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, it's only the size of a coconut. The brain works using a vast connection of nerve cells, billions, in fact, that connects 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 nerve cells of the brain that are 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 that is a specific structure that forms in the brain cells (Halter, 2014). This article will focus on Alzheimer’s disease as it is the most common form of dementia.

In 2015, there are over 5.3 million people in the United States with Alzheimer’s disease and of those about 5.1 million are over the age of 65 (2015 Alzheimer’s disease facts and figures, 2013, September, 17). About two-thirds are women. These numbers grow as the population ages. It is estimated that by 2050 13.8 million Americans will be diagnosed with Alzheimer’s disease (2015 Alzheimer’s disease facts and figures, 2013, September, 17).

As the population ages, Alzheimer’s is one of the most common causes of death and has increased significantly over the last several years. Between 2000 and 2013 deaths from Alzheimer’s disease rose to 71 percent (2015 Alzheimer’s disease facts and figures, 2013). Furthermore, it is estimated that those diagnosed with Alzheimer’s have a median survival rate of nine to three years depending on the age at the time they are diagnosed. Those diagnosed at around the age of 65, have a survival time of 8.3 years compared to those diagnosed at age 90 who have a survival rate of approximately 3.4 years (Life Expectancy Following Diagnosis of Alzheimer's Disease Depends on Age at Diagnosis, 2002).

The disease was first described by and named after Dr. Alois Alzheimer in 1907 (Halter, 2014). 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 over body functions (Halter, 2014). Currently, the actual cause of Alzheimer’s disease as well as the cure are unknown.

Alzheimer’s is a form of what is called a degenerative brain disease. It is rarely seen before the age of 50, but when it is seen in younger patients, the stages of symptoms progress much quicker. Since the disease is progressive, symptoms will present in stages (Hegner & Acello, 2010). Progressive deterioration of mental capacities, such as memory and confusion, lead 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 age of onset. It may be a few months to several years before complete loss of function is seen. Diagnosis is made based on symptoms alone. These 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 thoughts and actions of the body. These neurons create the movement of typing or 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, 2014). The protein creates what is referred to a 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 is not sent because of the increased amount sticky plaque and tangles that have developed. The neurons become clogged with the abnormal amount of tangles and plaques and die off. The only positive way to determine if plaques and tangles are in the brain is to view the tissue (Halter, 2014). Doctors usually do this in an autopsy.

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 the age of 65 (Bird, 2012). It is thought that multiple genes on chromosomes are involved as opposed to just one gene as seen in other inherited diseases (Halter, 2014). However, only one gene needs to be inherited from a parent to create a risk factor for Alzheimer’s disease. This 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 (“What is early-onset familial Alzheimer disease (eFAD)?” 2006). There is however, also evidence that late onset Alzheimer’s, which is normally seen, also has a genetic component. Researchers have shown that inheritability of Alzheimer’s can be as high as 80% (Yu, Tan & Hardy, 2014). This is due to a genetic protein called apolipoprotein E or APOE. This protein has been identified as an important risk factor in developing Alzheimer’s disease (Yu, Tan, & Hardy, 2014). 

The most important risk factor is age. Risk for the disease doubles every five years after the age of 65 (Halter, 2014). Other risk factors include incidents and disease states where the brain has trauma or damage (Sadock, Sadock, & Ruiz, 2014):

• Down Syndrome 
• Severe head trauma
• Alcohol Abuse
• Aluminum toxicity
• Exposure to viruses 
• Immune deficiency syndrome (AIDS)
• Parkinson’s disease

Because the disease is progressive, symptoms appear over time. At first, there may be no outward signs, but small memory issues will appear and become worse as the disease advances. Family usually notices these signs first as they are very subtle. The person may (Halter, 2014):

• 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
• Loose their train of thought easily
• Loose interest in things they like
• Repeat things

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 first to be affected. The person may not remember what they ate for breakfast or if they had a visitor just a few hours ago.

