Alzheimer's and Vascular Dementia

Dementia is a chronic or progressive syndrome caused by various brain illnesses that affect behavior, memory, thinking, and the ability to perform everyday activities. It is not a single disease but a condition characterized by a permanent decrease in intellectual functioning. Dementia is not only a decrease in memory but exhibits problems with language, judgment, problem-solving, and comprehension. Many conditions lead to dementia, but the most common cause of dementia in the United States is Alzheimer's disease (AD). It has no cure and progresses, eventually leading to total dependence and death.

According to the Alzheimer's Association (2021), it is estimated that 6.2 million Americans live with Alzheimer's dementia in 2021. Other significant findings include:

• 11.3% aged 65 and older have Alzheimer's dementia.
• Two-thirds of Americans over age 65 with Alzheimer's dementia (3.8 million) are women.
• During the COVID-19 pandemic, deaths from Alzheimer's increased by 16% in 2020 alone (Alzheimer's Association, 2021).

The Center for Disease Control and Prevention (2021) reports that one in three elders will die from Alzheimer's or another form of dementia. It also is a leading cause of disability and poor health. It is the 6th leading cause of death in the US. Alzheimer's is the only top 10 cause of death in the US that cannot be prevented or cured.

Alzheimer's places a significant burden on the health care system, with annual costs exceeding a quarter of a trillion dollars. The cost of care for people with Alzheimer's and other dementias is expected to increase to more than 1.1 trillion in 2050 (Alzheimer's Association, 2021, para. 3).

Dementia is caused by an alternation in the brain's structure, including a decrease in the chemicals in the brain and destruction of nerves vital to cognitive function. Amyloid, a starch-like product, is deposited abnormally in the brain in Alzheimer's and is responsible for many of the signs and symptoms. Amyloid plaques develop in areas of the brain used for memory and other cognitive functions.

Acetylcholine, a chemical produced by the nerves in the brain, is associated with the transmission of impulses between nerve cells and allows proper brain functioning. Dementia is associated with a decline in the amount of acetylcholine, which results in a decreased ability of the body to transmit impulses between brain cells.

Another characteristic change is neurofibrillary tangles. Neurofibrillary tangles are an abnormal growth of nerves that kill the normal function of cells and result in a malfunction of the brain. Neurofibrillary tangles lead to the death of nerve cells and synaptic failure. Neurofibrillary tangles, amyloid plaques, chemical imbalance, inflammation, and other cellular changes all contribute to the process of dementia.

Dementia comes in many forms, and the exact type cannot be diagnosed without a brain biopsy. Still, typically the disease can be determined on clinical grounds by exploring the history of dementia and physical exam. The following are common types or causes of dementia:

• Alzheimer's
• Vascular dementia
• Lewy body dementia
• Parkinson's disease dementia
• Frontotemporal dementia
• Mixed dementia
• Dementia symptoms due to normal pressure hydrocephalus, toxic substances such as alcohol, infection such as AIDS, brain tumor, Parkinson's disease
• Progressive supranuclear palsy
• Creutzfeldt-Jakob disease (mad cow disease)
• Subdural hematoma
• Reversible causes: hypothyroidism, B12 deficiency, depression
• In the most common form of dementia, Alzheimer's, Tau tangles contribute to poor connectivity between nerve cells, causing a loss of memory in Alzheimer's dementia. Due to the insidious development of the tau tangles, Alzheimer's has a gradual onset that ultimately impacts the hippocampus, where the ability to think, recall events (memory), and language are housed (Tong et al., 2018).

Figure 1: Hippocampus Functions

Vascular dementia often occurs after a stroke and affects the part of the damaged brain. The part of the brain that was not damaged by the stroke often remains unaffected. Vascular dementia affects 15-20% of patients with dementia and often co-exists with Alzheimer's. Like Alzheimer's, vascular dementia is progressive, but the symptoms typically begin more abruptly (Alzheimer's Association, 2021).

