Alzheimer's and Vascular Dementia - 2 Contact Hours
This course is approved through the California Board of Registered Nursing Provider #CEP 13509.
- Types of Dementia
- Risk Factors
- Non-Drug Interventions to Reduce Behavior Problems
- Behavior Analysis
- Drug Treatment
- Drug Therapy for Behavioral, Psychological & Emotional Symptoms
- Complications of Dementia
- Advanced Care Planning
- Impact of Alzheimer's Disease on Caregiver
- Case Study
≥92% of participants will be able to explain the differences between Alzheimer’s Dementia and vascular dementia.
After completing this educational activity, the learner will be able to complete the following objectives:
Explain the difference between Alzheimer's disease and Dementia.
Differentiate early, middle and late findings associated with dementia in the assessment of the patient.
Identify three causes of reversible dementia.
Incorporate three non-drug interventions for a dementia patient who develops behavioral problems.
Outline the risk and benefits of drugs used to treat behavioral disturbances in dementia.
Relate the challenges in caregiving of a dementia patient.
Dementia is a chronic or progressive syndrome caused by various brain illnesses that affect behavior, memory, thinking, and the ability to perform everyday activities. It is not a single disease but a condition characterized by a permanent decrease in intellectual functioning. Dementia is not only a decrease in memory but exhibits problems with language, judgment, problem-solving, and comprehension. Many conditions lead to dementia,
According to the Alzheimer's Association (2021), it is estimated that 6.2 million Americans live with Alzheimer's dementia in 2021. Other significant findings include:
11.3% aged 65 and older have Alzheimer's dementia.
- Two-thirds of Americans over age 65 with Alzheimer's dementia (3.8 million) are women.
- During the COVID-19 pandemic, deaths from Alzheimer's increased by 16% in 2020 alone (Alzheimer's Association, 2021).
The Center for Disease Control and Prevention (2021) reports that one in three elders will die from Alzheimer's or another form of dementia. It also is a leading cause of disability and poor health. It is the 6th leading cause of death in the US. Alzheimer's is the only top 10 cause of death in the US that cannot be prevented or cured.
Alzheimer's places a significant burden on the health care system, with annual costs exceeding a quarter of a trillion dollars. The cost of care for people with Alzheimer's and other dementias is expected to increase to more than 1.1 trillion in 2050 (Alzheimer's Association, 2021, para. 3).
Dementia is caused by an alternation in the brain's structure, including a decrease in the chemicals in the brain and destruction of nerves vital to cognitive function. Amyloid, a starch-like product, is deposited abnormally in the brain in Alzheimer's and is responsible for many of the signs and symptoms. Amyloid plaques develop in areas of the brain used for memory and other cognitive functions.
Acetylcholine, a chemical produced by the nerves in the brain, is associated with the transmission of impulses between nerve cells and allows proper brain functioning. Dementia is associated with a decline in the amount of acetylcholine, which results in a decreased ability of the body to transmit impulses between brain cells.
Another characteristic change is neurofibrillary tangles. Neurofibrillary tangles are an abnormal growth of nerves that kill the normal function of cells and result in a malfunction of the brain.
Types of Dementia
- Vascular dementia
- Lewy body dementia
- Parkinson's disease dementia
- Frontotemporal dementia
- Mixed dementia
Dementia symptoms due to normal pressure hydrocephalus, toxic substances such as alcohol, infection such as AIDS, brain tumor, Parkinson's disease
- Progressive supranuclear palsy
- Creutzfeldt-Jakob disease (mad cow disease)
- Subdural hematoma
Reversible causes: hypothyroidism, B12 deficiency, depression
- In the most common form of dementia, Alzheimer's, Tau tangles contribute to poor connectivity between nerve cells, causing a loss of memory in Alzheimer's dementia. Due to the insidious development of the tau tangles,
Alzheimer's has a gradual onsetthat ultimately impacts the hippocampus, where the ability to think, recall events (memory), and language are housed (Tong et al., 2018).
Figure 1: Hippocampus Functions
While drugs and supplements have hinted at their ability to prevent dementing illness, limited data suggest effectiveness. Cholinesterase inhibitors do not reduce progression rates from memory impairment to dementia.
