PNH301: Neurological Health Challenges

Alzheimer’s Disease: Learning Objectives

 Define Alzheimer’s Disease (AD)
 Briefly review the pathophysiology of AD
 Describe the stages and manifestations of AD
 Apply the Mini Mental State Exam (MMSE) for the assessment of
cognitive status
 Explain the priority problems and challenges of AD including:
confusion, aggitation/aggression, safety, ADLs, nutrition, and
caregiver role strain
 Recognize triggers for challenging behaviours
 Describe and demonstrate strategies for managing the major issues
identified and avoiding triggers
 Explain specific therapeutic approaches including medical
management
 Explore approaches/challenges to care of the person with AD in
1various settings
Dementia
 Broad term for slow progressive cognitive decline
 Many types

Dementia

1. Alzheimers
2. Vascular
dementia
3. others
Delirium
 Acute state of confusion
 Usually reversible in 3 weeks
 Unfamiliar settings eg. hospital
 Behaviour typically – hypo/hyperactive
 Many causes – infections UTIs, meds, metabolic
disturbances, surgery
 Management – remove the cause
Alzheimer’s Disease
 Chronic, progressive, degenerative disease
 accounts for 60% of dementias occurring in
people older than 65 years
 Loss of memory, judgment, and visuospatial
perception and change in personality
 Increasing cognitive impairment, severe physical
deterioration, death from complications of
immobility *aspiration pneumonia most frequent
cause of death
Structural Changes in the Brain
 Alzheimer’s disease creates changes that include:
 Neurofibrillary tangles
 Amyloid plaques
 Nerve cells stop working, lose connections with
other nerve cells and then die

 Leads to:
 Memory failure
 Personality changes
 Problems performing ADLs
Manifestations
 Changes in cognition
 Alterations in communication and language
abilities
 Changes in behavior, personality, and judgment
 Changes in self-care skills
 Short term memory impairment one of the first
symptoms*
 Requires Psychosocial assessment: especially
patient’s reaction to changes in routine
 Stages of Alzheimer’s Disease
Describe the stages of Alzheimer’s Disease

 Early: not enough decline to detect AD. MMSE 27-30 score.

 Middle:

 Late:

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 Cognitive Assessment
 Folstein’s Mini Mental State Exam (MMSE)
 List five major areas it assesses
 What is the range of possible scores and what does a high or
low score indicate?
 Which patients are excluded from assessment with the
MMSE?
 Score of 30 is a perfect score

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 Priority Problems
Confusion
 Agitation/aggression
 Confused & fearful
Safety: Risk for Injury
 No longer recognize danger
 May wander
Self Care
 Forget how to do things (ADLs)
 Nutrition
 Forget that they’ve eaten
 Dysphagia
 Lose recognition of hunger

Caregiver Role Strain

 Risk for abuse
 Burnout
9  Depression
 Agitation*
Non-Agressive Aggresive
 Verbal Behavior:  Verbal Behavior:
 Incoherent babbling,  Cursing and abusive
screaming or language
repetitive questions
 Physical Behavior:
 Physical Behavior:
 Hitting, scratching or
 Pacing, wandering,
repetitive body kicking
motions, hoarding
or shadowing
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 Agitation*
 Results when person:
 Tries to communicate boredom, fear, confusion
 Feels unsafe
 Cannot verbalize need for help or a feeling of
pain
 Increasing signs indicate that person is
losing control
 Ideal is to avoid situations that provoke
these reactions
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 Agitation triggers: Fatigue*
 If confusion and agitation increase late in the
day, suspect that fatigue may be a factor
 Try rest or quiet periods for up to two times a
day at the same time daily
 Rest or nap in an easy chair or on top of the
bed.
 Physical exercise is appropriate during the day,
but prepare short activities with calm periods
 If wakes confused at night, add another brief
rest period during the day
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 Agitation triggers: Change*
 Change in environment, routine or caregiver can
easily precipitate agitation; sameness and routine
help to minimize stress
 In a facility,
 Ask caregivers how person usually responds to
change in environment
 Have a routine & few environmental changes (e.g.,
no extensive holiday decorations).
 Family visits as much as possible on a regular
schedule
 At home, schedule day care for at least three days a
week so that individual will adapt it into his/her
routine

