Alzheimer's Disease
What is dementia?
Dementia is a syndrome
characterized by:
1.
impairment in memory,
2.
impairment in another area of thinking such as the ability to
organize thoughts and reason, the ability to use language, or the ability to
see accurately the visual world (not because of eye disease), and
3.
these impairments are severe enough to cause a decline in the
patient's usual level of functioning.
Although some kinds of
memory loss are normal parts of aging, the changes due to aging are not severe
enough to interfere with the level of function.
Many different diseases can cause dementia, but Alzheimer's disease is by far the most common cause for dementia in the United States and in most countries in the world.
Many different diseases can cause dementia, but Alzheimer's disease is by far the most common cause for dementia in the United States and in most countries in the world.
What is Alzheimer's disease?
Alzheimer's disease
(AD) is a slowly progressive disease of the brain that is characterized by
impairment of memory and eventually by disturbances in reasoning, planning,
language, and perception.
Many scientists believe that Alzheimer's disease results from an increase in the production or accumulation of a specific protein (beta-amyloid protein) in the brain that leads to nerve cell death.
Many scientists believe that Alzheimer's disease results from an increase in the production or accumulation of a specific protein (beta-amyloid protein) in the brain that leads to nerve cell death.
The likelihood of
having Alzheimer's disease increases substantially after the age of 70 and may
affect around 50% of persons over the age of 85.
Nonetheless, Alzheimer's disease is not a normal part of aging and is not something that inevitably happens in later life. For example, many people live to over 100 years of age and never develop Alzheimer's disease.
Nonetheless, Alzheimer's disease is not a normal part of aging and is not something that inevitably happens in later life. For example, many people live to over 100 years of age and never develop Alzheimer's disease.
Who develops Alzheimer's disease?
The main risk factor
for Alzheimer's disease is increased age.
As a population ages, the frequency of Alzheimer's disease continues to increase.
Ten percent of people over 65 years of age and 50% of those over 85 years of age have Alzheimer's disease.
Unless new treatments are developed to decrease the likelihood of developing Alzheimer's disease, the number of individuals with Alzheimer's disease in the United States is expected to be 14 million by the year 2050.
As a population ages, the frequency of Alzheimer's disease continues to increase.
Ten percent of people over 65 years of age and 50% of those over 85 years of age have Alzheimer's disease.
Unless new treatments are developed to decrease the likelihood of developing Alzheimer's disease, the number of individuals with Alzheimer's disease in the United States is expected to be 14 million by the year 2050.
There are also genetic
risk factors for Alzheimer's disease.
Most patients develop Alzheimer's disease after age 70.
However, 2%-5% of patients develop the disease in the fourth or fifth decade of life (40s or 50s).
At least half of these early onset patients have inherited gene mutations associated with their Alzheimer's disease.
Moreover, the children of a patient with early onset Alzheimer's disease who has one of these gene mutations has a 50% risk of developing Alzheimer's disease.
Most patients develop Alzheimer's disease after age 70.
However, 2%-5% of patients develop the disease in the fourth or fifth decade of life (40s or 50s).
At least half of these early onset patients have inherited gene mutations associated with their Alzheimer's disease.
Moreover, the children of a patient with early onset Alzheimer's disease who has one of these gene mutations has a 50% risk of developing Alzheimer's disease.
There is also a
genetic risk for late onset cases.
A relatively common form of a gene located on chromosome 19 is associated with late onset Alzheimer's disease. In the majority of Alzheimer's disease cases, however, no specific genetic risks have yet been identified.
A relatively common form of a gene located on chromosome 19 is associated with late onset Alzheimer's disease. In the majority of Alzheimer's disease cases, however, no specific genetic risks have yet been identified.
Other risk factors for
Alzheimer's disease include
Individuals who have completed less than eight years of education also have an increased risk for Alzheimer's disease.
These factors increase the risk of Alzheimer's disease, but by no means do they mean that Alzheimer's disease is inevitable in persons with these factors.
- high blood pressure (hypertension),
- coronary artery disease,
- diabetes, and possibly
- elevated blood cholesterol.
Individuals who have completed less than eight years of education also have an increased risk for Alzheimer's disease.
These factors increase the risk of Alzheimer's disease, but by no means do they mean that Alzheimer's disease is inevitable in persons with these factors.
All patients with Down
syndrome
will develop the brain changes of Alzheimer's disease by 40 years of age.
This fact was also a clue to the "amyloid hypothesis of Alzheimer's disease" (see section later in this article).
This fact was also a clue to the "amyloid hypothesis of Alzheimer's disease" (see section later in this article).
What are the symptoms of Alzheimer's disease?
The onset of
Alzheimer's disease is usually gradual, and it is slowly progressive.
