Alzheimer's Disease

Care Management Strategies

Within the past ten years, new medications were developed to address some of the signs and symptoms of cognitive decline experienced by the AD patient. These medications are classified as cholinesterase inhibitors. They act to slow the breakdown of acetylcholine, a brain chemical necessary for the sending and receiving of messages. As mentioned earlier, one proposed cause of AD is acetylcholine deficiency. Examples of these medications include tacrine (Cognex), donepezil (Aricept), rivastigmine (Exelon) and galantamine (Reminyl). Modest clinical improvement in memory and cognition have been reported especially if the medication is started early in the disease course. Some studies report 50% of patients taking the medications showing no improvement at all. The most frequently reported side effects of cholinesterase inhibitors are nausea, vomiting, diarrhea and decreased appetite. Additional medications are being developed and patients are being recruited for clinical trials as you read this. Researchers are also studying the brain-sparing effects that estrogen, Vitamin E and non-steroidal anti-inflammatory drugs (NSAIDS) may have on AD progression.

Let’s discuss some ways for managing some of the most common cognitive and behavioral issues of early and middle stage AD patients. These techniques have been validated by AD experts and are useful for family caregivers as well. It is important that an individualized care plan be developed that will be modified as the disease progresses. Cognitive losses maybe similar, but every patient loses different abilities at different rates and each responds to interventions differently. Nursing research shows that caregivers may maximize functional abilities by assessing specific cognitive abilities and then use that information to customize interventions. Patients with late-stage AD require the same TLC you provide to other patients who are totally dependent in their ADL’s and will not be discussed in this article.

Communicating with someone with memory impairments can be challenging for all. Something I have always found to be helpful is a relaxed, unrushed demeanor. Often time patients with AD will mimic our behaviors, so if we are anxious or upset, they will become more anxious and upset. Always identify who you are while making eye contact and smiling. Use a clear, low-pitched tone. Make short simple statements that address one subject at a time. Be patient and wait for a response. Avoid questions that require multiple choices. If your patient has trouble with word finding and you think you know the word they are looking for, say it. If supplying the word to your patient upsets them try some other strategies to help them come up with the word. Ask if they can describe it or point to it. Another frequently encountered situation is when the patient asks the same question over and over again. They don’t do that to drive us crazy-they ask it again because they have forgotten. This can be very trying when the patient asks you for the fiftieth time in ten minutes, “When will my daughter be here?” Instead of answering, “In three hours, at five o’clock,” think about why the patient keeps asking. Depending on where she is in the AD process, she might not comprehend time references. Maybe she is afraid she will be left behind or that she misses her daughter and needs some reassurance.