Care of the Patient with Alzheimer’s

The brain is an amazing organ. It monitors, regulates, initiates basic drives, stores, and retrieves information, performs intellectual functions, produces and interprets language, processes visual and auditory data, and is only the size of a coconut. The brain works using a vast connection of nerve cells that connect with billions of other nerve cells. However, when a person has Alzheimer's disease, the brain is affected in many ways. Usually, the disease begins in the brain's nerve cells responsible for memory, particularly learning new things. These nerve cells become damaged and eventually die. As a consequence, certain aspects of brain function are lost.

Alzheimer's disease is a form of dementia. Dementia is a broad term that covers several types of dementias, including vascular dementia that occurs after a stroke, Parkinson's disease dementia, which can occur with Parkinson's disease, or Lewy body dementia, which affects chemicals in the brain (Halter, 2022). This content will focus on Alzheimer's disease as it is the most common form of dementia.

In 2023, there were over 6.7 million people over the age of 65 in the United States with Alzheimer's disease (Alzheimer's Association, 2023). It is estimated that by 2050, Alzheimer's disease rates will have doubled (Alzheimer's Association, 2023). As the population ages, Alzheimer's is one of the most common causes of death and has increased significantly over the last several years. In 2019, the death rate per 100,000 people diagnosed with Alzheimer's was 37% (Alzheimer's Association, 2023). Studies have shown that, on average, patients older than 65 live up to eight years after their diagnosis (Alzheimer's Association, 2023). However, these statistics do not encompass every case.

The disease was first described by and named after Dr. Alois Alzheimer in 1907 (Halter, 2022). Alzheimer's disease is a progressive and fatal illness that causes areas of the brain to shrink. Symptoms typically appear in stages, starting with a gradual decline in memory, judgment, and personality changes. In later stages, physical symptoms appear, including loss of body functions (Halter, 2022). Currently, the actual cause of Alzheimer's disease and the cure are unknown.

Alzheimer's is a form of what is called a degenerative brain disease. It is rarely seen before age 50, but when seen in younger patients, the stages of symptoms progress much quicker. Since the disease progresses, symptoms will present in stages (Acello & Hegner, 2015). Progressive deterioration of mental capacities, such as memory and confusion, leads to other symptoms, such as dysphagia. As the disease advances, neurological signs develop, such as paralysis of limbs and weakness. The progression of the disease can vary depending on the age of onset. It may be a few months to several years before a complete loss of function is seen. Diagnosis is made based on symptoms alone. There are no tests to confirm the diagnosis. Diagnosis is confirmed after an autopsy is performed, and the damage to the brain can be seen.

Remember that the brain is made of billions and billions of nerve cells called neurons. These neurons are responsible for the thoughts and actions of the body. These neurons create the movement of typing, writing a paper, or driving a car. When these neurons become damaged, physical actions and thoughts are affected.

In Alzheimer's disease, researchers believe that the neurons and the spaces between the neurons fill with a protein deposit called beta-amyloid (Halter, 2022). Beta-amyloid creates what is referred to as plaques and tangles. Although this process is part of the normal aging process, those with Alzheimer's seem to develop more. The plaques and tangles prevent the neurons from working properly. The messages sent between neurons to have a thought or move an arm are not sent because of the increased amount of sticky plaque and tangles that have developed. The neurons become clogged with abnormal tangles and plaques and die off. Viewing the tissue by autopsy is the only positive way to determine if plaques and tangles are in the brain (Halter, 2022).

Researchers also believe that genetics may be involved in developing Alzheimer's disease. Familial Alzheimer's accounts for less than 10% of patients and is usually seen before age 65 (Bird, 2012). Multiple genes on chromosomes are thought to be involved instead of just one gene, as seen in other inherited diseases (Halter, 2022). However, only one gene must be inherited from a parent to create a risk factor for Alzheimer's disease. The pattern is called autosomal dominant inheritance and means that all children of the parent who has familial Alzheimer's have a 50/50 chance of developing the familial type of the disease (Strobel, 2019). There is, however, evidence that late-onset Alzheimer's, which is normally seen, also has a genetic component. Researchers have shown that the inheritability of Alzheimer's can be as high as 80% (Yu et al., 2014); this is due to a genetic protein called apolipoprotein E or APOE. This protein has been identified as an important risk factor for developing Alzheimer's disease (Yu et al., 2014).