Memory problems that family members initially dismiss as "a normal part of aging" are in retrospect noted by the family to be the first stages of Alzheimer's disease.
When memory and other problems with thinking start to
consistently affect the usual level of functioning; families begin to suspect
that something more than "normal aging" is going on.
Memory problems that family members initially dismiss as "a normal part of aging" are in retrospect noted by the family to be the first stages of Alzheimer's disease.
Problems of memory,
particularly for recent events (short-term memory) are common early in the
course of Alzheimer's disease. For example, the individual may, on repeated
occasions, forget to turn off an iron or fail to recall which of the morning's
medicines were taken.
Mild personality changes, such as less spontaneity, apathy,
and a tendency to withdraw from social interactions, may occur early in the
illness.
As the disease
progresses, problems in abstract thinking and in other intellectual functions
develop.
The person may begin to have trouble with figures when working on bills, with understanding what is being read, or with organizing the day's work.
Further disturbances in behavior and appearance may also be seen at this point, such as agitation, irritability, quarrelsomeness, and a diminishing ability to dress appropriately.
The person may begin to have trouble with figures when working on bills, with understanding what is being read, or with organizing the day's work.
Further disturbances in behavior and appearance may also be seen at this point, such as agitation, irritability, quarrelsomeness, and a diminishing ability to dress appropriately.
Later in the course of
the disorder, affected individuals may become confused or disoriented about
what month or year it is, be unable to describe accurately where they live, or
be unable to name a place being visited.
Eventually, patients may wander, be unable to engage in conversation, erratic in mood, uncooperative, and lose bladder and bowel control.
In late stages of the disease, persons may become totally incapable of caring for themselves.
Death can then follow, perhaps from pneumonia or some other problem that occurs in severely deteriorated states of health.
Those who develop the disorder later in life more often die from other illnesses (such as heart disease) rather than as a consequence of Alzheimer's disease.
Eventually, patients may wander, be unable to engage in conversation, erratic in mood, uncooperative, and lose bladder and bowel control.
In late stages of the disease, persons may become totally incapable of caring for themselves.
Death can then follow, perhaps from pneumonia or some other problem that occurs in severely deteriorated states of health.
Those who develop the disorder later in life more often die from other illnesses (such as heart disease) rather than as a consequence of Alzheimer's disease.
Ten warning signs of Alzheimer's disease
The Alzheimer's
Association has developed the following list of warning signs that include
common symptoms of Alzheimer's disease.
Individuals who exhibit several of these symptoms should see a physician for a complete evaluation.
Individuals who exhibit several of these symptoms should see a physician for a complete evaluation.
1.
Memory loss
2.
Difficulty performing familiar tasks
3.
Problems with language
4.
Disorientation to time and place
5.
Poor or decreased judgment
6.
Problems with abstract thinking
7.
Misplacing things
8.
Changes in mood or behavior
9.
Changes in personality
10.
Loss of initiative
It is normal for
certain kinds of memory, such as the ability to remember lists of words, to
decline with normal aging.
In fact, normal individuals 50 years of age will recall only about 60% as many items on some kinds of memory tests as individuals 20 years of age.
Furthermore, everyone forgets, and every 20 year old is well aware of multiple times he or she couldn't think of an answer on a test that he or she once knew.
Almost no 20 year old worries when he/she forgets something, that he/she has the 'early stages of Alzheimer's disease,' whereas an individual 50 or 60 years of age with a few memory lapses may worry that they have the 'early stages of Alzheimer's disease.'
In fact, normal individuals 50 years of age will recall only about 60% as many items on some kinds of memory tests as individuals 20 years of age.
Furthermore, everyone forgets, and every 20 year old is well aware of multiple times he or she couldn't think of an answer on a test that he or she once knew.
Almost no 20 year old worries when he/she forgets something, that he/she has the 'early stages of Alzheimer's disease,' whereas an individual 50 or 60 years of age with a few memory lapses may worry that they have the 'early stages of Alzheimer's disease.'
Mild cognitive impairment
The criteria for
dementia are conservative meaning that a patient must have had considerable
decline in the ability to think before a diagnosis of dementia is appropriate.
The progression of Alzheimer's disease is so insidious and slow that patients go through a period of decline where their memory is clearly worse than its baseline, yet they still do not meet criteria for dementia.
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This transitional syndrome is called Mild Cognitive Impairment (MCI). Individuals affected with MCI have cognitive impairment that is demonstrated on formal neuropsychological testing but are still able to function well.
Formal neuropsychological testing usually means that the patient is administered a battery of standardized tests of memory and thinking.
Some of these tests are something like the IQ tests we may have taken in school. When these tests were developed they were administered to hundreds or thousands of people so that statistics are available to say how a person's score compares to a sample of healthy persons of the same age.
