Nursing Care and Degenerative Neurological Syndrome(AD)

Degenerative Neurological Disorders

Nursing Care and  Degenerative Neurological Syndrome(AD), Historical Research Work, Difficulties in Diagnosing, Medically Recognized Stages, Medical And Nursing Care   

 Whats Is Alzheimer's Disease

    Alzheimer's disease (AD) is a progressively degenerative neurological disorder (syndrome) that results in impaired cognition, mood, behavior, and function. Dr. Alois Alzheimer (1906) first described the disorder in a published case report on a 52-year-old patient who suffered from psychosis, memory loss, agnosia (impaired sensory perception), apraxia (impairments in carrying out tasks), and aphasia (impaired communication).

     After the patient's death, Dr. Alzheimer performed an autopsy and discovered clumps-senile plaques-and knots-neurofibrillary tangles in the patient's brain ( Dharmarajan & Ugalino , 2003).

Historical Research Work 

    One hundred years later, despite decades of research, there remains no known etiology or cure for the disease. The diagnosis relies on a thorough clinical history and physical examination, including mental status testing, both to establish a diagnosis and to rule out other causes of dementia, such as brain tumors, metabolic disorders, or infection. 

    Many genetic and nongenetic factors, such as estrogen, nonsteroidal anti-inflammatory medication, and apolipoprotein, have been speculatively associated with AD; researchers continue to discover definitive links between these factors and the illness.

Difficulties in Diagnosing 

    Due to the lack of a diagnostic marker and the associated difficulties in diagnosing early stage AD, precise prevalence rates are difficult to determine. Although a rare familial form of AD (afflicting people between 30 and 60 years of age) exists the disease is more prevalent as people age. 

    Dementia, notably AD, affects only 1% of those between 60 and 64 years of age, with the number of cases. doubling every 5 years in people over 65 (Beers & Berkow , 2000). In 2000, 40% (1.8 million) of people over 85 years of age were estimated to be afflicted with the disease. 

    As a result of the rapidly aging US population, the next 50 years is expected to show a three-fold increase in the number of people with AD (Hebert, Scherr, Bienias , Bennett, & Evans, 2003).

Medically Recognized Stages 

    Alzheimer's disease has a protracted downward trajectory. The average length of the disease is 8 years, but it can span up to 20 years (National Institute of Aging, 1995). As a result of its progressively degenerative a course, symptom progression is typically divided into three stages: mild, moderate, and severe. 

    Mild symptoms consist of personality changes, memory loss, and impaired word finding. As the disease progresses, the initial symptoms worsen, with AD sufferers often. developing increased behavioral problems such as wandering, physical and verbal aggression, and resistance to personal care (grooming and hygiene). 

    In the severe stage, the AD sufferer is profoundly cognitively and functionally disabled, typically requiring 24-hour care. Death usually results from an infectious process such as pneumonia.

Medical And Nursing Care 

    Care is provided primarily by family members, and an estimated 75% of older adults with dementia are cared for at home (Dunkin & Anderson-Hanley, 1998). This care is primarily uncompensated and includes emotional, physical, and financial assistance. 

    As the disease progresses, families are increasingly burdened in trying to provide care, often suffering adverse personal physical and psychosocial consequences ( Ory , Hoffman, Yec , Tennstedt , & Schultz, 1999). 

    AD causes severe cognitive impairments, and families are often forced to make decisions for the AD sufferer (eg, whether to resuscitate or whether to institutionalize), without the guidance of advance directives.

Treatment 

    Treatments for AD are multiple and vary by illness stage. Pharmacologic treatments include medications to improve cognition, treat depression, or treat behavioral symptoms ( eg. physical aggression or agitation). 

    Because each person with AD experiences a unique confluence of symptoms, treatment strategies require careful tailoring to meet the respective needs of each person.

Chronological Data

    Researchers have discovered decreased levels of acetylcholine in the brains of AD sufferers; Thus, acetylcholinesterase inhibitors are indicated in the mild to moderate stages of AD to slow the progressive cognitive decline. Some families have reported that these drugs resulted in some amelioration of behavioral symptoms. 

    Certain behavioral symptoms, such as physical aggression or agitation, may require antipsychotic medications. However, these drugs are often associated with increased confusion, resulting in decreased function, and therefore require a careful risk-benefit analysis and ongoing evaluation of their effectiveness. 

    Benzodiazepines are generally not useful for the control of behavioral symptoms and have been associated with increased falls in older adults (Frenchman, Capo, & Hass, 2000). Depression is a common comorbid condition with AD, requiring early recognition and treatment both pharmacologic and non-pharmacologic-aimed at maximizing function and minimizing additional disability.

Behavioral Changes 

    Certain behavioral symptoms (eg, wandering, verbal aggressiveness, or resistance to personal grooming) do not respond favorably to pharmacologic therapy. These symptoms require environmental modifications and behavioral strategies. AD sufferer's agnosia, combined with other cognitive deficits (eg. memory loss or lack of insight/judgment), often results in unsafe behaviors. 

    For instance, AD sufferers may turn on stoves and then forget to turn them off. They may inadvertently drink toxic substances or step into a bathtub of scalding water. Driving becomes increasingly unsafe. Each AD sufferer needs to be evaluated for possible sources of injury, and strategies must be initiated to safeguard living environments. 

    In institutional settings, similar types of environmental modifications are needed to ensure the person's safety. Many assisted living and skilled nursing facilities have dedicated units designed to address the specific needs of this population. 

    Behavioral strategies are extremely varied, typically successful, and do not have the unfavorable side-effect profiles of many of the medications used to treat behavioral symptoms. Diversion and redirection to a preferred activity remain highly successful strategies to deal with problems related to the AD sufferer's short and long-term memory loss. 

    Reality orientation is often unsuccessful, so validation therapy (Feil, 2002) is the preferred form of communication. Validation therapy techniques include carefully attending to a confused older adult's expressions of impaired cognition (eg, thinking past events are occurring in the present) and responding with acceptance and empathy. 

    In communicating with confused older adults, careful attention also needs to be taken to provide implements such as hearing aids or glasses, to compensate for sensory losses.

Implementation Of Restrains 

    Physical restraints typically increase agitation and are not associated with a decrease in falls ( Strumpf , Robinson, Wagner, & Evans, 1998). 

    Individual and family therapy should be encouraged, to assist families in planning and preparing for the sufferer's future needs. Support groups, in particular the Alzheimer's support groups, are also an excellent source of information and assistance. In the latter stage of AD, hospice is another source of family support.

Sub-Cellular Changes 

    AD research is overwhelmingly biomedical, attempting to uncover a cause, better treatment, or a cure for the illness. Many behavioral strategies have been researched and reported to be clinically successful in treating AD, including music therapy, reminiscence therapy, strategies to prevent wandering, and therapy animals. 

    Although positive results have been reported in using behavioral strategies, the methodological limitations of the studies (small sample sizes, sampling bias, short evaluation periods, and lack of consideration of confounding variables) affect the scientific rigor of these findings (Beavis, Simpson, & Graham, 2002). The rapidly aging US society and subsequent increase in the number of people with AD afford unique nursing opportunities and challenges. 

    Most AD sufferers live in the community and are cared for by their families. Families interface with the health care delivery system at various points in time along the trajectory. It is then that nurses, in collaboration with people in other disciplines, can provide needed assistance to families struggling to manage in the face of this devastating illness.