain alignment and mobility but eliminate the pincer grasp, thus eliminating the ability to pick at the dressing.

What Do I Do When...? Tips for Working With Behaviors

General Guidelines

  • Think of behaviors (no matter how unusual) as communication signals from the patient that there is a problem or unmet need. Try to figure out that signal.
  • Remain calm.
  • Protect the patient both physically and from embarrassment.
  • Offer reassurance and appropriate assistance.

Changes In Sleep Patterns

Possible Causes:

  • Medications
  • Pain
  • Not enough activity during the day
  • Can't find the bathroom
  • Too hot or too cold
  • May be hungry

Possible Strategies:

  • Review medications for possible side effect of restlessness.
  • Evaluate your patient for pain and treat if needed.
  • Provide nightlights to aid the patient in finding the bathroom. Make sure the pathway is clear and well lit.
  • Attend to toilet needs right before bedtime.
  • Continue the patient's at-home bedtime routine as much as possible.
  • Limit beverages containing caffeine in the afternoon and evening.
  • If the patient wakes up at night, let him walk around (in sight) or sit at the nursing station until he is tired.

Confusion

Possible Causes:

  • Unfamiliar environment
  • Medications
  • Environment too noisy
  • Unfamiliar or difficult task
  • Unable to understand directions

Possible Strategies:

  • Identify any potential dangers in the environment.
  • Use pictures (symbols) instead of written signs to assist the patient with locating his room and bathroom.
  • Decrease noise level if possible by avoiding paging systems and buzzing call lights.
  • Place the patient's name in large block letters on the door to his room.
  • Review medications for side effect of confusion.
  • Simplify tasks. Break them down into smaller steps.
  • Simplify communication. Use short sentences and avoid lengthy explanations.
  • Ask the family member/caregiver about the comfort strategies used at home.

Wandering

Possible Causes:

  • Patient is stressed and anxious
  • Lifestyle related-previous work role or habits
  • Looking for security
  • Pain
  • Searching for something familiar

Possible Strategies:

  • Ask the caregiver where and when the patient usually wanders. Find out what strategies have worked at home.
  • Place the patient in a room that is convenient for you to keep a watchful eye on and that is away from stairs or elevator.
  • Keep the patient's suitcase, street shoes and street clothes out of sight.
  • Assess the patient for pain and treat if needed.
  • Plan walks with the patient.
  • Use distractions such as a snack or music.
  • Take time to talk with the patient.
  • Offer a simple, meaningful activity.

Catastrophic Reactions: Patient Feels Overwhelmed and Overreacts to a Situation

Possible Causes:

  • Fatigue
  • Environment is too stimulating
  • Patient is asked too many questions at a time
  • Too many strangers in a noisy, crowded atmosphere
  • Patient is asked to perform a task beyond his abilities
  • Fails at a simple task
  • Encounters irritable, impatient staff

Possible Strategies:

  • Remain calm.
  • Use a low tone of voice.
  • Do not argue with the patient.
  • Try the activity or task again later.
  • Refrain from forcing or restraining the patient.
  • Offer reassurance and try distraction.
  • Move the patient to a quieter area.
  • Simplify the task for the patient.
  • Build in rest periods.
  • Simplify communication.
  • Be aware of your own body language and what it is saying.

Preventing Catastrophic Reactions

  • Maintain a simple, structured, secure environment.
  • Follow routines and schedules.
  • Limit choices - choose between two items instead of five or six.
  • Introduce new treatments slowly.
  • Give step by step directions.

Disruptive Vocalizations: Calling out or screaming

Possible Causes:

  • Fear
  • Pain
  • Loneliness
  • Self-stimulation

Possible Strategies:

  • Offer the patient reassurance.
  • Place the patient where he can see a nurse.
  • Spend time with the patient.
  • Assess the patient for pain.
  • Provide a range of textures in the environment for stimulation.

The Hallmarks of AD

Alzheimer’s disease disrupts critical metabolic processes that keep neurons healthy. These disruptions cause nerve cells in the brain to stop working, lose connections with other nerve cells, and finally die. The destruction and death of nerve cells causes the memory failure, personality changes, problems in carrying out daily activities, and other features of the disease.

The brains of people with AD have an abundance of two abnormal structures—amyloid plaques and neurofibrillary tangles—that are made of misfolded proteins (see "Protein Misfolding" for more information). This is especially true in certain regions of the brain that are important in memory.

