Alzheimer's disease, dementia and cognition

Serotonin does and disease effect

-regulates sleep and sensory perception/ EPS & limbic systems Decreased amounts in depression Increased in mania and anxiety

Stats of AD

4 million older Americans suffer from Dementia 60-80% is AD 120,000 annual deaths from AD complications 50% of LTC admissions are due to Dementia Common cause of death: aspiration pneumonia Disease course 3-20 years. Average 3-8 years Most people with dementia are cared for at home

Hypoactive delirium

: Inability to focus attention or follow commands

Dopamine does and disease effect

:movement, cognition, motivation, pleasure, pain processing, other/limbic system, PNS/sympathetic, hypothalamus Decreased in Parkinson

The client in the early stage of AD and his adult son attends an appointment at the community mental health center. While conversing with nurse, the son states, "I'm tired of hearing how things were 30 years ago. Why does Dad always talk about the past?" Which response by the nurse is the most appropriate? a. " Your Dad's lost his short-term memory, but he still has his long-term memory. b. "You need to be more accepting of your Dad's level of anxiety." c. "I want you to understand your Dad's level of anxiety.' d. " Telling your Dad that you are tired of hearing about the past will help him stop."

A

Delirium define

A mental state characterized by a disturbance of cognition

Two family members are visiting their father who is experiencing acute delirium. They are upset that their father is so disoriented. " He knows who we are, but that's about it. We don't know what to say to him. What should the nurse tell the family? (Select all that apply). a. "Answer his questions simply, honestly, slowly, and clearly." b. "Correct him when he is hearing and seeing things that are not there." c. "Occasionally remind him of the time, day and place when he doesn't remember." d. "Include him in your conversation, instead of talking about him while he is present. " e. "Raise your voice a bit so you are sure he hears you."

A,C,D You can't argue with hallucinations you just move past them.

What happen to acetycholine in AD brain

ACh producing neurons decrease dramatically As ACh production falls the dementia worsens At death the cortex can have as much as a 90% reduction of ACh ACh deficit likely not the central event in AD but a part of the cascade of biochemical events causing neuron death

AD symptoms vs Age related changes

AD: Poor judgement and decision making Inability to manage budget Losing track of dated or season Difficulty have a conversation Misplacing things and being unable to retrace steps to find them Typical age related forgetting what day it is and remembering later Sometime forgetting which word to use Losing things from time to time Making a bad decision once in a while Missing a monthly payment.

ACH does and disease effect

Acetylcholine(Ach)-essential for motor control/critical to forming memories Depleted in AD, Increased in Depression/ Parkinson's disease (Slide right, book is wrong)

Dementia define

Acquired, persistent intellectual impairment with compromised function in multiple spheres of mental activity Chronic form of confusion irreversible condition

Risk factors for AD

Age: 65 and older Previous serious, traumatic brain injury but not all studies support this. Increases the ability of glutamate to cross the BBB. Lower educational achievement Down's syndrome Down's syndrome in a first-degree relative Women under 35 who give birth to a child with Down's syndrome Smoking Family history of Alzheimer's disease Associated with early onset Gene AZOE4

Hyperactive delirium

Agitation/ combativeness / excitement

Symptoms of Stage III AD

Also called the terminal stage Emaciation, indifference to food Inability to communicate Urinary and fecal incontinence Seizures Total loss of ability to care for self Lasts 1-2 year

Psychopathology of AD

Although the exact cause is unknown, the damaging and killing of nerve cells are most likely caused by plaques and tangles. Deposits of a protein fragment called beta-amyloid (plaques) build up in the spaces between nerve cells. Twisted fibers of protein called tau (tangles) build up inside the cell.

Memory impairment of one or more of what

Aphasia (no speech) Apraxia (no motor function) Agnosia (no recognition) Disturbance in executive functioning

Anti-cholinergic drugs

Are blocking the ACH Block acetylcholine receptors Inhibit breakdown of enzyme acetylcholinesterase

A 69 year old client is admitted and diagnosed with delirium. Later in the day, he tries to get out of the locked unit. He yells, "Unlock this door. I've got to go see my doctor. I just can't miss my monthly Friday appointment." Which of the following responses by the nurse is most appropriate? a. "Please come away form the door. I'll show you your room." b. "It's Tuesday and you are in the hospital. I'm Anne a nurse." c. "The door is locked to keep you form getting lost." d. " I want you to come eat your lunch before you go to the doctor."

