Degenerative Neurological Disorders
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Nursing Care and Degenerative Neurological Syndrome(AD), Historical Research Work, Difficulties in Diagnosing, Medically Recognized Stages, Medical And Nursing Care
Whats Is Alzheimer’s Disease
Alzheimer’s
disease (AD) is a progressively degenerative neurological disorder (syndrome)
that results in impaired cognition, mood, behavior, and function. Dr. Alois
Alzheimer (1906) first described the disorder in a published case report on a
52-year-old patient who suffered from psychosis, memory loss, agnosia (impaired
sensory perception), apraxia (impairments in carrying out tasks), and aphasia
(impaired communication).
After the patient’s death, Dr. Alzheimer performed an
autopsy and discovered clumps-senile plaques-and knots-neurofibrillary tangles
in the patient’s brain ( Dharmarajan & Ugalino , 2003).
Historical Research Work
One
hundred years later, despite decades of research, there remains no known
etiology or cure for the disease. The diagnosis relies on a thorough clinical
history and physical examination, including mental status testing, both to
establish a diagnosis and to rule out other causes of dementia, such as brain
tumors, metabolic disorders, or infection.
Many genetic and nongenetic factors,
such as estrogen, nonsteroidal anti-inflammatory medication, and
apolipoprotein, have been speculatively associated with AD; researchers
continue to discover definitive links between these factors and the illness.
Difficulties in Diagnosing
Due
to the lack of a diagnostic marker and the associated difficulties in
diagnosing early stage AD, precise prevalence rates are difficult to determine.
Although a rare familial form of AD (afflicting people between 30 and 60 years
of age) exists the disease is more prevalent as people age.
Dementia, notably
AD, affects only 1% of those between 60 and 64 years of age, with the number of
cases. doubling every 5 years in people over 65 (Beers & Berkow , 2000). In
2000, 40% (1.8 million) of people over 85 years of age were estimated to be
afflicted with the disease.
As a result of the rapidly aging US population, the
next 50 years is expected to show a three-fold increase in the number of people
with AD (Hebert, Scherr, Bienias , Bennett, & Evans, 2003).
Medically Recognized Stages
Alzheimer’s
disease has a protracted downward trajectory. The average length of the disease
is 8 years, but it can span up to 20 years (National Institute of Aging, 1995).
As a result of its progressively degenerative a course, symptom progression is
typically divided into three stages: mild, moderate, and severe.
Mild symptoms
consist of personality changes, memory loss, and impaired word finding. As the
disease progresses, the initial symptoms worsen, with AD sufferers often.
developing increased behavioral problems such as wandering, physical and verbal
aggression, and resistance to personal care (grooming and hygiene).
In the
severe stage, the AD sufferer is profoundly cognitively and functionally
disabled, typically requiring 24-hour care. Death usually results from an
infectious process such as pneumonia.
Medical And Nursing Care
Care
is provided primarily by family members, and an estimated 75% of older adults
with dementia are cared for at home (Dunkin & Anderson-Hanley, 1998). This
care is primarily uncompensated and includes emotional, physical, and financial
assistance.
As the disease progresses, families are increasingly burdened in
trying to provide care, often suffering adverse personal physical and
psychosocial consequences ( Ory , Hoffman, Yec , Tennstedt , & Schultz,
1999).
AD causes severe cognitive impairments, and families are often forced to
make decisions for the AD sufferer (eg, whether to resuscitate or whether to
institutionalize), without the guidance of advance directives.
Treatment
Treatments
for AD are multiple and vary by illness stage. Pharmacologic treatments include
medications to improve cognition, treat depression, or treat behavioral
symptoms ( eg. physical aggression or agitation).
Because each person with AD
experiences a unique confluence of symptoms, treatment strategies require
careful tailoring to meet the respective needs of each person.
Chronological Data
Researchers
have discovered decreased levels of acetylcholine in the brains of AD
sufferers; Thus, acetylcholinesterase inhibitors are indicated in the mild to
moderate stages of AD to slow the progressive cognitive decline. Some families
have reported that these drugs resulted in some amelioration of behavioral
symptoms.
Certain behavioral symptoms, such as physical aggression or
agitation, may require antipsychotic medications. However, these drugs are
often associated with increased confusion, resulting in decreased function, and
therefore require a careful risk-benefit analysis and ongoing evaluation of
their effectiveness.
Benzodiazepines are generally not useful for the control
of behavioral symptoms and have been associated with increased falls in older
adults (Frenchman, Capo, & Hass, 2000). Depression is a common comorbid
condition with AD, requiring early recognition and treatment both pharmacologic
and non-pharmacologic-aimed at maximizing function and minimizing additional
disability.
Behavioral Changes
Certain
behavioral symptoms (eg, wandering, verbal aggressiveness, or resistance to
personal grooming) do not respond favorably to pharmacologic therapy. These
symptoms require environmental modifications and behavioral strategies. AD
sufferer’s agnosia, combined with other cognitive deficits (eg. memory loss or
lack of insight/judgment), often results in unsafe behaviors.
For instance, AD
sufferers may turn on stoves and then forget to turn them off. They may
inadvertently drink toxic substances or step into a bathtub of scalding water.
Driving becomes increasingly unsafe. Each AD sufferer needs to be evaluated for
possible sources of injury, and strategies must be initiated to safeguard
living environments.
In institutional settings, similar types of environmental
modifications are needed to ensure the person’s safety. Many assisted living
and skilled nursing facilities have dedicated units designed to address the
specific needs of this population.
Behavioral strategies are extremely varied,
typically successful, and do not have the unfavorable side-effect profiles of
many of the medications used to treat behavioral symptoms. Diversion and
redirection to a preferred activity remain highly successful strategies to deal
with problems related to the AD sufferer’s short and long-term memory loss.
Reality orientation is often unsuccessful, so validation therapy (Feil, 2002)
is the preferred form of communication. Validation therapy techniques include
carefully attending to a confused older adult’s expressions of impaired
cognition (eg, thinking past events are occurring in the present) and
responding with acceptance and empathy.
In communicating with confused older
adults, careful attention also needs to be taken to provide implements such as
hearing aids or glasses, to compensate for sensory losses.
Implementation Of Restrains
Physical
restraints typically increase agitation and are not associated with a decrease
in falls ( Strumpf , Robinson, Wagner, & Evans, 1998).
Individual and
family therapy should be encouraged, to assist families in planning and
preparing for the sufferer’s future needs. Support groups, in particular the
Alzheimer’s support groups, are also an excellent source of information and
assistance. In the latter stage of AD, hospice is another source of family
support.
Sub-Cellular Changes
AD
research is overwhelmingly biomedical, attempting to uncover a cause, better
treatment, or a cure for the illness. Many behavioral strategies have been
researched and reported to be clinically successful in treating AD, including
music therapy, reminiscence therapy, strategies to prevent wandering, and
therapy animals.
Although positive results have been reported in using
behavioral strategies, the methodological limitations of the studies (small
sample sizes, sampling bias, short evaluation periods, and lack of
consideration of confounding variables) affect the scientific rigor of these
findings (Beavis, Simpson, & Graham, 2002). The rapidly aging US society
and subsequent increase in the number of people with AD afford unique nursing
opportunities and challenges.
Most AD sufferers live in the community and are
cared for by their families. Families interface with the health care delivery
system at various points in time along the trajectory. It is then that nurses,
in collaboration with people in other disciplines, can provide needed
assistance to families struggling to manage in the face of this devastating
illness.