Many risk factors are associated with dementia; age is the most dramatic. While age is not synonymous with dementia, the incidence of dementia is significantly higher as one ages. The disease is seen more frequently in people 65 years of age and older, although it may affect people in their 30s, 40s, and 50s (Healthline, 2021). Females are at greater risk than males. Another risk factor is having a family history of dementia in a parent or sibling. A history of head injury puts one at risk for dementia. Poor control of many chronic diseases, including congestive heart failure and lung disease, can make dementia worse. Risk factors typically associated with vascular disease, high blood pressure, diabetes, and high cholesterol, are associated with an increased risk of vascular dementia and Alzheimer's.
According to the Alzheimer's Association (2021), early research indicates that COVID-19 infection accelerates Alzheimer's-related symptoms and pathology by increasing neuroinflammatory biomarkers (total tau or t-tau, glial fibrillary acid protein or GFRAP) and decreasing oxygenation to the brain. Although this early research cannot be translated to other viruses, it does indicate that further research should be done investigating the impact of virus infections on long-term brain health.
Depending on the exact cause of dementia, the presenting signs and symptoms may vary.
It is at times difficult to differentiate between normal aging and dementia. Normal aging is characterized by slowness in the retrieval of information.
Misusing words, difficulty finding the right word, or general words to describe a specific item is a trait of dementia. A demented person uses the word "thing" to describe many items. Personality changes, making poor decisions, and mood swings are common symptoms of early dementia. Increased confusion at night, also known as sun-downing, is a common feature of early dementia.
Patients with early dementia can compensate well when they are in familiar environments. Problems are often first noticed when one gets out of their routine such as going on vacation or entering the hospital. Patients often become very anxious, depressed, scared, or have emotionally liable moods. These moods are often the direct results of the patient being aware of progressive dementia.
As the disease progresses, the patient has difficulty carrying out tasks of daily living such as bathing, handling finances, grooming, dressing, and preparing meals. This is when independence is significantly impaired, and patients will need to adjust to their living environment. During this middle (moderate) stage of progression, the patient may struggle with incontinence, become combative or resistant to help and physical care, and have an increased potential for wandering away from home.
Those with advanced (severe) dementia are dependent on others for care. They have very limited memory and usually are not oriented to place, time, and often name. Patients with advanced dementia may not know the name of their spouses or children.
Loss of the swallowing reflex is a common complication of advanced dementia, which leads to medical complications such as malnutrition and aspiration pneumonia. It has not been found that feeding tubes reduce the rates of aspiration pneumonia in the demented patient.
Malnutrition decreases the ability to fight off infection and increases the risk of death from infection. Loss of the swallowing reflex increases the risk of dehydration. Patients with advanced dementia have more seizures.
Behavioral changes are more common as dementia advances. With the patient going from calm and pleasant to entirely out of control within minutes, mood swings can occur. Personality changes are seen in dementia, with the demented patient showing an increased incidence of irritability, suspiciousness, and fearfulness. Hallucinations and delusions are hallmarks of advancing dementia.
Clinical history and exams can help differentiate between some of the different types of dementia. Alzheimer's is the most common dementia and the most likely diagnosis when dementia presents. Some salient features of Alzheimer's include early memory loss with cognitive impairment and at least one other area deficit such as language dysfunction, agnosia, apraxia, visuospatial disorder, and executive dysfunction. It typically has an insidious onset and a progressive course. A storage deficit highlights memory impairment; patients cannot recall something with a clue. For example, when performing the mini-mental status exam (MMSE) and the patient is asked to recall three items after five minutes, the patient will not be able to recall them even after being given a clue. As the disease progresses, long-term memory becomes impaired. Later changes also include seizures, apathy, aggression, wandering, agitation, depression, and anxiety.
Vascular dementia can have either an abrupt or insidious onset, and the progression can be stepwise, fluctuating, or a continuous decline. Patients with vascular dementia typically have cardiovascular risk factors such as hypertension, hyperlipidemia, and diabetes. Focal neurological deficits (e.g., speech, hearing, or vision problems) are common in those with vascular dementia. Memory impairment is not as pronounced in the early stage, whereas executive function (concentration, decision making, and higher-order problem solving) is impaired early.
DLB accounts for 10-15% of cases (National Institute on Aging, 2022). DLB typically presents with memory loss, early impairment of executive function, more problems in attention, visuospatial function, and constructional abilities compared to AD, and more autonomic involvement. Patients typically have recurrent visual hallucinations. There are often repeated falls and occasional syncope.