The third main feature of AD is the loss of connections between cells. This leads to diminished cell function and cell death.

AMYLOID PLAQUES

Amyloid plaques are found in the spaces between the brain’s nerve cells. They were first described by Dr. Alois Alzheimer in 1906. Plaques consist of largely insoluble deposits of an apparently toxic protein peptide, or fragment, called beta-amyloid.

We now know that some people develop some plaques in their brain tissue as they age. However, the AD brain has many more plaques in particular brain regions. We still do not know whether amyloid plaques themselves cause AD or whether they are a by-product of the AD process. We do know that genetic mutations can increase production of beta-amyloid and can cause rare, inherited forms of AD (see "Genes and Early-Onset Alzheimer’s Disease" for more on inherited AD).

From APP to Beta-Amyloid Plaques

Amyloid precursor protein (APP), the starting point for amyloid plaques, is one of many proteins associated with the cell membrane, the barrier that encloses the cell. As it is being made inside the cell, APP becomes embedded in the membrane, like a toothpick stuck through the skin of an orange.

In a number of cell compartments, including the outermost cell membrane, specific enzymes snip, or cleave, APP into discrete fragments. In 1999 and 2000, scientists identified the enzymes responsible for cleaving APP. These enzymes are called alpha-secretase, beta-secretase, and gamma-secretase. In a major breakthrough, scientists then discovered that, depending on which enzyme is involved and the segment of APP where the cleaving occurs, APP processing can follow one of two pathways that have very different consequences for the cell.

In the benign pathway, alpha-secretase cleaves the APP molecule within the portion that has the potential to become beta-amyloid. This eliminates the production of the beta-amyloid peptide and the potential for plaque buildup. The cleavage releases from the neuron a fragment called sAPPα, which has beneficial properties, such as promoting neuronal growth and survival. The remaining APP fragment, still tethered in the neuron’s membrane, is then cleaved by gamma-secretase at the end of the beta-amyloid segment. The smaller of the resulting fragments also is released into the space outside the neuron, while the larger fragment remains within the neuron and interacts with factors in the nucleus.

n the harmful pathway, beta-secretase first cleaves the APP molecule at one end of the beta-amyloid peptide, releasing sAPPβ from the cell. Gamma-secretase then cuts the resulting APP fragment, still tethered in the neuron’s membrane, at the other end of the beta-amyloid peptide. Following the cleavages at each end, the beta-amyloid peptide is released into the space outside the neuron and begins to stick to other beta-amyloid peptides. These small, soluble aggregates of two, three, four, or even up to a dozen beta-amyloid peptides are called oligomers. Specific sizes of oligomers may be responsible for reacting with receptors on neighboring cells and synapses, affecting their ability to function.

It is likely that some oligomers are cleared from the brain. Those that cannot be cleared clump together with more beta-amyloid peptides. As the process continues, oligomers grow larger, becoming entities called protofibrils and fibrils. Eventually, other proteins and cellular material are added, and these increasingly insoluble entities combine to become the well-known plaques that are characteristic of AD.

For many years, scientists thought that plaques might cause all of the damage to neurons that is seen in AD. However, that concept has evolved greatly in the past few years. Many scientists now think that oligomers may be a major culprit. Many scientists also think that plaques actually may be a late-stage attempt by the brain to get this harmful beta-amyloid away from neurons.

NEUROFIBRILLARY TANGLES

The second hallmark of AD, also described by Dr. Alzheimer, is neurofibrillary tangles. Tangles are abnormal collections of twisted protein threads found inside nerve cells. The chief component of tangles is a protein called tau.

Healthy neurons are internally supported in part by structures called microtubules, which help transport nutrients and other cellular components, such as neurotransmitter-containing vesicles, from the cell body down the axon.

Tau, which usually has a certain number of phosphate molecules attached to it, binds to microtubules and appears to stabilize them. In AD, an abnormally large number of additional phosphate molecules attach to tau. As a result of this “hyperphosphorylation,” tau disengages from the microtubules and begins to come together with other tau threads. These tau threads form structures called paired helical filaments, which can become enmeshed with one another, forming tangles within the cell. The microtubules can disintegrate in the process, collapsing the neuron’s internal transport network. This collapse damages the ability of neurons to communicate with each other.