Dementia with Lewy bodies (DLB) and Parkinson's disease dementia share many of the same symptoms of cognitive impairment and mood changes. The primary difference is where the Lewy bodies develop in the brain. With DLB, dementia always occurs first and presents with problems in executive function, the ability to interpret visual data (e.g., visual hallucinations), mood changes, and autonomic dysfunction severe enough to interfere with activities of daily living (Alzheimer's Association, 2021). In Parkinson's disease, dementia cognitive impairment only occurs after years of motor symptoms. For simplicity, Parkinson's disease dementia is only mentioned and will not be discussed further.

Research in preventing dementia is sparse but does provide some suggestions. Stimulating the mind through playing chess, reading, or playing a musical instrument is the most important thing one can do to keep the mind sharp and decrease the risk of getting dementia. Another question that has recently been looked at is the use of antidepressants to prevent dementia. Continued long-term use of antidepressants may lower the rates of dementia (Bartels et al., 2020). The study concluded that "Long-term treatment with Tricyclic antidepressants, Hypericum perforatum, escitalopram may be associated with reduced incidence of dementia."

While drugs and supplements have hinted at their ability to prevent dementing illness, limited data suggest effectiveness. Cholinesterase inhibitors do not reduce progression rates from memory impairment to dementia. Cholinesterase inhibitors (ChEI) are widely used in dementia, but there is a lack of practice guidelines in case of intolerance or absence of a perceived effect.

Many risk factors are associated with dementia; age is the most dramatic. While age is not synonymous with dementia, the incidence of dementia is significantly higher as one ages. The disease is seen more frequently in people 65 years of age and older, although it may affect people in their 30s, 40s, and 50s (Healthline, 2021). Females are at greater risk than males. Another risk factor is having a family history of dementia in a parent or sibling. A history of head injury puts one at risk for dementia. Poor control of many chronic diseases, including congestive heart failure and lung disease, can make dementia worse. Risk factors typically associated with vascular disease, high blood pressure, diabetes, and high cholesterol, are associated with an increased risk of vascular dementia and Alzheimer's.

According to the Alzheimer's Association (2021), early research indicates that COVID-19 infection accelerates Alzheimer's-related symptoms and pathology by increasing neuroinflammatory biomarkers (total tau or t-tau, glial fibrillary acid protein or GFRAP) and decreasing oxygenation to the brain. Although this early research cannot be translated to other viruses, it does indicate that further research should be done investigating the impact of virus infections on long-term brain health.

Depending on the exact cause of dementia, the presenting signs and symptoms may vary. Short-term memory loss is common, as evidenced by forgetting recent events. The early (mild) stages of dementia are characterized by forgetting where items were placed, asking questions repeatedly, and having difficulty learning new information.

It is at times difficult to differentiate between normal aging and dementia. Normal aging is characterized by slowness in the retrieval of information. Those with dementia have a difficult time recording new information. For example, the aged individual may have a hard time recalling the name of a friend they have not seen in a long-time. Those with dementia can be told something and not recall it. A husband may tell his wife (who has dementia) that friends are coming over for dinner, and the wife will not remember this when the friends arrive.

Misusing words, difficulty finding the right word, or general words to describe a specific item is a trait of dementia. A demented person uses the word "thing" to describe many items. Personality changes, making poor decisions, and mood swings are common symptoms of early dementia. Increased confusion at night, also known as sun-downing, is a common feature of early dementia.

Patients with early dementia can compensate well when they are in familiar environments. Problems are often first noticed when one gets out of their routine such as going on vacation or entering the hospital. Patients often become very anxious, depressed, scared, or have emotionally liable moods. These moods are often the direct results of the patient being aware of progressive dementia.

As the disease progresses, the patient has difficulty carrying out tasks of daily living such as bathing, handling finances, grooming, dressing, and preparing meals. This is when independence is significantly impaired, and patients will need to adjust to their living environment. During this middle (moderate) stage of progression, the patient may struggle with incontinence, become combative or resistant to help and physical care, and have an increased potential for wandering away from home.

Those with advanced (severe) dementia are dependent on others for care. They have very limited memory and usually are not oriented to place, time, and often name. Patients with advanced dementia may not know the name of their spouses or children.