The National Institute on Aging (2022) explains that frontotemporal dementia (FTD) is characterized by a shrinking of the brain's frontal and temporal anterior lobes and often presents with personality and behavioral changes over memory loss, at least early on. This disease runs in families. Symptoms of FTD fall into three clinical patterns that involve changes in behavior and problems with language and movement disorders. Patients are typically impulsive, act socially unacceptable, are disinhibited, lack insight, and are agitated or socially withdrawn. Those with language disturbance have difficulty speaking or understanding speech. Frontotemporal dementia occurs at a younger age than Alzheimer's, typically between 45 and 65.
Figure 2: Frontotemporal Disorders
The need to evaluate dementia can be picked up during a routine examination, patient or family concern, or routine screening. The workup includes performing a mental status examination. Standardized tests can be used to document mental decline, monitor decline, and help make the diagnosis. Mental status examinations test the patient's memory and intellectual function. These tests look for memory impairment, language disturbance, ability to carry out purposeful movements, and ability to recognize objects. Mental status exams ask the patient to report the date and location, recall lists of items, write sentences, follow written commands, name objects, and copy diagrams.
Scores on the MMSE range from 0 to 30, with scores of 25 or higher being traditionally considered normal. Scores less than ten generally indicate severe impairment, while scores between 11 and 20 indicate moderate dementia. Those with Alzheimer's have, on average, a decline in the MMSE score. The MMSE of 3-4 points per year occurs if they go untreated. It is important to note that one needs an IQ of about 90 to get a normal score on the MMSE (Rosenzweig, 2020).
The MMSE takes about 10 minutes to complete. It measures aspects of cognition that include orientation, word recall, attention and calculation, language abilities, and visual construction. Scores may need to be adjusted or interpreted differently to account for a person's age, educational level, and ethnicity/race.
Other testing is often employed. Early changes in mental decline are often not picked up on the MMSE. If the spouse or caregiver notices changes and the MMSE is normal, more sensitive testing may need to be utilized. If the diagnosis is in doubt, more extensive testing, known as neuropsychological testing, typically done by a specialist, is performed.
Neuropsychological testing is a more comprehensive method for the evaluation of mental status. Testing is done by a neurologist, psychiatrist, or psychologist. It looks at higher cognitive functions, including but not limited to abstract, logical, and conceptual reasoning, visuospatial orientation, memory, verbal fluency, and reasoning. The test identifies cognitive impairment in patients with higher baseline cognitive abilities and determines if dementia is present in its milder stages. It is more sensitive than other types of testing and can differentiate between mild cognitive impairment and dementia. The test is helpful for those who do not speak English as their native language and those with limited education. It also can help pick up anxiety and depression.
The workup of dementia rules out other causes of mental decline and consists of imaging and laboratory evaluation.
Many patients with dementia undergo an imaging examination to rule out other disease causes. Its ability to identify a reversible cause of dementia is low. Still, non-contrast computed tomography or magnetic resonance imaging is recommended for the initial evaluation of a patient with dementia. Neuroimaging in dementia is most likely helpful in a 61-year-old woman with an MMSE score of 20 and a history of breast cancer. Imaging can rule out brain tumors, subdural hematomas, stroke, or normal-pressure hydrocephalus. Those who are younger than 60, had recent head trauma, a history of cancer, gait disturbance, urinary incontinence, localized neurologic signs or symptoms, or those with a rapid or atypical course of dementia have the greatest chance of having a diagnostic yield from imaging studies. The only way to confirm the diagnosis is to perform a brain biopsy, which is rarely done or necessary.
More advanced testing includes photon emission tomography (PET) scans or single-photon emission computed tomography (SPECT) scans. These tests are not routinely done but are often done in research settings to help distinguish between different types of dementia. Current guidelines do not recommend their routine use.
Non-Drug Interventions to Reduce Behavior Problems
- Frequently orienting the patient to their surroundings, including time and place, aids the demented individual with confusion.
- Helping the patient remember the past with reminiscing and pictures.
- Providing sensory stimulation, including touch/massage and aromatherapy.
- Maintaining an active social life.