LOSS OF CONNECTION BETWEEN CELLS AND CELL DEATH

The third major feature of AD is the gradual loss of connections between neurons. Neurons live to communicate with each other, and this vital function takes place at the synapse. Since the 1980s, new knowledge about plaques and tangles has provided important insights into their possible damage to synapses and on the development of AD.

The AD process not only inhibits communication between neurons but can also damage neurons to the point that they cannot function properly and eventually die. As neurons die throughout the brain, affected regions begin to shrink in a process called brain atrophy. By the final stage of AD, damage is widespread, and brain tissue has shrunk significantly.

How is Alzheimer's disease treated?

Alzheimer's disease is complex, and it is unlikely that any one intervention will be found to delay, prevent, or cure it. That’s why current approaches in treatment and research focus on several different aspects, including helping people maintain mental function, managing behavioral symptoms, and slowing or delaying the symptoms of the disease.
 

What drugs are currently available to treat Alzheimer's?

Four medications are approved by the U.S. Food and Drug Administration to treat Alzheimer's. Donepezil (Aricept®), rivastigmine (Exelon®), or galantamine (Razadyne®) are used to treat mild to moderate Alzheimer's (donepezil can be used for severe Alzheimer's as well). Memantine (Namenda®), is used to treat moderate to severe Alzheimer's.

These drugs work by regulating neurotransmitters, the chemicals that transmit messages between neurons. They may help maintain thinking, memory, and speaking skills, and may help with certain behavioral problems. However, these drugs don’t change the underlying disease process, are effective for some but not all people, and may help only for a limited time.

No published study directly compares the four approved drugs. Because they work in a similar way, it is not expected that switching from one of these drugs to another will produce significantly different results. However, a patient may respond better to one drug than another.

Are there treatments available for managing behavioral symptoms?

Common behavioral symptoms of Alzheimer’s include sleeplessness, agitation, wandering, anxiety, anger, and depression. Scientists are learning why these symptoms occur and are studying new treatments—drug and non-drug—to manage them. Treating behavioral symptoms often makes people with Alzheimer’s more comfortable and makes their care easier for caregivers.

What potential new treatments are being researched?

NIA, part of the National Institutes of Health, is the lead Federal agency for Alzheimer's disease research. NIA-supported scientists are testing a number of drugs and other interventions to see if they prevent AD, slow the disease, or help reduce symptoms.Clinical trials?

People who want to help scientists test possible treatments may be able to take part in clinical trials, which are research studies that test the safety, side effects, or effectiveness of a medication or other intervention in humans. Study volunteers help scientists learn about the brain in healthy aging as well as what happens in Alzheimer’s disease. Results of clinical trials are used to improve prevention and treatment approaches.

Improving Support for Families and Other Caregivers

One of the greatest costs of AD can be the physical and emotional toll on family members, caregivers, and friends of people with the disease. The changes in a loved one’s personality and mental abilities; the need to provide constant, loving attention for years on end; and the demands of bathing, dressing, and other caregiving duties in the later stages of the disease can be hard to bear. Many caregivers must assume new and unfamiliar roles in the family, and these changes can be both difficult and sad. Not surprisingly, caregivers of people with dementia spend significantly more time on caregiving tasks than do caregivers of people with other types of illnesses.

One of the hardest decisions that many families face is whether and when to place a loved one with AD in a nursing home or other type of care facility. Once this decision is made, families must decide what type of care is best for the person and the family. Many investigators are working to identify strategies that can lead to improved quality of care in various facilities, including adult day care centers, assisted living facilities, continuing care retirement communities, nursing homes, and special care units (separate areas within nursing homes or assisted living facilities designed especially for people with dementia).

Who Are AD Family Caregivers?

Many primary caregivers are family members, and NIA-funded research has shown that the value of informal family caregiving of people with cognitive impairment adds up to billions of dollars every year. Who are these family caregivers?

Spouses: This is the largest group of caregivers. Most are older, too, and many have their own health problems.

Daughters: The second largest group of primary caregivers is daughters. Many are married and raising children of their own. Juggling two sets of responsibilities is often tough for these members of the “sandwich generation.”

Daughters-in-law: Many women in this group help take care of an older person with AD. They are the third largest group of family caregivers.

Sons: Although many are involved in the daily care of a parent with AD, sons often focus on the financial, legal, and business aspects of caregiving.

Brothers and sisters: Siblings may assume primary responsibility for care if they live close by. Many of these caregivers also are older and may be coping with their own frailties or health problems.

