Latest Approaches in Alzheimer's Care, from RN Magazine - July 1998

If you have any doubts about just how widespread a problem Alzheimer's disease has become, take a look at the
statistics: About four million Americans have Alzheimer's.  By the middle of the 21st century, that number may
reach 14 million.  Alzheimer's disease is the fourth leading cause of death in adults, preceded only by heart disease,
cancer, and stroke.  It is estimated that one in 10 families has a member who has Alzheimer's disease.'
While these numbers can be discouraging, recent advances in drug research may offer patients and their families
some relief.  Tacrine (Cognex), which was introduced in 1993, has been shown to significantly improve cognitive
function in Alzheimer's patients, as has the newest FDA-approved medication, donepezil (Aiicept).  Still in the
research pipeline is ENA-713 (Exelon), another antisenility agent that holds promise for patients with Alzheimer's
disease.
Of course, medication should only be part of a wider approach to the disease.  Equally important are a careful
nursing assessment and several non-drug interventions aimed at the patient and his family.

Evaluating mental status

Assuming that other causes of dementia have been ruled out, (see the June installment in this series) the evaluation
of an Alzheimer's patient should begin with a thorough neuropsychological evaluation by someone specially trained
in this area.  This type of assessment usually includes a battery of tests,questionnaires and interviews that look at
mental status, reasoning ability, memory, verbal skills, and functional status.  These tests determine how severe the
patient's condition is and what his specific cognitive and emotional deficits are; you can use the results to fine-tune
your interventions.
Regardless of whether a specialized assessment has been done, you will still want to check for common psychiatric
conditions-like depression, psychosis, and anxiety and assess for behavioral problems.
Detecting depression and suicidal tendencies can be especially difficult.  In general, a depressed elderly patient is
more likely to complain of anorexia or insomnia than to appear sad or have poor concentration.

When doing your evaluation, look for the following:

1. Any marked change in eating or sleeping habits 2. Somatic complaints that don't seem to have a physiological
basis 3. Increased instability, aggressiveness, or isolation 4. Excessive talking about death or dying
If you or the family suspect that the patient is having suicidal thoughts, directly ask the patient whether this is the
case: "I'm concerned that you've been so troubled lately, and I'm wondering if you've been thinking about suicide?"
or "I know that your memory problems have been upsetting you.  Are you feeling suicidal?"
Obviously, not all patients who are thinking about suicide are going to admit it.  But in such cases your queries
may elicit nonverbal clues, like restlessness or agitation, that suggest he has indeed been thinking about the subject.
In our experience, most suicidal patients do want to talk with someone.  When discussing the subject, we
acknowledge the patient's anguish and frustration over his mental deterioration, but point out that
clinical depression may be coloring how he feels about living.  Obviously these patients need a psychiatric
evaluation-and perhaps antidepressants.

Treating the patient with drug therapy

The antisenility drugs used in Alzheimer's disease-tacrine, donepezil, and ENA-713-are all acetylcholinesterase
inhibitors.  They increase the availability of acetylcholine, a neurotransmitter needed for normal memory and
learning.  When given in the early stages of Alzheimer's disease, these drugs may lessen cognitive signs and
symptoms and slow the disease's progression.
The usual starting dose of tacrine is 10 mg 4 times a day (qid), with meals, for at least six weeks.  The patient's
liver enzymes should be monitored during the initial course of treatment.  Assuming enzyme levels don't go up, the
dosage can be increased over time to a maximum of 40 mg qid.  Other adverse effects to watch for include dizziness,
agitation, confusion, ataxia, insomnia, son-molence, tremors, and headaches.  Nausea, vomiting, diarrhea, dyspepsia,
anorexia, myalgia, and rhinitis may also occur.
Tacrine is contraindicated in patients with asthma, hypotension, bradycardia, atrioventricular conduction
defects, hyperthyroidism, urinary tract obstructions, peptic ulcers, and intestinal obstructions.  It should be used
cautiously in anyone with seizure disorders, angleclosure glaucoma, or liver disease, and in patients taking
nonsteroidal anti-inflammatory agents.  It should also be used cautiously in patients who are being anesthetized with
succinyleholine, which is commonly given to those receiving electroconvulsive therapy.'
The starting dose for donepezil is 5 mg once a day just before bedtime, to be increased in some patients to 10 mg a
day after four to six weeks.  Compared to tacrine, the once-a-day dosing offers an advantage for patients who have
difficulty remembering to take divided doses.  The most frequent adverse effects are nausea, diarrhea, insomnia,
vomiting, muscle cramps, fatigue, and anorexia.
Donepezil is contraindicated in patients who are hypersensitive to pipeidine derivatives, which include drugs like
cyproheptadine (Periactin), mesoidazine (Serentil), and thioridazine (Mellaril).  The drug should be used cautiously
in patients on suceinylcholine and nonsteroidal anti-inflammatory drugs, as well as in those with bradycardia, peptic
ulcer disease, seizure disorders, obstructive bladder disease, and asthma.