The hallmark of Alzheimer’s disease is that it progresses gradually over a period of years. Typically, there are three stages that can be seen (Acello & Hegner, 2015). These 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 has an idea that something is not right and may try to cover up their symptoms with confabulation or making up stories unconsciously to maintain self-esteem (Halter, 2010). Symptoms in the first stage include difficulty learning new material, decline in recent memory, difficulty performing tasks, appearance deteriorates, decrease concentration and judgment, time disorientation, 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 action or words may be seen as well (Acello & Hegner, 2015). The patient’s mood be more labile or frequently change with no reason. They may also over react to situations or 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 (Hegner & Acell0, 2010). 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 is usually totally dependent on a care giver 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 is not able to swallow. Seizures may also be seen at this stage (Hegner, Acello, 2010). Eventually the patient is bedridden, incontinent and is not able to speak. It is important to talk to the nurse and other staff members so that everyone has knowledge about the patient’s needs and patterns. This can be done in a preconference or a report to each other and will help in caring for patient. 

How quickly symptoms are seen and how fast the stages progress will vary depending on age of onset and the person. Typically, the average patient lives from eight to 10 years after they are diagnosed. However, the patient can live for more than 20 years (Hegner & Acello, 2014). 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 keep several things in mind. Overstimulation, for example, may cause acting out behaviors or wandering behaviors in the Alzheimer patient. The care giver may also need to explain direction several times, slowly and as simply as possible. 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 to reminisce about happy times in their life is one way to accomplish self-esteem (Halter, 2014). Accept the patient without being judgmental or critical. For example, remember that confabulation is not lying. Confabulation is unconscious (Halter, 2014). Never argue with the patient. Instead try distraction using realities around the patient such as a photograph in the room (Hegner & Acello, 2014). The best way to work with a patient diagnosed with Alzheimer’s disease to provide a quiet, calm environment that is structured and consistent. It is also helpful to maintain eye contact when appropriate, watch body language, try to understand nonverbal cues of the patient, and use touch appropriately (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, 2014).

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, offer the patient finger foods one at a time can avoid confusion or over stimulation (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). The patient may also need help feeding themselves or be completely dependent upon someone feeding 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, the patient refuses food or fluid or is 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 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 may not understand the purpose any longer. 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 is able to perform activities of self-care, be sure to 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 is seeking 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 (Hegner & Acell0, 2010). 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 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 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 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 own body language as well as the patient. If the patient is clenching fists or threatening, stand more than an arms length away. Use a soft, low, calm voice to speak to the patient. Be careful with touch, some patient may react violently if they are already 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
• Increase 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 their current stage of the disease.  However, the hallmark signs of the disease is that it is a progressive disorder with memory loss and an increased physical impairments over time. Symptoms needs to be monitored, and any changes in behavior or activity should be reported. Notice their changes in behavior or personality. If they suddenly became upset or angry or get 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 delusion 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 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 3 months. Lately you notice that he has forgotten your name, his wife’s name and his son’s name. His wife reports that he is not eating as much and just is not himself lately. On this particular visit, Mr. J is trying to get out of bed telling you that he needs to go to work. You know that he has been retired for over 10 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 maybe, he would like to sit in a chair for a while. Once he is calmer, you can tell his wife that he is calm and you are going to talk to the nurse. Your report should contain the fact that he is more agitated, not eating, seems more confused, and has forgotten names of those around him. Before you leave, make sure the patient and his wife are safe and follow any direction the nurse gives you. 

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 any group activities. Just as an activity is about to start the nurse and regular CNA on the floor are called away to deal with a patient that is 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 so that you are 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.

Acello, B., & Hegner, B. (2015). Nursing assistant: A nursing process approach. Cengage Learning.

Bird, T. D. (2012). Early-onset familial Alzheimer disease. Retrieved from (Visit Source).

Halter, Margaret J. Varcarolis' Foundations of Psychiatric Mental Health Nursing: A Clinical Approach. 7th ed. St. Louis, Mo.: Elsevier, 2014. Print.

Latest Alzheimer's Facts and Figures. (2013, September 17). Retrieved December 21, 2015, from (Visit Source).

Life Expectancy Following Diagnosis of Alzheimer's Disease Depends on Age at Diagnosis. (2002, November 18). Retrieved December 25, 2015, from (Visit Source).

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry. United States: Lippincott Williams and Wilkins.

What is early onset familial Alzheimer disease (eFAD)? (2006). Retrieved December 30, 2015, from (Visit Source).

Yu, J. T., Tan, L., & Hardy, J. (2014). Apolipoprotein e in Alzheimer's disease: an update. Annual review of neuroscience, 37, 79-100.