If a person scores in the top 50%, it means that he or she did better than at least 50% of other normal people who took the test. Persons with lower scores - often in the bottom 7% - are considered to have MCI.
The progression of Alzheimer's disease is so insidious and slow that patients go through a period of decline where their memory is clearly worse than its baseline, yet they still do not meet criteria for dementia.
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This transitional syndrome is called Mild Cognitive Impairment (MCI). Individuals affected with MCI have cognitive impairment that is demonstrated on formal neuropsychological testing but are still able to function well.
Formal neuropsychological testing usually means that the patient is administered a battery of standardized tests of memory and thinking.
Some of these tests are something like the IQ tests we may have taken in school. When these tests were developed they were administered to hundreds or thousands of people so that statistics are available to say how a person's score compares to a sample of healthy persons of the same age.
If a person scores in the top 50%, it means that he or she did better than at least 50% of other normal people who took the test. Persons with lower scores - often in the bottom 7% - are considered to have MCI.
There are several forms of MCI. Perhaps the most common is associated with impairment in memory but not in the ability to plan and reason.
Persons with this type called "amnestic MCI" (amnestic comes from "amnesia" and means no memory) have a high risk of developing Alzheimer's disease over the next few years.
Persons with preserved memory but impaired reasoning or impaired judgment (call non-amnestic MCI) have a lower risk of developing Alzheimer's disease.
As treatments are
developed that decrease the risk of developing Alzheimer's disease or slow its
rate of progression (as of June 2007, no such medication has been approved by
the FDA), recognition of amnestic MCI will be increasingly important.
It is hoped that medications will be developed that will slow the rate of progression of MCI to Alzheimer's disease or completely prevent the development of Alzheimer's disease
It is hoped that medications will be developed that will slow the rate of progression of MCI to Alzheimer's disease or completely prevent the development of Alzheimer's disease
What are causes of Alzheimer's disease?
The cause(s) of
Alzheimer's disease is (are) not known.
The "amyloid cascade hypothesis" is the most widely discussed and researched hypothesis about the cause of Alzheimer's disease.
The strongest data supporting the amyloid cascade hypothesis comes from the study of early-onset inherited (genetic) Alzheimer's disease.
Mutations associated with Alzheimer's disease have been found in about half of the patients with early-onset disease.
In all of these patients, the mutation leads to excess production in the brain of a specific form of a small protein fragment called ABeta (Aβ).
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Many scientists believe that in the majority of sporadic (for example, non-inherited) cases of Alzheimer's disease (these make up the vast majority of all cases of Alzheimer's disease) there is too little removal of this Aβ protein rather than too much production.
In any case, much of the research in finding ways to prevent or slow down Alzheimer's disease has focused on ways to decrease the amount of Aβ in the brain.
The "amyloid cascade hypothesis" is the most widely discussed and researched hypothesis about the cause of Alzheimer's disease.
The strongest data supporting the amyloid cascade hypothesis comes from the study of early-onset inherited (genetic) Alzheimer's disease.
Mutations associated with Alzheimer's disease have been found in about half of the patients with early-onset disease.
In all of these patients, the mutation leads to excess production in the brain of a specific form of a small protein fragment called ABeta (Aβ).
.jpg)
Many scientists believe that in the majority of sporadic (for example, non-inherited) cases of Alzheimer's disease (these make up the vast majority of all cases of Alzheimer's disease) there is too little removal of this Aβ protein rather than too much production.
In any case, much of the research in finding ways to prevent or slow down Alzheimer's disease has focused on ways to decrease the amount of Aβ in the brain.
What are risk factors for Alzheimer's disease?
The biggest risk
factor for Alzheimer's disease is increased age.
The likelihood of developing Alzheimer's disease doubles every 5.5 years from 65 to 85 years of age.
Whereas only 1%-2% of individuals 70 years of age have Alzheimer's disease, in some studies around 40% of individuals 85 years of age have Alzheimer's disease.
Nonetheless, at least half of people who live past the 95 years of age do not have Alzheimer's disease.
The likelihood of developing Alzheimer's disease doubles every 5.5 years from 65 to 85 years of age.
Whereas only 1%-2% of individuals 70 years of age have Alzheimer's disease, in some studies around 40% of individuals 85 years of age have Alzheimer's disease.
Nonetheless, at least half of people who live past the 95 years of age do not have Alzheimer's disease.
Common forms of
certain genes increase the risk of developing Alzheimer's disease, but do not
invariably cause Alzheimer's disease.
The best-studied "risk" gene is the one that encodes apolipoprotein E (apoE).
The apoE gene has three different forms (alleles) --
The apoE4 form of the gene has been associated with increased risk of Alzheimer's disease in most (but not all) populations studied.
The frequency of the apoE4 version of the gene in the general population varies, but is always less than 30% and frequently 8%-15%.