Loss of the swallowing reflex is a common complication of advanced dementia, which leads to medical complications such as malnutrition and aspiration pneumonia. It has not been found that feeding tubes reduce the rates of aspiration pneumonia in the demented patient.

Malnutrition decreases the ability to fight off infection and increases the risk of death from infection. Loss of the swallowing reflex increases the risk of dehydration. Patients with advanced dementia have more seizures.

Behavioral changes are more common as dementia advances. With the patient going from calm and pleasant to entirely out of control within minutes, mood swings can occur. Personality changes are seen in dementia, with the demented patient showing an increased incidence of irritability, suspiciousness, and fearfulness. Hallucinations and delusions are hallmarks of advancing dementia. Hallucinations are a misinterpretation of sensory stimuli. They can include seeing things not there, such as dead relatives, or hearing voices when there are none. Delusions are fixed false beliefs. Common delusions include thinking people are out to get them, thinking that someone is trying to poison them, or believing they are God.

Clinical history and exams can help differentiate between some of the different types of dementia. Alzheimer's is the most common dementia and the most likely diagnosis when dementia presents. Some salient features of Alzheimer's include early memory loss with cognitive impairment and at least one other area deficit such as language dysfunction, agnosia, apraxia, visuospatial disorder, and executive dysfunction. It typically has an insidious onset and a progressive course. A storage deficit highlights memory impairment; patients cannot recall something with a clue. For example, when performing the mini-mental status exam (MMSE) and the patient is asked to recall three items after five minutes, the patient will not be able to recall them even after being given a clue. As the disease progresses, long-term memory becomes impaired. Later changes also include seizures, apathy, aggression, wandering, agitation, depression, and anxiety.

Vascular dementia can have either an abrupt or insidious onset, and the progression can be stepwise, fluctuating, or a continuous decline. Patients with vascular dementia typically have cardiovascular risk factors such as hypertension, hyperlipidemia, and diabetes. Focal neurological deficits (e.g., speech, hearing, or vision problems) are common in those with vascular dementia. Memory impairment is not as pronounced in the early stage, whereas executive function (concentration, decision making, and higher-order problem solving) is impaired early.

DLB accounts for 10-15% of cases (National Institute on Aging, 2022). DLB typically presents with memory loss, early impairment of executive function, more problems in attention, visuospatial function, and constructional abilities compared to AD, and more autonomic involvement. Patients typically have recurrent visual hallucinations. There are often repeated falls and occasional syncope.

The National Institute on Aging (2022) explains that frontotemporal dementia (FTD) is characterized by a shrinking of the brain's frontal and temporal anterior lobes and often presents with personality and behavioral changes over memory loss, at least early on. This disease runs in families. Symptoms of FTD fall into three clinical patterns that involve changes in behavior and problems with language and movement disorders. Patients are typically impulsive, act socially unacceptable, are disinhibited, lack insight, and are agitated or socially withdrawn. Those with language disturbance have difficulty speaking or understanding speech. Frontotemporal dementia occurs at a younger age than Alzheimer's, typically between 45 and 65.

Figure 2: Frontotemporal Disorders

The need to evaluate dementia can be picked up during a routine examination, patient or family concern, or routine screening. The workup includes performing a mental status examination. Standardized tests can be used to document mental decline, monitor decline, and help make the diagnosis. Mental status examinations test the patient's memory and intellectual function. These tests look for memory impairment, language disturbance, ability to carry out purposeful movements, and ability to recognize objects. Mental status exams ask the patient to report the date and location, recall lists of items, write sentences, follow written commands, name objects, and copy diagrams. According to A. Rosenzweig (2020), The American Academy of Neurology recommends using the mini-mental state exam (MMSE) or the memory impairment screen as tools to screen for dementia. However, the MMSE offers no suggestions as to how much assistance the person might need in daily life, nor does it try to apply the deficit in a cognitive area to practical living.