The most important risk factor is age. The risk for the disease doubles every five years after age 65 (Halter, 2022). Other risk factors include incidents and disease states where the brain has trauma or damage and include the following (Sadock et al., 2015):

• Down Syndrome
• Severe head trauma
• Alcohol Abuse
• Aluminum toxicity
• Exposure to viruses
• Acquired Immunodeficiency syndrome (AIDS)
• Parkinson's disease

Because the disease is progressive, symptoms appear over time. There may be no outward signs, but small memory issues will worsen as the disease advances. The family usually notices these signs first as they are very subtle. The person may (Halter, 2022):

• Feel anxious or suspicious
• Not be able to make simple decisions
• Forget names of family, places, or everyday items such as phone numbers or names of objects
• Misplace items more
• Forget how to get to places they go to regularly
• Unsure of what words to use to speak
• Lose their train of thought easily
• Lose interest in things they like
• Repeat things

Alzheimer's Symptoms

While mild memory loss with aging may be normal for some people, those with Alzheimer's will show a rapid decline in memory and other cognitive skills. Recent memory is usually the first to be affected. The person may not remember what they ate for breakfast or if they had visitors just a few hours ago.

The hallmark of Alzheimer's disease is that it progresses gradually over a period of years. Typically, three stages can be seen (Acello & Hegner, 2015). These stages are early, middle, and late. Each stage can also be classified as mild, moderate, or severe.

The first stage may be mild and not very noticeable. Usually, family or others close to the person notice the symptoms. The patient typically thinks something is wrong and may try to unconsciously cover up their symptoms with confabulation or create stories to maintain self-esteem (Halter, 2022). Symptoms in the first stage include difficulty learning new material, decline in recent memory, difficulty performing tasks, appearance deterioration, decreased concentration and judgment, time disorientation, and difficulty finding words or naming objects. In this stage, since the patient is usually aware of their forgetfulness, they may withdraw socially, and feelings of shame, helplessness, and frustration may be seen (Acello & Hegner, 2015).

In the middle stage, cognitive decline continues as memory deteriorates and confusion becomes more pronounced. Personality changes may be seen, as well as more physical problems. The patient may exhibit behavioral changes such as disinhibitions or inappropriateness in situations. Poor impulse control, wandering, sundowning (confusion and restlessness during the evening hours), inability to recognize and use common objects such as a spoon, and perseveration or repeating actions or words may also be seen (Acello & Hegner, 2015). The patient's mood is more labile or frequently changes for no reason. They may also overreact to situations or have catastrophic reactions. At this stage, there is little recent memory, little recall of information, little retention of learning, and even some remote memories may be lost (Acello & Hegner, 2015). There may also be subtle signs of psychotic behaviors, delusions, or hallucinations.

The last stage is an almost complete deterioration of bodily function, personality, and behaviors. The patient usually depends on a caregiver for daily activities (Acello & Hegner, 2015). As this stage progresses, the patient may only speak one word and is agitated or paranoid. The patient may not be able to respond to the environment and may not recognize others or even themselves in the mirror. Eating and drinking may be an issue as the patient cannot swallow. Seizures may also be seen at this stage (Acello & Hegner, 2015). Eventually, the patient is bedridden, incontinent, and unable to speak. It is important to talk to the nurse and other staff members so that everyone knows the patient's needs and patterns; this can be done in a pre-conference or a report to each other and will help care for the patient.

How quickly symptoms are seen and how fast the stages progress will vary depending on the age of onset and the person. Typically, the average patient lives around eight years after diagnosis. However, the patient can live for more than 20 years (Acello & Hegner, 2015). The younger the onset of the disease, the more aggressive the disease will be.