- Scheduled toileting and prompted voiding help patients suffering from urinary incontinence to maintain their continence.
- Regular toileting schedule.
Demented patients thrive in familiar environments. Providing consistency and structure is an essential step in managing dementia. Maintaining a routine schedule preserves orientation and allows them to function on a higher level. Keeping all items such as clothes, shoes, drugs, and furniture in the same place is one suggestion. Keep a large calendar in the home with important dates such as birthdays and doctor appointments visible. Keeping important phone numbers in plain view to be easily found reduces frustration. Labeling drawers and cabinets will help with orientation.
The holidays are particularly challenging for demented patients because parties, interrupted time schedules, and decorating lead to significant confusion. Decorating just one room of the house with holiday decorations and not allowing anyone with dementia to go in the room may help.
Keeping the patient with dementia safe becomes more important as the disease progresses. Keep instructions simple; minimize instructions to less than five words. Setting up a safe and pleasant environment is essential. Lighting needs to be bright to prevent falls; nightlights are helpful. Remove sharp objects from home or put them in a locked area to prevent the demented patient from harm. Occupational therapists provide home evaluations to assure safety measures to keep the demented patient safe. Cleaning services reduce clutter in the home, which reduces falls. Place identification tags, carried in many pharmacies, on the patient if they get lost. Alarms can be placed at the home's exits to prevent the patient from wandering off.
Simplifying tasks, developing routines, and providing proper rest reduce behavior problems. Structured games and activities minimize behavior problems. Re-assuring an upset patient, repeating instructions as needed, and redirecting the agitated person reduces agitation. Sensory deprivation exacerbates the disease process and assures that they can see (glasses on) and hear (hearing aids in) helps reduce behavioral problems.
Problem behaviors can trouble not only patients but caregivers. Paranoia, aggressiveness, and anxiety are more commonly a problem that leads to nursing home placement than memory loss. Analysis of behavior is another strategy that may be helpful for problem behaviors.
Behavior analysis is helpful in determining triggers that agitate the person or make them more confused. It should be the first step employed when behavior problems are encountered. Rather than using drugs if the patient is upset, try to understand why they might be agitated. Perhaps they need to use the bathroom, are in pain, or think they have lost something. Note what happens before the behavior, try something different the next time, and track the results (Heerema, 2021). Identify a particular behavior and note what seems to trigger the behavior. For example, if a shower always makes the patient agitated, try a bath instead. Or attempt to offer a shower at a different time of day. Controlling situations that agitate the patient or increase confusion can go a long way in making the disease more manageable.
Loved ones of patients with dementia can use a simple behavior chart to help understand what triggers behavior problems. Recording activities, drugs, the people present, and the corresponding behaviors identify patterns to help loved ones understand what agitates the patient. The behavior chart does not need to be filled out every day, but it should be filled out if there is a behavior change, a few days before a doctor's appointment, or after a drug change.
A behavior chart can be made at home and consists of up to six columns. The first column is where the time is recorded. The next column is where the patient's activity is recorded at that given time. Examples of activities include sleeping, talking on the phone (and with whom), interacting with people, watching television (be specific about which show), eating, or shopping. The next column is to record the people who are around. Certain people can make patients much more irritable, and filling out this column may reveal specific people that increase agitation. The next column is a place to record when drugs for dementia are taken. Behavior charts may demonstrate a pattern such as behaviors being much worse 6 hours after taking the medication prescribed for behavior control. These patterns are essential to recognize as they can affect how doctors prescribe drugs. The last column is a place for any miscellaneous comments.
|7:00||Waking Up||Hitting and yelling||daughter||none||Mom had to go to the bathroom|
Advances in pharmacology may prolong cognitive function in patients with dementia.
Class 1: Monoclonal antibodies
Aducanumab (Aduhelm®) is a monoclonal antibody that delays cognitive decline by binding to aggregated soluble and insoluble amyloid-beta, thus reducing amyloid-beta plaques in the brain. It is FDA approved for Alzheimer's disease treatment in mild cognitive impairment or mild dementia administered intravenously. Since this medication was FDA-approved under accelerated approval, continued FDA approval is contingent upon ongoing clinical benefits (Biogen, 2021).
Class 1: Cholinesterase Inhibitors
Class 1: Cholinesterase Inhibitors act by preventing the breakdown of acetylcholine in the brain.