Scores on the MMSE range from 0 to 30, with scores of 25 or higher being traditionally considered normal. Scores less than ten generally indicate severe impairment, while scores between 11 and 20 indicate moderate dementia. Those with Alzheimer's have, on average, a decline in the MMSE score. The MMSE of 3-4 points per year occurs if they go untreated. It is important to note that one needs an IQ of about 90 to get a normal score on the MMSE (Rosenzweig, 2020).

The MMSE takes about 10 minutes to complete. It measures aspects of cognition that include orientation, word recall, attention and calculation, language abilities, and visual construction. Scores may need to be adjusted or interpreted differently to account for a person's age, educational level, and ethnicity/race.

Other testing is often employed. Early changes in mental decline are often not picked up on the MMSE. If the spouse or caregiver notices changes and the MMSE is normal, more sensitive testing may need to be utilized. If the diagnosis is in doubt, more extensive testing, known as neuropsychological testing, typically done by a specialist, is performed.

Neuropsychological testing is a more comprehensive method for the evaluation of mental status. Testing is done by a neurologist, psychiatrist, or psychologist. It looks at higher cognitive functions, including but not limited to abstract, logical, and conceptual reasoning, visuospatial orientation, memory, verbal fluency, and reasoning. The test identifies cognitive impairment in patients with higher baseline cognitive abilities and determines if dementia is present in its milder stages. It is more sensitive than other types of testing and can differentiate between mild cognitive impairment and dementia. The test is helpful for those who do not speak English as their native language and those with limited education. It also can help pick up anxiety and depression.

The workup of dementia rules out other causes of mental decline and consists of imaging and laboratory evaluation. Recommended tests include a vitamin B12 level and thyroid test and a complete blood count, glucose, kidney function test, electrolyte tests, and liver function tests. Other tests can be performed if the patient is deemed at high risk and the clinician has reason to suspect a rarer cause of dementia, including serology for syphilis, HIV testing, genetic testing, Lyme disease titers, testing for heavy metals, urinalysis, erythrocyte sedimentation rate, and serum folic acid. A lumbar puncture is sometimes performed if cerebral Lyme disease, cerebral vasculitis, neurosyphilis, or HIV is suspected as a cause of dementia.

Testing for depression is critical as memory loss can be one of the manifestations of depression. Depression can present with memory loss, and memory loss can reverse with the treatment of depression. In addition, depression complicates the course of dementia if they both exist.

Many patients with dementia undergo an imaging examination to rule out other disease causes. Its ability to identify a reversible cause of dementia is low. Still, non-contrast computed tomography or magnetic resonance imaging is recommended for the initial evaluation of a patient with dementia. Neuroimaging in dementia is most likely helpful in a 61-year-old woman with an MMSE score of 20 and a history of breast cancer. Imaging can rule out brain tumors, subdural hematomas, stroke, or normal-pressure hydrocephalus. Those who are younger than 60, had recent head trauma, a history of cancer, gait disturbance, urinary incontinence, localized neurologic signs or symptoms, or those with a rapid or atypical course of dementia have the greatest chance of having a diagnostic yield from imaging studies. The only way to confirm the diagnosis is to perform a brain biopsy, which is rarely done or necessary.

More advanced testing includes photon emission tomography (PET) scans or single-photon emission computed tomography (SPECT) scans. These tests are not routinely done but are often done in research settings to help distinguish between different types of dementia. Current guidelines do not recommend their routine use.

Before initiating any medications, a provider should always attempt non-drug interventions to reduce behavior problems. Including one or several of the interventions below will decrease stress and maintain quality of life while maintaining the patient's dignity.

• Frequently orienting the patient to their surroundings, including time and place, aids the demented individual with confusion.
• Helping the patient remember the past with reminiscing and pictures.
• Providing sensory stimulation, including touch/massage and aromatherapy.
• Maintaining an active social life.
• Scheduled toileting and prompted voiding help patients suffering from urinary incontinence to maintain their continence.
• Regular toileting schedule.

Demented patients thrive in familiar environments. Providing consistency and structure is an essential step in managing dementia. Maintaining a routine schedule preserves orientation and allows them to function on a higher level. Keeping all items such as clothes, shoes, drugs, and furniture in the same place is one suggestion. Keep a large calendar in the home with important dates such as birthdays and doctor appointments visible. Keeping important phone numbers in plain view to be easily found reduces frustration. Labeling drawers and cabinets will help with orientation.