The patient should be encouraged to maintain their independence in as many ways as possible for as long as possible. However, as the disease progresses, it is important to remember several things. Overstimulation, for example, may cause acting out behaviors or wandering behaviors in Alzheimer's patients. The caregiver may also need to explain directions several times, slowly and simply. Communication will be impaired. Understand that the patient may not communicate well or not at all. They may lose their train of thought or forget words. If changes are noted, report those to the nurse.

It is important to support the patient and help them maintain their self-esteem. Helping the patient reminisce about happy times is one way to accomplish increased self-esteem (Halter, 2022). Accept the patient without being judgmental or critical. For example, remember that confabulation is not lying. Confabulation is unconscious (Halter, 2022). Never argue with the patient. Instead, try distraction using realities around the patient, such as a photograph in the room (Acello & Hegner, 2015). The best way to work with a patient diagnosed with Alzheimer's disease is to provide a quiet, calm environment that is structured and consistent. Maintaining eye contact when appropriate, watching body language, trying to understand the patient's nonverbal cues, and using touch appropriately are also helpful (Acello & Hegner, 2015). Use simple, short phrases and words when giving directions. Speak slowly and clearly while standing close to the patient; this will help them to focus on you and what you are saying (Halter, 2022).

Monitor the patient's eating habits. Be sure to offer fluids that the patient likes. The family may be of valuable help and offer suggestions. Also, offering the patient finger foods one at a time can avoid confusion or overstimulation (Acello & Hegner, 2015). Too much food in front of the patient may cause them to become anxious and not eat. Check food for the temperature as well. Reheating food that the patient is eating slowly may also help with acceptance. Help the patient prepare food, such as buttering bread or removing wrappers. Puree foods may be required if the patient is not able to chew well (Acello & Hegner, 2015). Patients may also need help feeding themselves or completely depend upon someone to feed them. Take the time to help the patient eat slowly and encourage food intake. Remember that they may be slow to eat food. If there are any changes in behavior, such as the patient refusing food or fluid or being unresponsive, notify the nurse. The patient may also need to have their mouth checked for food in their cheeks; this can cause choking and cause the patient to stop eating (Acello & Hegner, 2015).

The Alzheimer's patient will also have good days and bad days. There may be problems with various aspects of their daily routine, such as bathing or dressing, as well as wandering or behavioral problems. The patient may have forgotten how to bathe or eat or no longer understand the purpose. It is important to be patient and not agitate the patient. If the patient refuses to eat, dress, or bathe, keep trying throughout the day. Try to change the environment or your approach toward the patient (Acello & Hegner, 2015). Consult the nurse if the patient does become agitated or if the refusal continues. If the patient can perform self-care activities, allow plenty of time and give simple, short tasks and only a few choices. Directions should be given one step at a time so they are not overwhelmed. Watch the patient carefully for nonverbal cues as well as verbal cues.

Wandering or sundowning is another issue that is particular to dementia patients. No one knows why this occurs. The patient will try to leave the facility or wander around the unit; this usually happens toward the evening hours but can occur anytime during the day. Remember that a patient with Alzheimer's often gets their night and day hours mixed up. They may think it is time to go to work when it is actually dinner time. The person seeks a state of mind, not a place (Acello & Hegner, 2015). Avoid arguing or telling the patient they are in a facility and cannot leave. Instead, use distraction by getting the patient to tell you what kind of hobbies they like or what they used to do for a living. Walking with the patient can also be a strategy to gently guide them back to where they should be (Acello & Hegner, 2015). Sundowning can have many triggers. Try to keep a log to see if there is a pattern to the behavior (Acello & Hegner, 2015). Are there unmet needs or feelings that the patient is seeking? The wandering patient can also become exhausted. Watch the patient for an unsteady gait or leaning on the wall. Be sure there are chairs nearby for the patient to sit. Encourage the patient to sit frequently and offer fluid or finger foods.