Researchers estimate that for about 50 percent of people with Alzheimer's who take cholinesterase inhibitors, the progression of Alzheimer's symptoms is delayed for an average of six to 12 months (Heerema, 2021).
There are three cholinesterase inhibitor drugs currently approved and prescribed to treat Alzheimer's (Heerema, 2021):
- donepezil: Approved for mild, moderate, and severe Alzheimer's
- rivastigmine: Approved for mild to moderate Alzheimer's
- galantamine: Approved for mild to moderate Alzheimer's
The first drug developed, tacrine (Cognex®), is no longer available. Its dosing schedule is inconvenient (four times a day), and it has an adverse side effect profile, including hepatotoxicity, nausea, and diarrhea.
Donepezil (Aricept®), a drug dosed once a day, has decreased memory loss and functional decline. It is indicated for mild, moderate, and severe dementia. Side effects include nausea, nightmares, headache, dizziness, vomiting, and diarrhea. Less commonly, bradycardia and syncope can occur. Side effects are more common when this drug is started and dissipates as the body gets used to the drug (Lexicomp, 2018; Stahl et al., 2017).
Rivastigmine (Exelon®), another medicine in the same class, may improve memory, functional impairment, and behaviors. It is approved for mild to moderate dementia and Parkinson's disease dementia. Rivastigmine acts on slightly different chemical compounds in the brain, but most studies suggest it is no more beneficial than any other cholinesterase inhibitor. It acts on both acetyl and butyrylcholinesterase and has a short half-life. The dose needs to be titrated to reach maximal effect.
Rivastigmine is beneficial for those with mild to moderate dementia. It slows down the decline of cognitive function and reduces the rate of decline in the ability to perform activities of daily living.
Rivastigmine has more GI side effects than donepezil, with weight loss being one significant problem. Other side effects include nausea, vomiting, diarrhea, anorexia, dizziness, and headache. Interestingly the addition of memantine (Namenda) to rivastigmine significantly lowered the incidence of nausea and vomiting. Rivastigmine is now available as a transdermal patch. The low dose patch is associated with fewer side effects than the oral form or the high dose patch (Lexicomp, 2018; Stahl et al., 2017).
Galantamine (Razadyne) is another drug in this class with similar efficacy and benefits. It also acts on acetylcholinesterase and butyrylcholinesterase. In addition, it acts on the nicotinic receptor sites. This drug also needs to be titrated and is associated with gastrointestinal side effects such as GI upset, weight loss, and anorexia (Lexicomp, 2018; Stahl et al., 2017).
These are not miracle drugs and are not effective for all individuals. Many experts feel that these drugs are not beneficial except in a small subgroup of patients. Limited data is available on the efficacy of these drugs on other types of dementia, such as vascular dementia or dementia with Lewy bodies. Since there are no other drugs approved for these conditions and considering some similar pathology, they are often used off-label to improve cognition.
While there is some evidence that these drugs work, the evidence is not overwhelming. Given that fact, few other options are often used. When used, patients must be given reasonable advice on what to expect.
Class 2: N-Methyl D-Aspartate (NMDA) Antagonists
Other medicines suggested for treating dementia include non-steroidal anti-inflammatory drugs, vitamin E, estrogen, and ginkgo biloba. Caution must be exercised with these drugs as they have not been rigorously studied and are not approved for dementia.
Non-steroidal anti-inflammatory drugs include ibuprofen (Advil®, Motrin®), celecoxib (Celebrex®), and naproxen (Aleve®). They are postulated to benefit patients with Alzheimer's, but research does not convincingly back up that claim (NCCIH, 2020). Theoretically, they slow down neuro-degeneration as they reduce inflammation in the brain, which is associated with the development of neurotic plaques. Some data shows these drugs reduce the incidence of dementia, but there is some question of bias in these studies. Therefore it is not recommended as an agent to prevent dementia. Due to its theoretical benefit, scientists are still hoping that further research will prove it is a therapeutic strategy for Alzheimer's.
Free radicals can damage nerves in the brain. They are the by-products of oxidative metabolism, and some evidence suggests that vitamin E, selegiline, and ginkgo biloba may be protective against this process. Vitamin E, at doses of 1000 IU two times a day, may be slightly beneficial in patients with Alzheimer's as it may delay the need for patients with Alzheimer's to need placement in long-term care. Caution must be used with Vitamin E because it increases the risk for bleeding, especially concerning if on blood thinners.