The holidays are particularly challenging for demented patients because parties, interrupted time schedules, and decorating lead to significant confusion. Decorating just one room of the house with holiday decorations and not allowing anyone with dementia to go in the room may help.

Keeping the patient with dementia safe becomes more important as the disease progresses. Keep instructions simple; minimize instructions to less than five words. Setting up a safe and pleasant environment is essential. Lighting needs to be bright to prevent falls; nightlights are helpful. Remove sharp objects from home or put them in a locked area to prevent the demented patient from harm. Occupational therapists provide home evaluations to assure safety measures to keep the demented patient safe. Cleaning services reduce clutter in the home, which reduces falls. Place identification tags, carried in many pharmacies, on the patient if they get lost. Alarms can be placed at the home's exits to prevent the patient from wandering off.

Simplifying tasks, developing routines, and providing proper rest reduce behavior problems. Structured games and activities minimize behavior problems. Re-assuring an upset patient, repeating instructions as needed, and redirecting the agitated person reduces agitation. Sensory deprivation exacerbates the disease process and assures that they can see (glasses on) and hear (hearing aids in) helps reduce behavioral problems.

Problem behaviors can trouble not only patients but caregivers. Paranoia, aggressiveness, and anxiety are more commonly a problem that leads to nursing home placement than memory loss. Analysis of behavior is another strategy that may be helpful for problem behaviors.

Behavior analysis is helpful in determining triggers that agitate the person or make them more confused. It should be the first step employed when behavior problems are encountered. Rather than using drugs if the patient is upset, try to understand why they might be agitated. Perhaps they need to use the bathroom, are in pain, or think they have lost something. Note what happens before the behavior, try something different the next time, and track the results (Heerema, 2021). Identify a particular behavior and note what seems to trigger the behavior. For example, if a shower always makes the patient agitated, try a bath instead. Or attempt to offer a shower at a different time of day. Controlling situations that agitate the patient or increase confusion can go a long way in making the disease more manageable.

Loved ones of patients with dementia can use a simple behavior chart to help understand what triggers behavior problems. Recording activities, drugs, the people present, and the corresponding behaviors identify patterns to help loved ones understand what agitates the patient. The behavior chart does not need to be filled out every day, but it should be filled out if there is a behavior change, a few days before a doctor's appointment, or after a drug change.

A behavior chart can be made at home and consists of up to six columns. The first column is where the time is recorded. The next column is where the patient's activity is recorded at that given time. Examples of activities include sleeping, talking on the phone (and with whom), interacting with people, watching television (be specific about which show), eating, or shopping. The next column is to record the people who are around. Certain people can make patients much more irritable, and filling out this column may reveal specific people that increase agitation. The next column is a place to record when drugs for dementia are taken. Behavior charts may demonstrate a pattern such as behaviors being much worse 6 hours after taking the medication prescribed for behavior control. These patterns are essential to recognize as they can affect how doctors prescribe drugs. The last column is a place for any miscellaneous comments.

Example:

Advances in pharmacology may prolong cognitive function in patients with dementia.

Behavior problems are a concern with dementia as the disease progresses. Psychosis, depression, and anxiety are three common problems. These symptoms are difficult for those with Alzheimer's and can be associated with risk for others as there is, at times, physical aggression. Non-drug interventions are the first interventions to treat behavioral problems. Keeping a behavioral chart defines the problem and facilitates the treatment of undesirable behaviors.

Psychotropics are typically used in conjunction with other non-drug approaches or after attempting non-drug therapies and finding them inadequate. They are used at times to treat the behavioral, psychological, and emotional symptoms of Alzheimer's. These symptoms can include emotional distress, depression, anxiety, insomnia, hallucinations, paranoia, and some challenging behaviors, so it is essential to be proactive in identifying and treating them (Heerema, 2021).

The class of psychotropic drugs is antidepressants, anti-anxiety medications, antipsychotics, mood stabilizers, and drugs for insomnia (Heerema, 2021). These drugs can be effective but can also potentially cause significant side effects.