B

A client with early dementia exhibits disturbances in her mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which of the following other areas? A. Speech B. Judgment C. Endurance D. Balance

B

Which statement is the scientific rationale for prescribing and administering donepezil (Aricept) a cholinesterase inhibitor for the Alzheimer's client? a. Aricept works to bind the dopamine at neuron receptor sites to increase ability b. Arcept increases the availability of acetylcholine at cholinergic synapses c. Aricept decreases acetylcholine in the periphery to increase movement d. Arcept delays transmission of acetylcholine at the neuronal junction

B

Diagnosing AD

Brief tests (5-15 minutes) Abbreviated mental test score(AMTS) Mini mental state examination (MMSE) Modified Mini-Mental State Examination (3MS), Cognitive Abilities Screening Instrument (CASI) Clock drawing test. Blood Tests CT / MRI (doesn't show the disease used to rule out other things) Brain biopsy is the only way to truly know

Late stage AD cognitive and functional impairment stage 2

C: Little cognitive ability, language not clear, change in personality, no longer recognizes family,wanders, repetitive F: Activities of daily living dependent, incontinent, difficulty eating.

Early stage AD cognitive and functional impairment

C: Measurable short term memory loss, difficulty planning, disorientation to location F: Mild instrumental activities of daily living problems.

End stage AD cognitive and functional impairment stage 3

C: No significant cognitive function, no ability to form words F: Non ambulatory, bedridden, unable to eat.

Middle stage AD cognitive and functional impairment stage 1

C: Significant forgetfulness, easy to get lost, inappropriately dress, hallucinations. F: Instrumental activities of daily living dependent with some activities of daily living problems

Extrapyramidal Symptoms (EPS)

Caused by anti-psychotic drugs 1-2 weeks of tx Acute Dystonic Reactions Occur within the first days of treatment Long lasting contractions or spasms of muscles Usually involves eyes, jaw, tongue or neck Painful Treatment - anticholinergic or antihistamine agents such as benztropine (Congentin 1-2mg IM or 1-2 mg PO BID-TID)

What are the factors of early AD

Caused by deterministic genes Presenilin 1 & 2, amyloid precursor protein (APP) and apolioprotein E (ApoE)-allele 4 Affects family members in multiple generations Symptoms develop in 30s, 40s and 50s Occurs in approximately 5-10% of population with Alzheimer's

Secondary dementia

Caused by or R/T another disease or condition Example: HIV, CVA

Cholinergic drugs

Cholinergic: helpful in keeping the ACH going produce actions which stimulate or mimic actions of parasympathetic nervous system Direct acting: mimic actions of acetylcholine Indirect acting (cholinesterase inhibitors) inhibits action of enzyme acetylcholinesterase enzyme acts to destroy acetylcholine

Cholinesterase Inhibitors AD

Cholinesterase inhibitors block degradation of acetylcholine by inhibiting acetylcholinesterase tacrine (Cognex) Caution: client with hepatic dysfunction/not used much due to this donepezil (Aricept) Well tolerated/ used the most Cause peripheral cholinergic effects: N/D, bradycardia, Serious reaction: seizures, respiratory depression Antidote for cholinergic drugs: For adverse affects atropine and other anticholinergic drugs

Symptoms of delirium

Confusion Disorientation Clouding of consciousness Hallucinations are common Decline in cognition Perceptual disturbance

Complementary treatment in AD

DHEA Precursor to androgens and estrogens May improve cognitive function Gingko Biloba Herbal anti-inflammatory and antioxidant Improves cognition, ADL performance, and social behavior (according to research) CO Q10 Antioxidant occurring naturally in the body

List 3 difference between dementia and delirium

Delirium is acute/sudden onset, reversible if you catch underlying cause and treat if not treated can be deadly, and increase hospitalization. Dementia has primary and secondary. Delirium effects the LOC dementia should not.

Types of AD

Early and late

Sympathetic nervous system function

Fight or flight ability to survive situation Adrenergic receptors Neurotransmitter: Norepinephrine & Dopamine Alpha & Beta receptors

Two types of delirium

Hyperactive and hypo active

Symptoms of Stage II AD

Impaired cognition and abstract thinking Restlessness and agitation Wandering, "Sundown syndrome" Inability to carry out ADLs Impaired judgment Inappropriate social behavior Lack of insight, abstract thinking Repetitive behavior Voracious appetite Lasts several years

Primary dementia

Major sign of organic brain disease Not related to other organic illness Un-treatable

Cognition definition and examples

Mental process by which knowledge is acquired and processed including: Reasoning Logic Judgment Memory Awareness Perception Language Learning

What are the factors of late onset (sporadic)

Most common form, no specific gene association Symptoms develop in those over the age of 65 Associated with more risk factors Occurs in 90+% of population with Alzheimer's

AD pathophysiology

Neurofibrillary Tangles Hair like protein fibers tangled tightly together like yarn Inside the neurons Neuritic plaques Made of a protein core called beta - amyloid surrounded by debris from degenerating neurons Outside the neurons near the synapse" Shrinkage and Death of Neurons May be of greater significance than tangles and plaques.

