Alzheimer’s Disease

• Provide patient and family with preloaded, single-injection syringes of corticosteroid for use in emergencies and instruct when and how to use.

• Advise patient to inform health care providers (eg, dentists) of steroid use.

• Urge patient to wear a medical alert bracelet and to carry information at all times about the need for corticosteroids.

• Teach patient and family signs of excessive or insufficient hormone replacement.

Continuing Care

• If patient cannot return to work and family responsibilities after hospital discharge, refer to home health care nurse to assess the patient’s recovery, monitor hormone replacement, and evaluate stress in the home.

• Assess patient’s and family’s knowledge about medication therapy and dietary modifications.

• Assess patient’s plans for follow-up visits to clinic or physi-cian’s office.

• Remind the patient and family about the importance of par-ticipating in health promotion activities and health screening.

For more information, see Chapter 42 in Smeltzer, S. C., Bare, B.

G., Hinkle, J. L., & Cheever, K. H. (2010). Brunner and Suddarth’s textbook of medical-surgical nursing (12th ed.). Philadelphia:

Lippincott Williams & Wilkins.

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AD can be classified into two types: familial or early-onset AD (which is rare, and accounts for less than 10% of cases) and sporadic or late-onset AD.

Clinical Manifestations

Symptoms are highly variable; some include the following:

• In early disease there is forgetfulness and subtle memory loss, although social skills and behavioral patterns remain intact. Forgetfulness is manifested in many daily actions with progression of the disease (eg, the patient gets lost in a familiar environment or repeats the same stories).

• Conversation becomes difficult, and word-finding difficulties occur.

• Ability to formulate concepts and think abstractly disap-pears.

• Patient may exhibit inappropriate impulsive behavior.

• Personality changes are evident; patient may become depressed, suspicious, paranoid, hostile, and combative.

• Speaking skills deteriorate to nonsense syllables; agitation and physical activity increase.

• Voracious appetite may develop from high activity level;

dysphagia is noted with disease progression.

• Eventually patient requires help with all aspects of daily liv-ing, including toileting because incontinence occurs.

• Terminal stage may last for months or years.

Assessment and Diagnostic Findings

The diagnosis, which is one of exclusion, is confirmed at autopsy, but an accurate clinical diagnosis can be made in about 90% of cases.

• Clinical symptoms are found through health history, includ-ing physical findinclud-ings and results from functional abilities assessments (eg, Mini-Mental Status Examination)

• Electroencephalography (EEG)

• Computed tomography (CT) scan

• Magnetic resonance imaging (MRI)

• Laboratory tests (complete blood cell count, chemistry pro-file, and vitamin B12and thyroid hormone levels) and exam-ination of the cerebrospinal fluid (CSF)

Medical Management

Without a cure or a way to slow progression of AD, treatment relies on managing cognitive symptoms with cholinesterase inhibitors, such as donepezil hydrochloride (Aricept), rivastig-mine tartrate (Exelon), galantarivastig-mine hydrobromide (Razadyne [formerly known as Reminyl]), and tacrine (Cognex). These drugs enhance acetylcholine uptake in the brain to maintain memory skills for a period of time. Donepezil and the newest medication memantine (Namenda) can be used for manage-ment of moderate to severe AD symptoms.

N U R S I N G P R O C E S S

T

HE

P

ATIENT WITH

AD

Assessment

Obtain health history with mental status examination and physical examination, noting symptoms indicating dementia. Report findings to physician. As indicated, assist with diagnostic evaluation, promoting calm environment to maximize patient safety and cooperation.

Nursing Diagnoses

•Impaired thought processes related to decline in cognitive function

•Risk for injury related to decline in cognitive function

•Anxiety related to confused thought processes

•Imbalanced nutrition: less than body requirements related to cognitive decline

•Activity intolerance related to imbalance in activity/rest pattern

•Deficient self-care, bathing/hygiene, feeding, toileting related to cognitive decline

•Impaired social interaction related to cognitive decline

•Deficient knowledge of family/caregiver related to care for patient as cognitive function declines

•Ineffective family processes related to decline in patient’s cognitive function

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Planning and Goals

Goals for the patient may include supporting cognitive function, physical safety, reduced anxiety and agitation, adequate nutrition, improved communication, activity tol-erance, self-care, socialization, and support and education of caregivers.

Nursing Interventions Supporting Cognitive Function

•Provide a calm, predictable environment to minimize con-fusion and disorientation.

•Help patient feel a sense of security with a quiet, pleasant manner; clear, simple explanations; and use of memory aids and cues.

Promoting Physical Safety

•Provide a safe environment (whether at home or in the hospital) to allow patient to move about as freely as possi-ble and relieve family’s worry about safety.

•Prevent falls and other accidents by removing obvious hazards and providing adequate lighting; install handrails in the home.

•Prohibit driving.

•Allow smoking only with supervision.

•Reduce wandering behavior with gentle persuasion and distraction. Supervise all activities outside the home to protect patient. As needed, secure doors leading from the house. Ensure that patient wears an identification bracelet or neck chain.

•Avoid restraints because they may increase agitation.

Promoting Independence in Self-Care Activities

•Simplify daily activities into short achievable steps so that patient feels a sense of accomplishment.

•Maintain patient’s personal dignity and autonomy.

•Encourage patient to make choices when appropriate and to participate in self-care activities as much as possible.

Reducing Anxiety and Agitation

•Provide emotional support to reinforce a positive self-image.

•When skill losses occur, adjust goals to fit patient’s declin-ing ability and structure activities to help prevent agitation.

•Keep the environment simple, familiar, and noise-free;

limit changes.

•Remain calm and unhurried, particularly if the patient is experiencing a combative, agitated state known as

catastrophic reaction (overreaction to excessive stimulation).

Improving Communication

•Reduce noises and distractions.

•Use easy-to-understand sentences to convey messages.

Providing for Socialization and Intimacy Needs

•Encourage visits, letters, and phone calls (visits should be brief and nonstressful, with one or two visitors at a time).

•Encourage patient to participate in simple activities or hobbies.

•Advise that the nonjudgmental friendliness of a pet can provide satisfying activity and an outlet for energy.

•Encourage spouse to talk about any sexual concerns and suggest sexual counseling if necessary.

Promoting Adequate Nutrition

•Keep mealtimes simple and calm; avoid confrontations.

•Cut food into small pieces to prevent choking, and con-vert liquids to gelatin to ease swallowing. Offer one dish at a time.

•Prevent burns by serving typically hot food and beverages warm.

Balancing Activity and Rest

•Offer music, warm milk, or a back rub to help patient relax and fall asleep.

•To enhance nighttime sleep, provide sufficient opportuni-ties for daytime exercise. Discourage long periods of day-time sleeping.

•Assess and address any unmet underlying physical or psy-chological needs that may prompt wandering or other inappropriate behavior.

Supporting Home- and Community-Based Care

•Be sensitive to the highly emotional issues that the family is confronting.

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