Treatment of depression is necessary because it improves mental function, lessens confusion, and improves dementia. Depression can be a vexing problem that is difficult to uncover in dementia. SSRI [sertraline (Zoloft®), citalopram (Celexa), and escitalopram (Lexapro) are first-line agents in the treatment of depression. If SSRIs are used to treat depression, it is important to check sodium levels one month after starting treatment, as hyponatremia can cause fatigue, malaise, and delirium. Paxil is generally not recommended in elderly populations as it has one of the greatest anticholinergic effects of all the SSRIs (similar to that of the tricyclics desipramine and nortriptyline). Prozac is also not recommended due to its long half-life and prolonged side effects (Heerema, 2021; Lexicomp, 2018; Stahl et al., 2017).

Tricyclic antidepressants are not recommended in this population as there is the potential for increased confusion, urinary retention, constipation, blurred vision, sedation, and increased agitation (Lexicomp, 2018; Stahl et al., 2017).

Anti-anxiety medicines, such as lorazepam (Ativan®) or alprazolam (Xanax®), reduce anxiety and related behavior problems. However, benzodiazepines can cause excessive sedation and potentially paradoxical agitation. They are also highly addictive and are linked to cognitive dulling (Lexicomp, 2018; Stahl, 2017).

Visual hallucinations and paranoid delusions are two of the most common psychotic features in dementia. Psychotic symptoms are often treated with antipsychotics with varied success. While no drug is approved for behavioral disturbances in dementia, they are often used. In addition to their use in psychosis, neuroleptics are used with variable success in treating behavioral disturbances in dementia such as agitation, aggressiveness, and wandering. Aggression and agitation are commonly treated with antipsychotic drugs. They help manage these symptoms in the short-term for less than three months, but they are associated with some risks.

Antipsychotics (dopamine antagonists) can be broken down into typical and atypical drugs. Typical antipsychotics are more commonly associated with extrapyramidal effects such as restlessness, muscle rigidity and/or involuntary muscle contractions, and repetitive movements (e.g., eye spasms, blinking, twisting head, protruding tongue). Most patients can tolerate a low maintenance dose without extrapyramidal effects. Atypical agents are less likely to have extrapyramidal effects. Risperidone (Risperdal®), quetiapine (Seroquel®), and olanzapine (Zyprexa®) are atypical antipsychotics. Low doses of atypical antipsychotics help control agitation and psychosis and are usually well tolerated. Patients with DLB are more prone to neuroleptic sensitivity, and extreme caution must be used when using these drugs in DLB due to the increased risk for Neuroleptic Malignant Syndrome (Lexicomp, 2018; Stahl et al., 2017).

Acute psychotic crises can arise and may require hospitalization. An intramuscular antipsychotic drug such as haloperidol in a dose of 5-10 mg often calms an acute psychosis. After the acute episode, a lower maintenance dose may be needed to prevent another crisis.

While these drugs are widely used for those with dementia and behavioral disturbances, they need to be used with extreme caution. They are not approved for psychosis in dementia.

Increased death rates and stroke rates are a significant concern with atypical antipsychotics in the demented population. Stroke rates were shown to be 2-3 times higher, and mortality showed a 1.6-1.7-fold increase (Lexicomp, 2018). While other studies raise questions about such high numbers, significant caution should be used with these drugs. Altogether avoiding these drugs is not appropriate as some patients see significant improvement in quality of life with their use.

The degree of symptoms may predict how well antipsychotic drugs work. Those with more severe behavioral disturbances in nursing home residents respond better to antipsychotic medications. The response to medication may be most effective in those most profoundly affected by agitation and aggression without psychosis.

As dementia progresses, there is often a decrease in the severity and frequency of behavioral disturbances. Therefore, it is wise to try to taper or discontinue antipsychotic drugs after 2-8 months of treatment.