Treatment of AD

No Cure: meds may slow Cognitive & Behavioral Interventions Educate/ emotional support to caregivers PREVENTION: Bilingualism: 4 year delay Live an active life, both mentally and physically Regular moderate consumption of alcohol (beer, wine, or distilled spirits) may reduce risk Medication / prevent onset Control hypertension Mediterranean diet Living with a companion or pet

Treatment of AD

No cure for AD Drugs may be used to help cognitive and behavioral problems, but they DO NOT treat AD or change the course of disease Cholinesterase Inhibitors: enhance cholinergic transmission, stabilizing cognitive symptoms for limited amount of time Anxiety and Depression medication can be discussed for behavioral problems Compensation techniques can be used to help retain ability to perform ADL's Memory aids

What other neurotransmitter abnormalities in AD

Norepinephrine: changes mood, cognition Serotonin: sleep disturbance Dopamine: Cog, pleasure, pain Glutamate: intracellular calcium and Neuron degeneration and cell death. When glutamate is active increases calcium levels.

Two type of dementia

Primary ex: Alzheimer's Secondary: caused by another condition ex: Parkinson's

Parasympathetic nervous system function

Rest and Digest Cholinergic receptors Neurotransmitter: Acetylcholine Para-Slows things down preparing you to fight or flight

Memantine Namenda s/e

SE's: dizziness H/A confusion constipation May take several weeks to see improvement Treats moderate to severe AD

What anti-depressant is used in patient's with AD

SSRI Tricyclics not recommended block action of ACH

Goals of treating AD

Support the function they have left and keeping as long as possible (use it or you lose it)

How is the focus of nursing care differ for clients with dementia vs clients with delirium?

Treating underlying cause vs managing symptoms. Different ways you orient the patient. Delirium you re-orient Alzheimer's you don't Greater risk due to being in hospital setting. Hospitals should have a delirium protocal

Can a client with dementia also experience delirium? Why?

Yes, because of changes in health mentally or physically, like an UTI infection or other disease process, medication toxicity,

Memantine a newer AD drug works by

blocking glutamate an exicitatory neurotransmitter NMDA receptor antagonist: modulates affect of glutamate: helps intracellular calcium to be normalized/ shields brain from overexposure to glutamates toxic effects

When describing Alzheimer's disease to a group of nursing students, which of the following should the nurse identify as the characteristic found in Alzheimer's disease that distinguishes it from other dementias? a. Hypoxic destruction of brain cells b. Hyperkinesis causing choreiform movements c. Neurofibrillary tangles and plaques d. An infectious particle called a prion.

c

Anti-psychotics s/e

can cause Parkinson's like symptoms.

When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? a. Allow the client to go to bed four to five times during the day b. Test the cognitive functioning of the client several times a day. c. Provide reality orientation even if the memory loss is severe d. Maintain consistency in environment, routine and caregivers

d

Acetylcholinesterase (AchE) does and disease effect

enzyme that destroys Ach Inhibiting properties utilized for meds when more Ach is desired

Where are tangles located

in neuron itself

Apraxia define

is a motor disorder caused by damage to the brain (specifically the posterior parietal cortex), in which the individual has difficulty with the motor planning to perform tasks or movements when asked, provided that the request or command is understood and he/she is willing to perform the task

Agnosia

is the inability to process sensory information. Often there is a loss of ability to recognize objects, persons, sounds, shapes, or smells while the specific sense is not defective nor is there any significant memory loss.

What is Alzheimer's Disease

is the most common form of dementia, accounting for 60-80% of dementia cases. AD is a progressive brain disorder that develops slowly and gradually gets worse over time. Throughout disease process, brain cells are damage and destroyed leading to declined brain function causing memory loss and changes in thinking. Brain cells eventually weaken and die

mild cognitive impairment

mild memory loss (recent new info)

Where are plaques located

on the synapse (blocking transmission)

mild functional impairment

possible depressed or anxious

Gamma (GABA): does and disease effect

regulate neuronal excitability, muscle tone/ CNS Meds related : epilepsy control

Norepinephrine does and disease effect

regulates mood, cognition, perception, locomotion, cardiovascular function/ CNS & PNS sympathetic Decreased in Depression Increased in Mania and Anxiety

Sundowning means

symptoms get worse in evening