Studies do not support the benefit of vitamin E in treating Alzheimer's. Vitamin E may help maintain cognition in some people with Alzheimer's. In others, vitamin E has a negative effect on cognition. Based on current medical science, it is impossible to determine who will be responders and non-responders (NCCIH, 2020).
Ginkgo biloba is an herbal product with multiple uses, including depression, anxiety, ringing in the ears, confusion, headaches, and memory problems. One of its biggest uses is for memory conditions. Ginkgo biloba, an herbal preparation, showed mild effectiveness on the cognitive deficit in Alzheimer's. More studies are needed to prove its effectiveness in preventing and treating dementia. Risks associated with ginkgo include bleeding and seizures. Use caution with the simultaneous use of any blood thinners.
Estrogen has antioxidant and anti-inflammatory properties that are likely associated with their benefit in dementia. It also has positive effects on nerves in the brain and acetylcholine concentrations. Science does not have enough clinical data to make conclusions about the efficacy of estrogen in the treatment and prevention of dementia and Alzheimer's. Given the current data and the risks of side effects (increased cardiovascular risk, blood clot formation, and death rates), estrogen is not recommended as a treatment modality to improve cognitive function or prevent cognitive decline in women older than 65.
Drug Therapy for Behavioral, Psychological & Emotional Symptoms
Psychotropics are typically used in conjunction with other non-drug approaches or after attempting non-drug therapies and finding them inadequate. They are used at times to treat the behavioral, psychological, and emotional symptoms of Alzheimer's. These symptoms can include emotional distress, depression, anxiety, insomnia, hallucinations, paranoia, and some challenging behaviors, so it is essential to be proactive in identifying and treating them (Heerema, 2021).
The class of psychotropic drugs is antidepressants, anti-anxiety medications, antipsychotics, mood stabilizers, and drugs for insomnia (Heerema, 2021). These drugs can be effective but can also potentially cause significant side effects.
Treatment of depression is necessary because it improves mental function, lessens confusion, and improves dementia. Depression can be a vexing problem that is difficult to uncover in dementia.
Tricyclic antidepressants are not recommended in this population as there is the potential for increased confusion, urinary retention, constipation, blurred vision, sedation, and increased agitation (Lexicomp, 2018; Stahl et al., 2017).
Anti-anxiety medicines, such as lorazepam (Ativan®) or alprazolam (Xanax®), reduce anxiety and related behavior problems. However,
Acute psychotic crises can arise and may require hospitalization. An intramuscular antipsychotic drug such as haloperidol in a dose of 5-10 mg often calms an acute psychosis. After the acute episode, a lower maintenance dose may be needed to prevent another crisis.
While these drugs are widely used for those with dementia and behavioral disturbances, they need to be used with extreme caution. They are not approved for psychosis in dementia.
The degree of symptoms may predict how well antipsychotic drugs work. Those with more severe behavioral disturbances in nursing home residents respond better to antipsychotic medications. The response to medication may be most effective in those most profoundly affected by agitation and aggression without psychosis.
As dementia progresses, there is often a decrease in the severity and frequency of behavioral disturbances. Therefore, it is wise to try to taper or discontinue antipsychotic drugs after 2-8 months of treatment.
Sleep problems are a common complication of dementia.
Complications of Dementia
Dementia is a progressive disease that has the potential to cause many problems as it advances. Dysphagia is typically a later disease concern. Aspiration is a significant problem in those who develop dysphagia. A speech therapist can perform a swallowing study and make recommendations to decrease the risk of aspiration. Some possible interventions include:
- Alternating the consistency of food
- Cutting food into smaller pieces
- Changing the position of the client when they swallow
- Encouraging the client to tuck the chin while swallowing
- Eating with someone who can monitor for aspiration and provide clues for swallowing
The use of feeding tubes has fallen out of favor over the last number of years as they have not proven to extend life expectancy nor improve quality of life. They can be utilized if aspiration is severe or the patient does not eat enough to maintain nutrition. It is wanted by the patient and durable power of attorney of health care. Feeding tubes do not prevent malnutrition, reduce the incidence of aspiration pneumonia, improve function, or extend life. If permanent feeding tube replacement is desired, a percutaneous gastrostomy is better than a nasogastric tube. Consideration must be given to the quality of life and complications when deciding on a feeding tube. Hand-feeding is an alternative to feeding tubes, and it may provide more comfort to the patient.