Caring for the caregivers

While medication can offer some relief to patients and their caregivers, it can't replace psychosocial support. 
Research has shown that when spouses join support groups and receive counseling to help them cope with the
patient's symptoms, their partners fare better and remain at home longer.  Studies also confirm that caregivers who
participate in an awareness training and problem solving program are better able to manage difficult behaviors like
wandering, hoarding, and 'inappropriate sexual behavior.'
To apply this research, start by explaining the stages of the disease to the family.  While the progression of
symptoms varies from person to person, patients usually go through three general stages.' During the amnestic stage,
memory begins to fail; typically patients forget names or misplace things.  During the dementia stctge, there's also a
significant decline in cognitive abilities.  Routine tasks like cooking, managing a checkbook, or matching clothing
colors becomes difficult.  Language skills deteriorate.  Patients experience disorientation, confusion, and poor
concentration.
In the final vegetative stage, the patient is completely unable to care for himself.  He is no longer capable of
communicating coherently-many lose the ability to speak altogether-and he cannot perform activities of daily living
like feeding himself, dressing, and toileting.
In addition to educating caregivers about these stages, explore the family's emotional reaction to their loved one's
slow deterioration.  To most families, it's like attending a funeral that lasts for 20 years.  So the mourning, that a
spouse would normally do at the time of her partner's death becomes a long, drawn out process, during which the
couple experiences the loss of shared activities, future plans, and social contacts.
As the disease advances, the caregiver also experiences the loss of the partner as a lover and must struggle with
feelings of guilt, anger, and fear.  She worries over financial problems, too, especially if the patient requires
institutionalization.
Family members also find they have to protect the patient's dignity as he deteriorates.  It's difficult
to break down the patient's delusion about his mental competence, telling him, for instance, that he can no longer
handle the checkbook.  Perhaps the solution is to redefine the term dignity.  For an Alzheimer's patient who is losing
his cognitive ability, it may mean enjoying children's games and songs without feeling humiliated.
To minimize confusion, encourage the family to maintain a structured home environment and keep to routines as
much as possible.  It also helps to label household items that the patient uses frequently, to limit the number of foods
placed before him at one time, and to use simple words and questions that require Yes or No answers, whenever
possible. 7
To help families find other coping strategies, refer them to a support group or one of the resources listed in the box at
right.  In the absence of a cure for Alzheimer's, your guidance and compassion, along with the medications and
nursing interventions discussed here, can make a world of difference to patients and their families.  

Alzheimer's Association
919 Michigan Ave
Suite 1000
Chicago, Illinois 60611
312-335-8700
800-272-3900 to find a local chapter

Alzheimer's Disease Education and Referal Center
PO Box 8250
Silver Spring, MD 20907-8250
800-438-4380

Benjamin B. Greenfield National Alzheimer's Library and Referal Center
919 North Michigan Ave.
Suite 1000
Chicago, IL 60611-1676
312-335-5767

The Joseph and Kathleen Bryan Alzheimer's Disease Research Center
2200 West Main St.
Suite A230
Durham, NC 27705
919-286-3228

Washington University in St. Louis Alzheimer Page
http://www.biostat.wustl.edu/alzheimer/

And do a search on Yahoo looking for "alzheimer's disease" or just "alzheimer"