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Alzheimei's Bisease

What it is anu Bow it's Tieateu



Lor|e kes|er
12]10]2009




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Dementia is an umbrella term that includes many cognitive loss conditions. t is not
a normal part of aging, it is a disease. Dementia is characterized by the loss of memory
and other cognitive abilities and is caused various diseases and/or conditions that result
in damaged brain cells. To be classified as Dementia, the following criteria must be
met:
O t must include decline in memory and at least one of the following cognitive abilities:
1) Ability to generate coherent speech or understand spoken or written language;
2) Ability to recognize or identify objects, assuming intact sensory function;
3) Ability to execute motor activities, assuming intact motor abilities, sensory
function and comprehension of the required task; and
4) Ability to think abstractly, make sound judgments and plan and carry out complex
tasks.
O The decline in cognitive abilities must be severe enough to interfere with daily life.
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There are many types of Dementia; the most common is Alzheimer's disease it
accounts for approximately 50 to 70 percent of all dementia cases
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, is predicted to
double every 20 years and is the 7
th
leading cause of death in the United States.
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Currently 5.3 million Americans are living with Alzheimer's and a new case is diagnosed
every 70 seconds
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.
Alzheimer's disease is caused by damage to nerves in the brain and their
eventual death. Alzheimer's was first discovered in 1906 by Dr. Alois Alzheimer when

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he performed an autopsy on a patient he was treating. When he began treating the
patient, she was suffering from memory problems, paranoia and difficulty speaking and
understanding what was said to her. Upon her death, Dr. Alzheimer obtained the
family's permission for the autopsy where he found dramatic shrinkage of the cortex,
fatty deposits in the blood vessels, dead brain cells and abnormal deposits in and
around the cells. These deposits are now known to be Plaques and Tangles. Plaques
build up between nerve cells which interrupt the flow of information; they contain
deposits of a protein fragment beta-amyloid
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. Tangles are twisted fibers of another
protein called tau
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and they form inside dying cells which short circuit information flow.
While most people develop some plaques and tangles as they age, people with
Alzheimer's tend to develop more.
Alzheimer's is a progressive disease causing the loss of mental abilities; people
who develop Alzheimer's can't learn new things. The only way Alzheimer's can be truly
diagnosed is through autopsy. Typically the onset occurs between the ages of 60 and
90 years old; in those diagnosed before the age of 60, the disease progresses more
rapidly. The average lifespan of someone with Alzheimer's disease is four to eight
years from the time of diagnosis however; some people have been known to live up to
20 years with the disease. Some possible contributors to developing Alzheimer's
disease are the intake of metals, primarily aluminum, head trauma, high fat diet
combined with lack of exercise, age, ethnicity, gender and heredity.

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Dementia experts have documented common patterns of disease progression
that occur in many Alzheimer's patients, based on these patterns, five levels of
cognitive loss have been developed. The five levels and some of the common
symptoms are as follows:
Level 5 Early Loss
O Some word problems and loss of reasoning skills
O Easily frustrated by changes in routines
O Seeks reassurance but resents take over
O Still does well with personal care and activities
O Seeks out authority figures when upset
O Points out others errors but doesn't notice own behavior
O Can't remember 30 rules, locations, plans or facts
Level 4 Moderate Loss
O Still completes tasks but quality becomes a problem
O Asks 'what/where/when' a lot
O Can do personal care tasks with supervision and prompts but often refuses help
O Still very social but content is limited and confusing at times
O Can't remember what happened AND can mis-remember it, goes back in time at
times
O May try to elope in an effort to get to an older familiar time
Level 3 Middle Loss
O Touches and handles almost anything that is visible
O Does not recognize other's ownership, takes things, invades space
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O Still able to walk around and go places
O Language is poor and comprehension is limited
O Responds to tone of voice, body language and facial expressions
O Loses the ability to use tools and utensils
O Does things because, they feel good, look good, taste good - refuse if they don't
O Stops doing when it isn't interesting anymore
Level 2 Severe Loss
O Paces, walks, rocks, swings, hums, claps, pats, rubs (this is called self soothing)
O Frequently ignores people and small objects
O Doesn't stay down long in any one place
O Often not interested in food significant weight loss should be expected
O Generally enjoys rhythm and motion (music and dance)
O Either moves towards people and activity(shadow) or leaves busy, noisy places
(ghost)
O Chewing and swallowing problems are common
O May not talk much, understands demonstration better than words
Level 1 Profound Loss
O Generally bed or chair bound, can't move much on own
O Often contracted muscles, primitive reflexes reappear (fetal position)
O Poor swallowing and eating
O Still aware of movement and touch
O Difficulty with temperature regulation
O Limited responsiveness at times
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O Moves faces and lips a lot, may babble or repeatedly moan or yell
O Caregiver should use slow rhythmic movements, use flats of fingers and open
palms
O Caregiver should keep voice deep and slow, easy and rhythmic
t is important to keep in mind however, while these levels are helpful when trying to
understand how Alzheimer's affects a person, not everyone will experience the same
symptoms or progress through the disease at the same rate.
Symptoms of Alzheimer's disease can be divided into one of three categories,
cognitive, psychosocial or behavioral. Some cognitive symptoms are memory loss of
recent events, confusion, disorientation to time and place and difficulty with abstract
thinking; psychosocial symptoms would be personality changes, mood swings,
depression, delusion and anxiety or agitation; behavioral symptoms are wandering,
misplacing items, the inability to perform activities of daily living (ADLs) such as bathing,
dressing, grooming, feeding and toileting. Alzheimer's disease is a complex disease,
there is no 'magic bullet', there is no cure, but drug and non-drug treatment may help
with the cognitive, psychosocial and behavioral symptoms. There are several factors
that determine what the best treatment may be such as, age, overall health and medical
history, extent of the disease, tolerance for medicines, procedures and therapies,
expectations for the course of the disease and the opinion or preference of the patient
or caregiver.
While there are no drugs that will cure or slow the progression, the U.S. Food
and Drug Administration (FDA) has approved two types of medication to treat the