Grandchildren: Older children may become major helpers in caring for a grandparent with AD. Grandchildren may need extra support if their parents’ attention is heavily focused on the ill grandparent or if the grandparent with AD lives in the family’s home.

New Techniques Help in Diagnosing AD

A man in his mid-60s begins to notice that his memory isn’t as good as it used to be. More and more often, a word will be on the tip of his tongue but he just can’t remember it. He forgets appointments, makes mistakes when paying his bills, and finds that he’s often confused or anxious about the normal hustle and bustle of life around him. One evening, he suddenly finds himself walking in a neighborhood he doesn’t recognize. He has no idea how he got there or how to get home.

Not so long ago, this man’s condition would have been swept into a broad catch-all category called “senile dementia” or “senility.” Although we now know that AD and other causes of dementia are distinct diseases, in the early stages it is difficult to differentiate between the onset of AD and other types of age-related cognitive decline. We have improved our ability to diagnose AD correctly, and doctors experienced in AD can diagnose the disease with up to 90 percent accuracy. A definitive diagnosis of AD, however, is still only possible after death, during an autopsy, and we are still far from the ultimate goal—a reliable, valid, inexpensive, and early diagnostic marker that can be used in any doctor’s office.

Early diagnosis has several advantages. For example, many conditions cause symptoms that mimic those of AD. Finding out early that the observed changes in cognitive abilities are not AD but something else is almost always a relief and may be just the prod needed to seek appropriate medical treatment. For the small percentage of dementias that are treatable or even reversible, early diagnosis increases the chances of successful treatment. Increasing early diagnosis and improving treatment are among NIA’s most important goals.

Other benefits are practical. The sooner the person with AD and the family have a firm diagnosis, the more time they have to make future living arrangements, handle financial matters, establish a durable power of attorney and advance directives, deal with other legal issues, create a support network, and even consider joining a clinical trial or other research study. Being able to participate for as long as possible in making personal decisions is important to many people with AD.

Early diagnosis also gives families time to recognize that life does not stop with a diagnosis of AD. The person is still able to participate in many of the daily activities he or she has always enjoyed, and families can encourage the person to continue with them for as long as possible. Finally, early diagnosis gives family caregivers the opportunity to learn how to recognize and cope with changes over time in their loved one as well as to develop strategies that support their own physical, emotional, and financial health.

Scientists also see advantages to early diagnosis. Developing tests that can reveal what is happening in the brain in the early stages of AD will help them understand more about the cause and development of the disease. It also will help scientists learn when and how to prescribe the use of drugs and other treatments so they can be most effective.

Current Tools for Diagnosing AD

With the tools now available, experienced physicians can be reasonably confident about making an accurate diagnosis of AD in a living person. Here is how they do it.

They take a detailed patient history, including:

  • A description of how and when symptoms developed.
  • A description of the person’s and his or her family’s overall medical condition and history.
  • An assessment of the person’s emotional state and living environment.

They get information from family members or close friends:

  • People close to the person can provide valuable insights into how behavior and personality have changed; many times, family and friends know something is wrong even before changes are evident on tests.

They conduct physical and neurological examinations and laboratory tests:

  • Blood and other medical tests help determine neurological functioning and identify possible non-AD causes of dementia.

They conduct neuropsychological testing:

  • Question-and-answer tests or other tasks that measure memory, language skills, ability to do arithmetic, and other abilities related to brain functioning help show what kind of cognitive changes are occurring.

They may do a computed tomography (CT) scan or a magnetic resonance imaging (MRI) test:

  • CT and MRI scans can detect strokes or tumors or can reveal changes in the brain’s structure that indicate early AD.

Exams and tests may be repeated every so often to give physicians information about how the person’s memory and other symptoms are changing over time.

Based on findings from these exams and tests, experienced physicians can diagnose or rule out other causes of dementia, or determine whether the person has MCI, “possible AD” (the symptoms may be due to another cause), or “probable AD” (no other cause for the symptoms can be found).

Causes of Dementia

Dementia is the loss of cognitive functioning—thinking, remembering, and reasoning—to such an extent that it interferes with a person’s daily life and activities. It is not a disease itself, but a group of symptoms that often accompanies a disease or condition. Some dementias are caused by neurodegenerative diseases. Dementia also has other causes, some of which are treatable.