Those with dementia are typically older, and older age comes with a greater risk of many chronic diseases. Having dementia makes it more likely that proper treatment will not ensue. For example, those with a heart attack may not be able to communicate the pain they are feeling due to dementia, resulting in delayed care and worse outcomes.
Poor nutrition is another common complication of dementia. Poor nutrition increases the risk of infection and poor body healing. The combination of older age, poor communication, and a compromised immune system put the demented individual at high risk for poor outcomes.
Advanced Care Planning
Dementia is a progressive disease that eventually robs one of their memories. Before memory fails, it is paramount to make medical wishes known. Advanced care planning helps communicate patients' wishes with their medical providers and loved ones. Making life and death decisions can be uncomfortable but making these wishes known will ensure advance directives are carried out.
Impact of Alzheimer's Disease on Caregiver
Eighty-three percent of the help provided to older adults in the United States comes from family members, friends, or other unpaid caregivers. Nearly half of all caregivers who help older adults do so for someone with Alzheimer's or another dementia (CDC, 2019).
- About one in three caregivers (34 percent) is 65 or older.
- Approximately 60% of caregivers are women.
- Approximately one-quarter of dementia caregivers are "sandwich generation" caregivers, meaning that they are not only for an aging parent but also for children under the age of 18.
- Approximately 40% of caregivers report feelings of depression, and 60% of them rate caregiving as stressful (CDC, 2019, para. 9).
Primary and secondary caregivers often become sick themselves due to the additional stress. This is especially true as the care recipient starts to need more supervision or becomes more unpredictable and possibly violent with frequent hallucinations. Compared with caregivers of people without dementia, twice as many caregivers of those with dementia indicate substantial emotional, financial, and physical difficulties (Heerema, 2021).
Of the total lifetime cost of caring for someone with dementia, 70 percent is borne by families, either through out-of-pocket health and long-term care expenses or from the value of unpaid care (Heerema, 2021). Caregiver challenges include:
- Coordinating care and Monitoring care are received, results of treatments, social service assistance, and changes in a parent or loved one.
- Dealing effectively with family and disagreements with siblings and significant others.
- Assisting with ADLs as needed and providing outside help as warranted.
- Works with community agencies
The caregiver may experience emotional stress, depression, a decline in health (e.g., impaired immune system, illness, etc.), financial stress due to job disruptions, and loss of savings due to financial instability. People who are long-distance caregivers live an hour or more from their care recipient. Psychological stress and emotional distress often occur. Frustration develops when the caregiver is not readily present and available to deal effectively with emergencies. The caregiver may harbor feelings of regret or remorse owing to self-assessments that distance has restricted their caregiving capacity (CDC, 2019).
Long-distance primary caregivers have significantly higher annual out-of-pocket expenses for care-related costs than local caregivers. These expenses include travel costs, telephone bills, paying for hired help, and other expenses associated with providing for the care recipient's safety, daily needs, and emergency needs.
Includes a structured program providing information about the disease
Provides a list of resources and services.
Gives information on how to expand skills to effectively respond to symptoms of the disease (i.e., behavioral symptoms, cognitive impairment, care-related needs).
Includes lectures by professionals with specialized training, discussions, and up-to-date written material.
Focuses on building support among participants in a stress-free environment where problems, successes, and feelings related to caregiving can be discussed.
Groups may be professionally or peer-led in which group members realize they have similar concerns and challenges. Ideas and strategies, and resources can be shared.
Relationship between a trained therapist and caregiver is developed. The therapist educates the caregiver in self-monitoring skills, challenges negative thoughts and assumptions, helps the caregiver develop problem-solving abilities, works on time management techniques, identifies overload, manages emotions, and helps to re-develop positive experiences.