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 Agitation triggers: Loss*
 May remember activities they used to enjoy
such as being able to:
 drive a car
 cook
 care for children
 Whether at home or in a facility, safe
activities should be substituted that satisfy
the individual
 Depression should be treated

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 Agitation triggers - Stimuli
 Excessive, noise, commotion or people
can trigger agitation behavior
 More than 20 people in a group can
cause undue stress
 TV, images in mirror, dolls or figurines
may represent extra people in the
environment.
 Before medicating with anti-psychotic
drugs, the family member & health care
team should decrease above factors
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 Agitation triggers – Excessive Demand
 Mental functions  Cause stress & a sense of
steadily lost = cannot futility rather than
bringing back lost function
perform routine tasks
 Instead, provide
 Avoid
 Positive support &
 Quizzing,
understanding
 Reality orientation
 Encourage
 “Brain exercises”
independence as able
 Retraining or pushing
 Assist when they are
individual to try harder unable to perform a
task

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 Agitation triggers - Delirium
 Infections, hypoxemia, pain, constipation, trauma
or drug interactions may cause dementia-like
symptoms!
 Check for the above sources of confusion
 Prevent if possible via:
 Good oral care
 Balanced nutrition
 Adequate fluid intake
 Adequate exercise balanced with rest periods
 Simplified medication regimens

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Problem behaviours
 Screaming:
 Consider pain, depression or hearing loss as possible causes for
screaming
 Sexual aggression:
 Try to determine whether the sexual gesture is indeed sexual in
nature & not an expression of the need to go to the bathroom
 Hallucinations/illusions:
 Consider presence of confusing stimuli (e.g., shadowy lighting,
televisions, dolls)
 Pacing & wandering:
 Wanders for a reason, which may be hard to determine
 Locking him/her in a room or restraining in a chair is inappropriate
 Gathering/shopping:
 May rearrange objects around the home, hoard or take other’s
possessions
 Provide a canvas “shopping bag” and a “safe” place where s/he
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can store items
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 Terms
 What is sundowning?
 What is traumatic relocation syndrome?

Define:
 Apraxia

 Aphasia

 Anomia

 Agnosia

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Management – overall approach
 Modify the environment:
 Create a calm environment; reduce glare, noise, background noise; move to a
quieter place; offer rest, privacy
 Limit caffeine; develop soothing rituals; use gentle reminders
 Simplify tasks & routines
 Schedule wisely:
 Schedule the most difficult tasks (e.g., bathing, medical appointments) for time
of day when individual is most calm & agreeable
 Establish routines to make the day more predictable/less confusing
 Modify the behavior
 Check personal comfort – pain, hunger, thirst, constipation, full bladder, fatigue,
infection, skin irritation
 Be sensitive to fears, misperceived threats & frustration
 Check own response: use low voice, do not corner, restrain, criticize, ignore,
argue with or shame the person
 Medicate as a last resort

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Management - reduce frustrations
 Let him or her help. Involve in tasks as much as possible.
 Limit choices. Having fewer options makes deciding easier.
E.g.,
 Provide only two snacks (apple or orange) to choose
between
 Reduce distractions at mealtimes or during
conversations
 Take more time. Expect things to take longer
 Schedule more time to complete even simple tasks
 Provide instructions one step at a time

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Management – prevent agitation
 Music Therapy:
 Calming music or favorite type of music can lead to a decrease in
agitation
 During meals, soothing music can increase food consumption
 During bathing, relaxing or favorite music can make it easier to give a
bath
 Exercise and Movement:
 Regular light exercise (e.g., chair exercises)
 Walking for up to 1½ hours after dinner several times each week

