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Alzheimer’s disease (AD) is a form of dementia that is an irreversible and progressive brain disorder that impacts patient’s memory, thinking skills, insight, language and judgment. Alzheimer’s disease accounts for roughly 50-75% of all dementia cases (Ferri, 2019). Currently the incidence of AD is around 10% for people over the age of 85 years old and the risk for developing it doubles every 5 years once a person is over the age of 65 (Ferri, 2019). Research estimates that there are currently 5.5 million Americans that have AD and most of them are aged 65 or older (National Institute on Aging, 2020). 3% of adults that have AD are between 65-74 years old, 17% between 75-84 and then adults aged 85 and older make up 32% (Ferri, 2019). It has also been found that women are at greater risk than men. Recent research indicates that AD is actually the third leading cause of death in the United States (National Institute on Aging, 2020).

Alzheimer’s disease is a cortical disconnection syndrome that is both progressive and irreversible. This disease depletes the cerebral cortices of neurons which causes generalized cortical atrophy, enlarged ventricles and widened cortical sulci (Dunphy, Winland-Brown, Porter & Thomas, 2015). Certain neurons are susceptible to the disease, especially ones that use acetylcholine as a neurotransmitter. Other areas that are usually impacted by AD are cortical areas such as the hippocampus, the temporal cortex, olfactory system, corticocortical connections and the amygdala (Dunphy et al., 205). The hippocampus is impacted by loosing a majority of its inputs and outputs and the amygdala becomes depleted, which leads to it shrinking. There are two pathological lesions that are found in patients with AD. These lesions appear in the brain in large numbers and are called neuritic plaques and neurofibrillary tangles. Neurofibrillary tangles cause the most impact because they immobilize and deactivate neurons dynamic cytoskeleton which then leads to cell death (Dunphy et al., 2015). The most significant biochemical issue that causes AD is the defect in the metabolism of beta-amyloid precursor proteins. Usually several different types of cells make these proteins and they are broken down by certain secretases and create the by-product of beta-amyloid peptides. People that have AD have an excessive amount of these beta-amyloid peptides that accumulate in the brain. Abnormalities in the function of the secretases leads to an overproduction of the beta-amyloid peptides. A current theory suggests that this excessive accumulation of beta-amyloid peptides in the brain is the primary issue in AD and that the neurofibrillary tangles are the result of the toxic effects of these peptides on neurons leading to AD (Dunphy et al., 2015).

Patients that have AD typically present with issues of memory problems or the family of the patient are concerned that the patient’s memory has changed. When doing a physical assessment on the patient a cognitive exam is essential for determining if the patient has AD. The patient should be asked questions about their life such as, “What did you eat for breakfast this morning?” The patient should also complete the min-mental state exam to test their cognition. The score from this test helps classify what stage of AD the patient has. The physical assessment should include the get up and go test and a gait assessment as well as a thorough neurological exam. During the physical exam patients should also be screened for depression because it can either be a coexisting condition or could be mimicking AD. A functional activities questionnaire should be completed to see the patient’s functional level. During the physical exam assessing to see how the patient is able to follow commands can also help with assessing their cognitive function.

There should be a couple of diagnostic tests ordered to ensure that the patient does not have any other conditions in addition to Alzheimer’s disease that could be making their brain function worse. A complete blood count, electrolytes, serum calcium, thyroid-stimulating hormone level and blood glucose would all be ordered. A CT of the head would also be ordered to see the extent of vascular disease. When treating patients with AD the goal is to help slow the progression of the disease by use of medications while protecting their physical health and providing emotional support to help them maintain maximum function. For patients just diagnosed with AD that is mild to moderate that do not have any potential safety issues if they took medication and that could benefit from medication should be started on a cholinesterase inhibitor to help improve cognitive function. The patient would be prescribed donepezil 5mg daily at bedtime for 4-6 weeks and if the patient has moderate to severe AD, then they would be prescribed memantine 5mg once daily (Woo & Robinson, 2016). Donepezil requires monitoring of blood chemistries and hematology and these will be ordered routinely every 3 months. In addition to pharmacological treatment, patients should remain as active as possible and continue to have good nutrition and preventative care. Patient safety also needs to be addressed as part of the treatment plan. This includes patients no longer driving due to impaired driving or risk of them getting lost, and if they are at risk for wandering or severe safety issues such as leaving the stove on and unattended then further care needs to be discussed. This care plan can include referring home health to work with the patient if the patient does not have a high safety risk. If the patient it high risk for wandering, getting lost, or at risk of harming themselves then a plan needs to be discussed with case management and the family regarding placement to a long-term care facility, Alzheimer’s unit or getting 24-hour care at home. At this point there should also be a discussion of an advanced directive and end-of-life decisions if the patient were to rapidly decline. Patient will be referred to a memory disorder center so they can be offered multidisciplinary services.

There are several essential components that need to be discussed for patient education and this education needs to be addressed with the patient’s family present. There needs to be a thorough explanation of Alzheimer’s disease and that is it a progressive condition. The patient might have mild AD and the patient and family need to understand that the patient may progress quickly or slowly to severe AD. The family needs to be taught treatment options such as putting the patient on medications including donepezil and memantine. Teach patient and family that donepezil does not prevent the progression of AD, but it can help slow down the rate of cognitive decline. Teach the family if the patient is prescribed donepezil that the initial 5mg dose will be taken for 4-6 weeks and then increased to 10mg because it can be more beneficial for the patient (Woo & Robinson, 2016). If the patient is on memantine then the patient will also be titrated up if the dosing is tolerated. Teach patient and family possible side effects of medications including for donepezil digestive complaints such as diarrhea, anorexia, weight loss and nausea (Dunphy et al., 2015). Taking it with food can help with these side effects. Side effects of memantine include syncope, dizziness, confusion, constipation, hypotension and paranoid reactions (Woo & Robinson, 2016). The patient and family should be educated on advanced directives and decision options for end-of-life. Teach family that the patient is at increased risk for falling due to cognitive decline and if the patient is to remain at home fall precautions needs to be taken at home such as removal of throw rugs, moving cords and providing adequate lighting. Teach family that patient can participate in memory training and exercises to help them remain active and be able to complete activities of daily living.

Follow-up for patients with AD will be in 4-6 weeks. At the follow-up another cognitive exam will be completed to see if the patient cognitive function has declined. And if the patient is on medications to see if the patient has been able to tolerate medication and if there needs to be medication adjustments. During the follow-up family will be asked if there are any changes in the patient’s memory or behavior and to see if the current treatment plan is working. Since AD is a progressive disease, follow-ups can be scheduled to re-assess patient’s status.

References

Dunphy, L. M. H., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary Care: The Art and Science of Advanced Practice Nursing (4th ed.). Philadelphia, PA: F.A. Davis Company.

Ferri, F. F. (2019). Ferri’s Clinical Advisor 2019. Philadelphia, PA: Elsevier.

National Institute on Aging. (2020). Alzheimer’s disease fact sheet. Retrieved from https://www.nia.nih.gov/health/alzheimers-disease-…

Woo, T. M., & Robinson, M. V. (2016). Pharmacotherapeutics for Advanced Practice Nurse Prescribers (4th ed.). Philadelphia, PA: F.A. Davis Company.

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