Sleep problems are a common complication of dementia. First-line interventions include non-drug interventions such as: reducing caffeine/nicotine/alcohol, regular exercise, discouraging long day-time naps, instituting soothing bedtime rituals, and maintaining a consistent bedtime routine. If this fails, then the addition of short-acting sedative-hypnotic drugs is one solution to restoring sleep. Agents to be considered include zolpidem (Ambien®), eszopiclone (Lunesta®) and ramelteon (Rozerem®). Zolpidem is approved for short-term use and comes in an extended-release form. Eszopiclone helps in the initiation of sleep and maintenance. Ramelteon, which acts on different receptors, is another option when other drugs fail. Ramelteon and eszopiclone are approved for long-term use (Lexicomp, 2018; Stahl et al., 2017).

Dementia is a progressive disease that has the potential to cause many problems as it advances. Dysphagia is typically a later disease concern. Aspiration is a significant problem in those who develop dysphagia. A speech therapist can perform a swallowing study and make recommendations to decrease the risk of aspiration. Some possible interventions include:

• Alternating the consistency of food
• Cutting food into smaller pieces
• Changing the position of the client when they swallow
• Encouraging the client to tuck the chin while swallowing
• Eating with someone who can monitor for aspiration and provide clues for swallowing

The use of feeding tubes has fallen out of favor over the last number of years as they have not proven to extend life expectancy nor improve quality of life. They can be utilized if aspiration is severe or the patient does not eat enough to maintain nutrition. It is wanted by the patient and durable power of attorney of health care. Feeding tubes do not prevent malnutrition, reduce the incidence of aspiration pneumonia, improve function, or extend life. If permanent feeding tube replacement is desired, a percutaneous gastrostomy is better than a nasogastric tube. Consideration must be given to the quality of life and complications when deciding on a feeding tube. Hand-feeding is an alternative to feeding tubes, and it may provide more comfort to the patient.

Those with dementia are typically older, and older age comes with a greater risk of many chronic diseases. Having dementia makes it more likely that proper treatment will not ensue. For example, those with a heart attack may not be able to communicate the pain they are feeling due to dementia, resulting in delayed care and worse outcomes.

Poor nutrition is another common complication of dementia. Poor nutrition increases the risk of infection and poor body healing. The combination of older age, poor communication, and a compromised immune system put the demented individual at high risk for poor outcomes.

Dementia is a progressive disease that eventually robs one of their memories. Before memory fails, it is paramount to make medical wishes known. Advanced care planning helps communicate patients' wishes with their medical providers and loved ones. Making life and death decisions can be uncomfortable but making these wishes known will ensure advance directives are carried out.

The advanced directive should include a durable power of attorney for health care and a living will. The durable power of attorney for health care is naming a person to make health care decisions for the patient when they cannot. It is often a relative or close friend. Ideally, this person will know what type of medical wishes the patient wants. A Living Will articulates the patient's medical wishes in advance; this helps guide the health care team and the durable power of attorney in making decisions when the patient cannot do so.

Eighty-three percent of the help provided to older adults in the United States comes from family members, friends, or other unpaid caregivers. Nearly half of all caregivers who help older adults do so for someone with Alzheimer's or another dementia (CDC, 2019).

• About one in three caregivers (34 percent) is 65 or older.
• Approximately 60% of caregivers are women.
• Approximately one-quarter of dementia caregivers are "sandwich generation" caregivers, meaning that they are not only for an aging parent but also for children under the age of 18.
• Approximately 40% of caregivers report feelings of depression, and 60% of them rate caregiving as stressful (CDC, 2019, para. 9).

Primary and secondary caregivers often become sick themselves due to the additional stress. This is especially true as the care recipient starts to need more supervision or becomes more unpredictable and possibly violent with frequent hallucinations. Compared with caregivers of people without dementia, twice as many caregivers of those with dementia indicate substantial emotional, financial, and physical difficulties (Heerema, 2021).