 Activities: Select safe activities that mimic individual’s previous hobbies &
career
 Socialization:
 Have a few regular visitors or caregivers
 Small gatherings of family or friends on a regular, predictable basis
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 Talk with him/her
Eating
 Eat at regular times; may need 4-5 small meals instead of 3 large
 Vary the menu
 Choose foods that contrast with the colour of the plate; use plain colour plate
 Serve things one at a time
 Be careful when serving hot food
 Limit distractions during mealtimes; phone & TV off; no extra items on table
Dressing:
 Limit choices.
 Offer no more than two clothing options each morning
 Clear closets of rarely worn clothes that may complicate the decision
 Provide direction.
 Lay out pieces of clothing in the order they should be put on, or,
 hand out clothing one piece at a time & provide short, simple dressing instructions
 Be patient.
 Rushing the dressing process may cause anxiety.
 Consider person’s tastes and dislikes.
 Don't argue if individual doesn't want to wear a particular garment or wants to wear the
same outfit repeatedly.
 Could buy duplicates of a few favorite outfits.
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Bathing
 Find the right routine.
 Preference for showers or tub baths?
 Preferred time of day? Experiment with morning,
afternoon & evening bathing
 Be flexible. If daily bathing is traumatic, alternate tub
baths or showers with sponge baths.
 Help individual feel in control.
 Explain each step of the bathing process
 Make it comfortable.
 Make sure the bathroom is warm
 keep towels or bath blankets handy
 Keep it private.
 Provide a towel for cover when he or she gets in & out
of the shower or tub
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 Toileting
 Make the bathroom easy to find. Place a sign that says
"Toilet" or a picture of a toilet on the door.
 Be alert for signs. Restlessness or tugging on clothing
may signal the need to use the bathroom.
 Establish a schedule. Schedule bathroom breaks every
two hours, before and after meals and before
bedtime.
 Make clothing easy to open or remove. Replace
zippers and buttons with Velcro. Choose pants with an
elastic waist.
 Take accidents in stride. Praise toileting success — and
offer reassurance when accidents happen.

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 Communication
See:
1. http://www.alzinfo.org/alzheimers-treatment-
communicating.asp
2. http://www.ec-
online.net/community/Activists/difficultbehavior
s.htm
(Number 2 uses labeling: “dementia person”, which
is demeaning but otherwise has excellent
suggestions.)

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 Reality orientation
 Reorient confused individual to time place & person
 Used when change in environment + stressors such as
pain, surgery, medications have caused disorientation
 Use reminders & environmental cues such as clocks,
calendars, stability of routine
 Useful in the early stages of Alzheimer’s
 Reorientation often inappropriate in the later stages
of Alzheimer’s
 Person becomes agitated if contradicted
 Clocks & calendars no longer have meaning
 BUT: Stable routine continues to be useful

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 Validation Therapy
 Acceptance of the reality and personal truth of
another's experience
 Work around rather than confront expression of
factual inaccuracies
 Focus on emotional content of the message rather
than factual content
 Does not involve re-orienting to present time
 Works well with gentle re-direction

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 Reminiscence
 Recollection of the past to
 bring meaning & understanding to the present
 resolve current conflicts
 find new meaning in past events
 Reminds person of past positive coping
 Express personal identity
 Support self-esteem
 Suitable for person with dementia

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Drug Therapy
Cholinesterase Inhibitors
 Donepezil (Aricept), galantamine (Reminyl),
rivastigmine (Exelon)
 Slows onset of cognitive decline in some patients
 Do not alter course of disease

NMDA Receptor Antagonist

 Memantine (Namenda)
For advanced AD
May slow deterioration
Drug Therapy
Antidepressants (SSRIs)
 Paroxetine (Paxil)
 Avoid anticholinergics due to side effects

 Psychotropic drugs (antipsychotic or neuroleptic)

 For pts with emotional and behavioural problems
Eg: hallucinations, delusions
 Considered chemical restraints
 Not intended for agitation, combativeness,
restlessness
 Drugs of last resort eg: Risperidone or a
benzodiazepine such as Lorazepam
Ignatavicius &Workman (2013)