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Module 6: Understanding the Signs of Dementia

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Defining Alzheimer's Disease

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Understanding Dementia

Defining Alzheimer's Disease

Stages of Alzheimer’s Disease - Early/ Mild

The early stage lasts for two to four years. It is characterized by forgetfulness, increasing difficulty with problem solving and withdrawing from activities.

The early stage of alzheimer’s begins when the symptoms begin to manifest themselves with the individual. If these symptoms are recognized and diagnosed at an early stage, it can save both the individual and their families a lot of time and hardship.

During this stage you can expect the person with alzheimer’s to forget experiences, rather than details (like names), the person may need minor assistance or reminders, but may live alone.

Efforts to hide the confusion are sometimes successful at this early stage.

Stages of Alzheimer’s Disease - Middle/ Moderate

The middle stage is characterized by an increase in memory loss,confusion, shorter attention span, increase in language difficulties and in repetitiveness.

The middle stage lasts for two to ten years. In the middle stage, the confusion is apparent to caregivers. The person may be aware of his/her impairment, but lacks the ability to hide it from others.

There is full loss of executive function (i.e. reasoning or problem solving) and difficulty taking care of self. The person may need help with activities of daily living (ADL’s), such as dressing and bathing. As tasks become more challenging, both physically and cognitively, the person may become delusional, paranoid, and develop associated behavioral changes.

Optimizing physical, mental and social stimulation is key to slowing rate of decline into next stage.

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Constant supervision is needed. The person shows poor judgment needs and cannot live alone for safety reasons.

At this time, patients are often placed in adult day care programs and/or assisted living.

Toward the end of the middle stage the person loses the ability to control bladder and / or bowel function.

Stages of Alzheimer’s Disease – Late/ Severe

The late stage is a time of severe confusion and loss of all functional skills. The person has no awareness of his/her condition and lasts for 1-3 years.

During the late stage of Alzheimer’s the person has loss of self-care ability and loss of language, is incontinent and unable to recognize self or others, and requires more sleep. Other signs include weight loss, despite good diet; possibly swallowing problems, and general failure to thrive.

The individual responds best to sensory activities and cannot be in crowded or noisy environments. Typical for this stage are care in dementia care units/ nursing homes with 24-hour supervision and assistance.

The final stage lasts for one to three years and ends in death.

Severe Alzheimer’s can be quite distressing to witness and ends in death!

Associated Problems with Alzheimer’s Disease – Behaviors

When you work with a client who has been diagnosed with Alzheimer’s Disease (at any stage), it is important to know that their behavior can be unpredictable.

This often a response to discomfort, an unmet need, and increasing confusion. They also reflect an increase in difficulty with communication, progressive loss of independence, and poor insight and judgment.

Key to reducing behavioral disturbances is to identify triggers. These include pain, fatigue, acute illness, sensory deficits, hallucinations and/or delusions.

Behaviors may be psychomotor (pacing, wandering, repeated crying out, etc.), verbal (belligerence, nastiness towards others, repetitiveness) and/or physical (combativeness, often associated with personal care; inappropriate touching).

Careworkers need to be aware of the types of behaviors that can be expected from their clients!

Associated Problems with Alzheimer’s Disease – Emotional or Mood Disturbances

Alzheimer’s patients often experience a strong sense of depression. This may be reflected as irritability, fearfulness, or tearfulness, hopelessness, somatic complaints (i.e. feeling ill physically), lack of energy and/or interest, change in appetite.

They also may experience feelings of anxiety. This includes feelings of nervousness, worry and apprehension. This is more common in early dementia when the client with dementia are aware of their deficits.

Alzheimer’s patients can also experience apathy, a flatness of mood that can occur in later stages. It represents the inability to interact within one’s environment on one’s own.

Figure 1. Alzheimer’s patients often experience anxiety and depression

Associated Problems with Alzheimer’s Disease – Sleep Disturbance/ Delirium

Sleep disturbance occurs in 50% of Alzheimer’s patients living in a community setting. It is one of the most disturbing behaviors for caregivers and can cause exhaustion and despair in caregivers.

Patients may have trouble falling or staying asleep, or with resuming sleep. They may wander, may reverse night and day, appear more confused; and/or may have exacerbation of anxiety, physical or verbal outbursts

Alzheimer’s patients can also delirium a sudden increase in mental confusion, accompanied by hallucinations.

Figure 2. Alzheimer’s patients often need medication to help them sleep

The Treatment of Alzheimer’s Disease and Associated Problems

This section focuses on medications that have been proven to be effective in the treatment of Alzheimer’s. Later discussion will address , non- pharmacological interventions.

Cognitive Changes

Aricept, Exelon, Razadyne: Indicated for mild dementia, used throughout the course of the disease. Side effects are mainly gastro-intestinal (GI) in nature, minimized by giving in morning with food. There may also be vivid dreams or leg cramps.

Namenda: Indicated for moderate dementia, used either alone or together with one of three medications previously noted.

Mood

Antidepressants of the class known as Selective Serotonin Reuptake Inhibitors (SSRI) are generally best tolerated. They address depression and anxiety.

Medications such as tricyclics (for example, Elavil) and benzodiazepines (such as Lorazepam or Valium) should not be used because of the potential for increased confusion and dizziness and the increased risk for falls with potential injury.

Behavior

Atypical antipsychotics (such as Seroquel, Zyprexa, Risperdal) can be helpful, but they carry a concern for side effects . These can include movement disorders, increased confusion, and the potential for increased cardiac complications.

Seizure medications (e.g., Depakote) may be given. Blood serum levels need to be closely monitored.

Pain

It is important to recognize and treat pain. This may require careful attention to body language and behavior, avoid medications like Darvon, percocet, and opioids.

Tylenol, regularly dosed, is a very effective analgesic (pain medication). Consider options such as moist heat, massage, and repositioning.

General Considerations

When treating an Alzheimer’s patient with medication remember that it is administered for the benefit of the patient – not for staff convenience.

The administration of medication should be tailored to the individual. Carers should constantly aiming to identify links between certain behaviors and medications.

Carers should employ strategies that do not require medications, but medications can and should be considered when such strategies are ineffective or not effective enough.

Risks versus benefits should always be taken into consideration.

Figure 3. Always tailor the medication to each specific patient.

General Considerations

Carers also need to remember the importance of limiting the number of medications administered to patients. If they fail to do so, it is difficult to tell what medications patients react to well and what ones they react to poorly.

It is important to provide medication in a slow and infrequent manner because elderly do not tolerate medications as well or in the same way as younger people.

Avoid medications with undesirable side effects, those which can cause more confusion or sedation, or act counter to medications meant to benefit.

Typical side effects to watch for: Nausea , vomiting, change in appetite, diarrhea or constipation, headache, dizziness, postural instability, increased confusion, over sedation.

Figure 4. Always avoid medications with undesirable side effects.

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