Neurodegenerative Diseases That Cause Dementia

  • Alzheimer’s disease
  • Vascular dementia
  • Parkinson’s disease with dementia
  • Frontotemporal lobar degeneration, including:
    • frontotemporal dementia
    • frontotemporal dementia with parkinsonism linked to chromosome 17 (FTDP-17)
    • Pick’s disease
    • supranuclear palsy
    • corticobasal degeneration

Other Causes of Dementia

  • Medication side effects
  • Depression
  • Vitamin B12 deficiency
  • Chronic alcoholism
  • Certain tumors or infections of the brain
  • Blood clots pressing on the brain
  • Metabolic imbalances, including thyroid, kidney, or liver disorders

EXCITING NEW DEVELOPMENTS IN AD DIAGNOSIS

Scientists are now exploring ways to help physicians diagnose AD earlier and more accurately. For example, some studies are focusing on changes in mental functioning. These changes can be measured through memory and recall tests. Tests that measure a person’s abilities in areas such as abstract thinking, planning, and language can help pinpoint changes in these areas of cognitive function. Researchers are working to improve standardized tests that might be used to point to early AD or predict which individuals are at higher risk of developing AD in the future.

One of the most exciting areas of ongoing research in this area is neuroimaging. Over the past decade, scientists have developed several highly sophisticated imaging systems that have been used in many areas of medicine, including AD. PET scans, single photon emission computed tomography (SPECT), and MRI are all examples. These “windows” on the living brain may help scientists measure the earliest changes in brain function or structure in order to identify people who are at the very first stages of the disease—well before they develop clinically apparent signs and symptoms.

To help advance this area of research, NIA launched the multi-year AD Neuroimaging Initiative (ADNI) in 2004. This project is following about 200 cognitively healthy individuals and 400 people with MCI for 3 years and 200 people with early AD for 2 years. Over the course of this study, participants undergo multiple MRI and PET scans so that study staff can assess how the brain changes in the course of normal aging and MCI, and with the progression of AD. By using MRI and PET scans at regularly scheduled intervals, study investigators hope to learn when and where in the brain degeneration occurs as memory problems develop.

Another innovative aspect of ADNI is that scientists are correlating the participants’ imaging information with information from clinical, memory, and other cognitive function tests, and with information from blood, cerebrospinal fluid, and urine samples. Results from these samples may provide valuable biomarkers of disease progress, such as changing levels of beta-amyloid and tau, indicators of inflammation, measures of oxidative stress, and changing cognitive abilities.

An important ADNI achievement is the creation of a publicly accessible database of images, biomarker data, and clinical information available to qualified researchers worldwide. Biological samples also are available for approved biomarker projects. NIA hopes that this initiative will help create rigorous imaging and biomarker standards that will provide measures for the success of potential treatments. This would substantially increase the pace and decrease the cost of developing new treatments. The ADNI study is being replicated in similar studies by researchers in Europe, Japan, and Australia.

These types of neuroimaging scans are still primarily research tools, but one day they may be used more commonly to help physicians diagnose AD at very early stages. It is conceivable that these tools also may someday be used to monitor the progress of the disease and to assess responses to drug treatment.

 

Sources

Alzheimer's Disease Fact Sheet, National Alzheimer's Association, Chicago, IL, 1994.

Effective Communication with Patients with Dementia, Zimmermann, Polly G., RN, MS, MBA, CEN, Journal of Emergency Nursing, Vol. 24, Number  5, October, 1998, pp. 412-415.

Managing the Care of Patients with Irreversible Dementia During Hospitalization for Comorbidities, Stolley, Jacqueline M., Hall, Geri R., MA, RN, CS, Collins, Judith, RN, CS, et al, Nursing Clinics of America, Vol. 28, Number 4, December, 1993, pp. 774 -775.

Nursing the Hospitalized Dementia Patient, Evans, Lois K., DNSc, RN, Journal of Advanced Medical-Surgical Nursing, March, 1989, pp. 22, 24- 26, 28-29.

The Person With Dementia: ED Assessment Tips for This At-Risk Patient, Royer, Mark, RN, MSW, CSW, Journal of Emergency Nursing, Volume 24, Number 4,  August, 1998, pp. 331-332.

This Hospital Patient Has Alzheimer's, Hall, Geri R., MA, RN, CS, American Journal of Nursing, October, 1991, pp. 45-50.

When Your Patient Has Alzheimer's Disease, Stolley, Jacqueline M., RN,C, MA,  American Journal of Nursing, August, 1994, p.38.

 

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