cognitive symptoms of Alzheimer's disease. The first of these is Cholinesterase
inhibitors, which prevent the breakdown of acetylcholine, a chemical messenger
important for learning and memory
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. The most commonly prescribed inhibitors are
Aricept (Donepezil), approved to treat all stages, Exelon (Rivastigmine), approved to
treat mild to moderate stages and Razadyne (Galantamine), approved to treat mild to
moderate stages. These drugs are used to support communications among nerve cells
and on average, delay the worsening of symptoms for about 6 to 12 months. The other
approved medication is Memantine which works by regulating glutamate, a different
messenger chemical involved in learning and memory. Namenda is the only
Memantine currently being prescribed, it is relatively new, having been approved in
2003 and temporarily delays the worsening of symptoms for some people.
While the FDA has not approved any specific drugs for treatment of psychosocial
or behavioral symptoms, often physicians will prescribe medications for 'off label use'
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,
a practice in which a medication is prescribed for a different purpose other than one it
was approved for. Antidepressant medications such as Celexa (citalopram), Prozac
(fluoxetine), Paxil (paroxeine), Zoloft (sertraline) and Desyrel (trazodone) are often
prescribed for low mood and irritability. The following Anxiolytics, Ativan (lorazepam)
and Serax (oxazepam) are used to treat anxiety, restlessness, verbally disruptive
behavior and resistance. Antipsychotic medications such as Abilify (aripiprazole),
Clozaril (clozapine), Haldol (haloperidol), Zyprexa (olanzapine), Seroquel (quetiapine),
Risperdal (risperidone) and Geodon (ziprasidone) are prescribed for treatment of
hallucinations, delusions, aggression, agitation, hostility and uncooperativeness.

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Antipsychotic drugs should never be used to sedate or restrain patients with Alzheimer's
disease or any other type of dementia. n fact, there are government warnings and
guidance that state antipsychotic drugs should only be used with dementia patients
when their behavioral symptoms are due to mania or psychosis
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, the symptoms present
a danger to the patient or others
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, or the individual is experiencing inconsolable or
persistent distress, a significant decline in function or substantial difficulty receiving
needed care
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. On occasion, physicians may also prescribe a seizure medication/mood
stabilizer such as Tegretol (carbamazepine) or Depakote (divalproex) for agitation.
There is an Alzheimer's vaccine that is also being studied however, due to unwanted
side effects; the clinical trial has been stopped until the vaccine can be modified to
improve the safety.
Just as drug treatments may work best on a specific category of symptoms, non-
drug treatments too may be more effective on different categories of symptoms. Most
experts feel that non-drug approaches should always be tried prior to drug treatments.
While cognitive symptoms are typically treated with medications, some therapies such
as cognitive stimulation have started to gain momentum, especially in recent
international studies. Some examples of cognitive stimulating activities are trivia
games, poetry reading, storytelling, reminiscing, word games, puzzles with large pieces,
bingo using limited numbers or pictures, crossword puzzles or 'name that tune'. The
following are suggestions to keep in mind when attempting cognitive stimulating
programs: provide activities that encourage, not frustrate the individual, allow time to