Merry is a well-educated long-distance caregiver who lives 3 hours away from her mother. She is the primary caregiver. Her mother still is independent and takes care of her activities of daily living. She does not drive because she gets lost or forgets where she is going. She is showing signs of Alzheimer's. Merry schedules her mother's doctor appointments and goes with her to ensure that her mother is on the right drugs and reports any side effects she has noticed. Merry takes her mother shopping, takes her to exercise classes, helps clean her apartment, and makes sure her mother can still pay her bills. On her days off, Merry plans activities to keep her mother interested in her surroundings and takes her to visit her friends, out to eat, and to the movies.
Merry is aware that she sometimes needs help from her sister, who is the secondary caregiver and lives at least six hours from her mother. Her sister relieves Merry and stays with her mother, taking her to her hair appointment, shopping, area holiday events, and helping clean her apartment. When their mother cannot make decisions about her care, they both listen to what their mother thinks she needs and responds appropriately.
Merry is constantly challenged to obtain accurate information about her mother's condition from local caregivers or close neighbors when working from a distance. Merry's sister fails to keep her commitments to help.
This additional stress causes Merry's employment to suffer. More time is needed off when having to be the primary caregiver. Merry had to cut back on her working hours and turned down a promotion. Merry finally chose early retirement to avoid being fired.
Merry moved in with her mother and sought local part-time employment. The distance from her friends and the monopoly of her time caring for her mother causes Merry to be socially isolated and depressed.
What started as a good plan did not work out over time. Realistic planning can improve Merry's quality of life. Moving her mother into Merry's home or assisted living would have had a better outcome. However, giving up independence and change is difficult, particularly for people with dementia.
Dementia is a devastating disease that affects the mind and the body. Current medical science does not have a cure for the disease, but there are many treatment options. Treatment should always focus on non-pharmacological interventions with sparing the use of drugs to improve the quality of life. More research is needed to find a cure and prevent this devastating disease. Support programs are available, and more will be needed as our population ages and dementia becomes more prolific. Nurses and other healthcare professionals need to understand the disease and how to help patients and families cope with dementia.
- Alzheimer's Association. (n.d.). Food and eating. Alzheimer's Disease and Dementia. Retrieved February 7, 2022. Visit Source.
- Alzheimer's Association. (2021). New alzheimer's association report examines racial and ethnic attitudes on alzheimer's and dementia. Alzheimer's Disease and Dementia. Retrieved February 7, 2022. Visit Source.
- Bartels C., Belz, M., Vogelgsang, J., Hessman, P., Bohlen., J., Wiltfang, J., & Kostev, K. (20202). To Be Continued? Long-Term Treatment Effects of Antidepressant Drug Classes and Individual Antidepressants on the Risk of Developing Dementia: A german Case-Control Study. J.Clin Psychiatry. Visit Source.
- Biogen. (2021). Aducanumab (Aduhelm). Highlights of prescribing information. Retrieved February 7, 2022. Visit Source.
- Centers for Disease Control and Prevention. (2022, January 13). FASTSTATS - leading causes of death. Centers for Disease Control and Prevention. Retrieved February 7, 2022. Visit Source.
- Healthline (2021) 11 Early Signs of Dementia. Retrieved April 25, 2022. Visit Source.
- Heerema, E. (2021, October 2). Alzheimer's disease treatment. Verywell Health. Retrieved February 7, 2022. Visit Source.
- Lexicomp. (2018). Drug information handbook for Advanced Practice Nursing (17th ed.). Wolters Kluwer.
- Rosenzweig, A. (2020, July 31). Screening tests used for Alzheimer's and other Dementias. Verywell Health. Retrieved February 2, 2022. Visit Source.
- Stahl, S. M., Grady, M. M., & Muntner, N. (2018). Stahl's essential psychopharmacology: Prescriber's Guide. Cambridge University Press.
- Tong, B. C., Wu, A. J., Li, M., & Cheung, K. H. (2018). Calcium signaling in Alzheimer's disease & therapies. Biochimica et biophysica acta. Molecular cell research, 1865(11 Pt B), 1745–1760. Visit Source.
- U.S. Department of Health and Human Services. (2020, November). Dietary supplements and cognitive function, dementia, and alzheimer's disease. National Center for Complementary and Integrative Health (NCCIH). Retrieved February 7, 2022. Visit Source.
- U.S. Department of Health and Human Services. (n.d.). What are frontotemporal disorders? causes, symptoms, and treatment. National Institute on Aging (NIA). Retrieved February 7, 2022. Visit Source.