Try to understand if the patient is uncomfortable or has unmet needs such as toileting, hunger, or clothes that are pinching. Unmet needs can also cause anxiety or agitation (Acello & Hegner, 2015). This type of behavior can occur due to a sudden change in routine, place, or even people. Too much stimulation may be another reason for agitation. Distraction is one way to help the patient overcome this behavior. It is easier to deal with agitation or aggression before it gets out of hand. If you see a sign of a patient becoming agitated, try to find the cause and remove it. The patient may also exhibit pacing or preservation behaviors. If the patient becomes agitated, do not use force or demand that the patient behave. Only a few of the staff should approach the patient. It can be dangerous to approach alone, but too many staff can create additional agitation. Be aware of your body language as well as the patient's. If the patient is clenching fists or threatening, stand more than an arm's length away. Use a soft, low, calm voice to speak to the patient. Be careful with touch; some patients may react violently if agitated (Acello & Hegner, 2015). Notify the nurse if the patient continues to become agitated or violent.

Any changes in the patient's behavior should be reported; this includes bathing or eating habits, grooming, activity, behavior, dressing, or thought process. Furthermore, anything out of the ordinary, such as profuse sweating, diarrhea, excessive drowsiness, falls, bruises, vomiting, muscle spasms, confusion, trouble breathing, or constipation, should also be reported. Listed below are other observations that should be reported (Acello & Hegner, 2015):

• Changes in alertness or awareness of current surroundings
• Changes in mood or emotions
• Changes in awareness of person, place, or time
• Changes in communication, such as verbal or non-verbal responses
• Memory changes such as more forgetful or a sudden inability to recall items or people
• Unusual or new behavior not seen before
• Increased anxiety or agitation
• Tired for no reason, falling asleep at odd times
• Wandering more
• Unusual pattern of bowels
• Increases in confusion
• Changes in vital signs
• Signs of other illness

In conclusion, patients with Alzheimer's disease need special care. The patient can present with a variety of symptoms based on the current stage of the disease.  However, the hallmark signs of the disease are that it is a progressive disorder with memory loss and increased physical impairments over time. Symptoms need to be monitored, and any changes in behavior or activity should be reported. Notice their changes in behavior or personality. If they suddenly become upset, angry, or depressed, try to identify the problem and report the behavior to the nurse. The patient may hide objects or lose interest in objects. They may wander excessively, pace, or become inappropriate with others. The patient may also have delusions or hallucinations. Remember not to argue with the patient. Comfort the patient if they are fearful or use distraction techniques, but if they become combative, get help. The Alzheimer's patient can be well cared for if the providers are able to understand the disease progression and needs of the patient.

You have been caring for Mr. J in his home for three months. Lately, you notice that he has forgotten his wife's and son's names. His wife reports that he is not eating as much and just has not been himself lately. On this particular visit, Mr. J is trying to get out of bed, telling you he needs to go to work. You know that he has been retired for over ten years. His wife is very concerned and becomes tearful. What do you do?

First, you should help Mr. J calm down. If he can get out of bed, he might like to sit in a chair for a while. Once he is calmer, you can tell his wife he is calm, and you will talk to the nurse. Your report should contain that he is more agitated, is not eating, seems more confused, and has forgotten the names of those around him. Before you leave, ensure the patient and his wife are safe and follow the nurse's directions.

Today, you are assigned to the dementia unit in the long-term care facility where you work. You are asked to work in the common area, helping patients with daily activities, including group activities. Just as an activity is about to start, the nurse and regular certified nursing assistant (CNA) on the floor are called away to deal with a patient having an outburst. The nurse asks that you start working with the two ladies who seem interested in a group activity. The women are watching you approach apprehensively. What do you do?

Remember, patients with a diagnosis of Alzheimer's may be paranoid or frightened of new people. Approach in a friendly, non-threatening manner. You may want to sit with them to be on their level. Start by telling them your name in a calm voice. Ask them if they would like to do an activity with you. You may suggest coloring, for example, as an activity that allows for movement and conversation. Watch for signs of agitation or fear. Report to the nurse what you did and how the ladies responded.

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