Of the total lifetime cost of caring for someone with dementia, 70 percent is borne by families, either through out-of-pocket health and long-term care expenses or from the value of unpaid care (Heerema, 2021). Caregiver challenges include:

• Coordinating care and Monitoring care are received, results of treatments, social service assistance, and changes in a parent or loved one.
• Dealing effectively with family and disagreements with siblings and significant others.
• Assisting with ADLs as needed and providing outside help as warranted.
• Works with community agencies

The caregiver may experience emotional stress, depression, a decline in health (e.g., impaired immune system, illness, etc.), financial stress due to job disruptions, and loss of savings due to financial instability. People who are long-distance caregivers live an hour or more from their care recipient. Psychological stress and emotional distress often occur. Frustration develops when the caregiver is not readily present and available to deal effectively with emergencies. The caregiver may harbor feelings of regret or remorse owing to self-assessments that distance has restricted their caregiving capacity (CDC, 2019).

Long-distance primary caregivers have significantly higher annual out-of-pocket expenses for care-related costs than local caregivers. These expenses include travel costs, telephone bills, paying for hired help, and other expenses associated with providing for the care recipient's safety, daily needs, and emergency needs.

The type of intervention or combination needs to be unique to each caregiver. The efficacy of these support programs has to consider the benefits for caregivers across racial, clinical, ethnic, socioeconomic, and geographic contexts. Caregiver interventions include (CDC, 2019):

1. Psychoeducational
   1. Includes a structured program providing information about the disease
   2. Provides a list of resources and services.
   3. Gives information on how to expand skills to effectively respond to symptoms of the disease (i.e., behavioral symptoms, cognitive impairment, care-related needs).
   4. Includes lectures by professionals with specialized training, discussions, and up-to-date written material.
2. Supportive
   1. Focuses on building support among participants in a stress-free environment where problems, successes, and feelings related to caregiving can be discussed.
   2. Groups may be professionally or peer-led in which group members realize they have similar concerns and challenges. Ideas and strategies, and resources can be shared.
3. Psychotherapy
   1. Relationship between a trained therapist and caregiver is developed. The therapist educates the caregiver in self-monitoring skills, challenges negative thoughts and assumptions, helps the caregiver develop problem-solving abilities, works on time management techniques, identifies overload, manages emotions, and helps to re-develop positive experiences.

Merry is a well-educated long-distance caregiver who lives 3 hours away from her mother. She is the primary caregiver. Her mother still is independent and takes care of her activities of daily living. She does not drive because she gets lost or forgets where she is going. She is showing signs of Alzheimer's. Merry schedules her mother's doctor appointments and goes with her to ensure that her mother is on the right drugs and reports any side effects she has noticed. Merry takes her mother shopping, takes her to exercise classes, helps clean her apartment, and makes sure her mother can still pay her bills. On her days off, Merry plans activities to keep her mother interested in her surroundings and takes her to visit her friends, out to eat, and to the movies.

Merry is aware that she sometimes needs help from her sister, who is the secondary caregiver and lives at least six hours from her mother. Her sister relieves Merry and stays with her mother, taking her to her hair appointment, shopping, area holiday events, and helping clean her apartment. When their mother cannot make decisions about her care, they both listen to what their mother thinks she needs and responds appropriately.

Merry is constantly challenged to obtain accurate information about her mother's condition from local caregivers or close neighbors when working from a distance. Merry's sister fails to keep her commitments to help.

This additional stress causes Merry's employment to suffer. More time is needed off when having to be the primary caregiver. Merry had to cut back on her working hours and turned down a promotion. Merry finally chose early retirement to avoid being fired.

Merry moved in with her mother and sought local part-time employment. The distance from her friends and the monopoly of her time caring for her mother causes Merry to be socially isolated and depressed.

What started as a good plan did not work out over time. Realistic planning can improve Merry's quality of life. Moving her mother into Merry's home or assisted living would have had a better outcome. However, giving up independence and change is difficult, particularly for people with dementia.

Dementia is a devastating disease that affects the mind and the body. Current medical science does not have a cure for the disease, but there are many treatment options. Treatment should always focus on non-pharmacological interventions with sparing the use of drugs to improve the quality of life. More research is needed to find a cure and prevent this devastating disease. Support programs are available, and more will be needed as our population ages and dementia becomes more prolific. Nurses and other healthcare professionals need to understand the disease and how to help patients and families cope with dementia.

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