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respond, ensure activities are not too difficult or too elementary as both can cause
agitation or behavior problems and cognitive programs are more successful when done
in smaller groups. Reminiscing activities can have a profound value, by focusing on
reminiscing and using suitable cues and prompts, caregivers can enhance the
individual's feeling of self worth, it can validate his/her contributions and feelings.
Non-drug treatment of behavioral symptoms begin with analyzing the behavior,
identifying what may have caused it and creating an approach that either changes the
person's environment or the caregiver's reaction to the behavior. Everyone who
develops behavioral symptoms should receive a medical examination, especially if the
symptoms suddenly appear. Typically the primary cause of behavior problems is the
effect of Alzheimer's disease but sometimes an exam will reveal that something as
simple as a common illness or drug side effect is the culprit. Environmental factors can
also contribute to behavioral symptoms. Events or changes is the surroundings of an
Alzheimer's patient may create a sense of uneasiness or increase fear and confusion.
Some potential solutions are monitoring the individual's personal comfort, check for
pain, hunger, full bladder, fatigue, infections and skin irritations; avoid being
confrontational or arguing, instead respond to the feelings behind what is being
expressed; redirect the person's attention, remain flexible, patient and supportive;
create a calm environment, avoid noise, glare and too much background distraction and
finally, simplify the environment, tasks and solutions. Although there are no long term
effects, music therapy is another way to improve behavior and social interaction
sometimes results in improvement in psychosocial symptoms in some individuals.
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Snoezelen therapy is another treatment that aids in eliminating behavior
symptoms. Snoezelen is a combination of two Dutch verbs: snuffelen which means to
seek out, sniff or explore and doezelen which means to relax
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. Snoezelen was
developed in the late 1970s by two Dutch therapists, at the time, it was considered to be
radical, and today it is a common practice. t is based on the idea that symptoms such
as anxiety and agitation might result from periods of sensory deprivation, it was
originally used for autistic children but quickly became an accepted therapy for
dementia patients. Snoezelen is an environment filled with lights, sounds, textures and
aromas used to stimulate, calm, relax or energize the individual. t is usually set up in a
designated room and can be staged to provide a multisensory experience or a single-
sensory experience. A Snoezelen environment is safe, non-threatening and has been
proven effective with long term care residents who have been diagnosed with dementia
as well as other injuries or diseases. Reports on Snoezelen environments document
accounts of residents who have stopped self abusive behavior; of people who have
'seen' (become aware of the physical environment); spoken or smiled for the first time in
years; and of those who have showed unusual (for them) peace, happiness and
contentment
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.
Yet another important aspect of Alzheimer's treatment has to do with the
environment whether it's in a facility or in the private home. Environmental
modifications are known to improve day to day functioning in people with Alzheimer's.
Some examples of environmental modifications in a long term care facility would be to
build a round structure, often, individuals with Alzheimer's tend to pace or walk, if the

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structure is circular, it creates an environment with no blind alleys and provides self
queuing; there should be private rooms that open to a central family/great room; there
should be a secure outdoor area to protect patients who wander or exit seek and the
facility should have landmarks differentiated by color or shape to assist with queuing.
Home modifications are primarily safety modifications however, there are a number of
specific modifications have been shown to be beneficial in reducing problem behavior:
O Low levels of light during meals may improve eating habits
O Simply furnished spaces with little or no clutter minimize distractions
O Consistent background noise, music or simulated nature sounds
O Place objects that cue memories in clear view
O Ensure privacy and personal space
Researchers are still investigating which modifications are most beneficial.
The final treatments to discuss are alternative treatments. There are a growing
number of herbal remedies, vitamins and other dietary supplements that are promoted
as memory enhancers or Alzheimer's treatments. Because FDA approval is not
required for dietary supplements, the effectiveness of these products are primarily
based on testimonials. There are of course concerns about these treatments because
the effectiveness and safety are unknown, the purity is unknown, adverse reactions are
not routinely monitored and dietary supplements can have serious side effects with
prescription medications. The supplements being touted as Alzheimer's treatments are
Coenzyme Q10, an antioxidant, Coral Calcium, Ginkgo Biloba which has been shown to
have no benefit in treating Alzheimer's, Huperzine A which is a moss extract and has
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been used in Chinese medicine for centuries, Omega-3 fatty acid, research has linked a
high intake of Omega-3 to a possible reduction in risk of dementia and
Phosphatidylserine, a kind of lipid that is thought to shore up the cell membrane and
possibly protect cells from degenerating.
n closing, despite the efforts of some of the world's best researchers and
regardless of the treatment, Alzheimer's is a devastating disease with no cure at this
time. With the generation of baby boomers entering the ranks of our senior population it
will only become more devastating unless a cure is discovered. Until that time, it is
important to remember, that it only takes one word or action to trigger what seemed like
a long lost memory and bring your loved one back if only for a moment.









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