Persons with one copy of the E4 gene usually have about a two to three fold increased risk of developing Alzheimer's disease.
Persons with two copies of the E4 gene (usually around 1% of the population) have about a nine-fold increase in risk.
Nonetheless, even persons with two copies of the E4 gene don't always get Alzheimer's disease.
At least one copy of the E4 gene is found in 40% of patients with sporadic or late-onset Alzheimer's disease.
The best-studied "risk" gene is the one that encodes apolipoprotein E (apoE).
The apoE gene has three different forms (alleles) --
- apoE2,
- apoE3, and
- apoE4.
The apoE4 form of the gene has been associated with increased risk of Alzheimer's disease in most (but not all) populations studied.
The frequency of the apoE4 version of the gene in the general population varies, but is always less than 30% and frequently 8%-15%.
Persons with one copy of the E4 gene usually have about a two to three fold increased risk of developing Alzheimer's disease.
Persons with two copies of the E4 gene (usually around 1% of the population) have about a nine-fold increase in risk.
Nonetheless, even persons with two copies of the E4 gene don't always get Alzheimer's disease.
At least one copy of the E4 gene is found in 40% of patients with sporadic or late-onset Alzheimer's disease.
This means that in
majority of patients with Alzheimer's disease, no genetic risk factor has yet
been found.
Most experts do not recommend that adult children of patients with Alzheimer's disease should have genetic testing for the apoE4 gene since there is no treatment for Alzheimer's disease.
When medical treatments that prevent or decrease the risk of developing Alzheimer's disease become available, genetic testing may be recommended for adult children of patients with Alzheimer's disease so that they may be treated.
Most experts do not recommend that adult children of patients with Alzheimer's disease should have genetic testing for the apoE4 gene since there is no treatment for Alzheimer's disease.
When medical treatments that prevent or decrease the risk of developing Alzheimer's disease become available, genetic testing may be recommended for adult children of patients with Alzheimer's disease so that they may be treated.
Many, but not all,
studies have found that women have a higher risk for Alzheimer's disease than
men.
It is certainly true that women live longer than men, but age alone does not seem to explain the increased frequency in women.
The apparent increased frequency of Alzheimer's disease in women has led to considerable research about the role of estrogen in Alzheimer's disease.
Recent studies suggest that estrogen should not be prescribed to post-menopausal women for the purpose of decreasing the risk of Alzheimer's disease. Nonetheless, the role of estrogen in Alzheimer's disease remains an area of research focus.
It is certainly true that women live longer than men, but age alone does not seem to explain the increased frequency in women.
The apparent increased frequency of Alzheimer's disease in women has led to considerable research about the role of estrogen in Alzheimer's disease.
Recent studies suggest that estrogen should not be prescribed to post-menopausal women for the purpose of decreasing the risk of Alzheimer's disease. Nonetheless, the role of estrogen in Alzheimer's disease remains an area of research focus.
Some studies have
found that Alzheimer's disease occurs more often among people who suffered
significant traumatic head
injuries
earlier in life, particularly among those with the apoE 4 gene.
In addition, many, but
not all studies, have demonstrated that persons with limited formal education -
usually less than eight years - are at increased risk for Alzheimer's disease.
It is not known whether this reflects a decreased "cognitive reserve"
or other factors associated with a lower educational level.
How is the diagnosis of Alzheimer's disease made?
As of June 2007, there
is no specific "blood test" or imaging test that is used for the
diagnosis of Alzheimer's disease.
Alzheimer's disease is diagnosed when:
1) a person has sufficient cognitive decline to meet criteria for dementia;
2) the clinical course is consistent with that of Alzheimer's disease;
3) no other brain diseases or other processes are better explanations for the dementia.
Alzheimer's disease is diagnosed when:
1) a person has sufficient cognitive decline to meet criteria for dementia;
2) the clinical course is consistent with that of Alzheimer's disease;
3) no other brain diseases or other processes are better explanations for the dementia.
What other conditions should be screened for?
There are many
conditions that can cause dementia, to include the following:
Neurological
disorders:
Parkinson's disease, cerebrovascular disease and strokes, brain tumors, blood clots, and multiple sclerosis can sometimes be associated with dementia although many patients with these conditions are cognitively normal.
Parkinson's disease, cerebrovascular disease and strokes, brain tumors, blood clots, and multiple sclerosis can sometimes be associated with dementia although many patients with these conditions are cognitively normal.
Infectious diseases:
Some brain infections such as chronic syphilis, chronic HIV, or chronic fungal meningitis can cause dementia.
Some brain infections such as chronic syphilis, chronic HIV, or chronic fungal meningitis can cause dementia.
Side effects of
medications:
Many medicines can cause cognitive impairment, especially in elderly patients. Perhaps the most frequent offenders are drugs used to control bladder urgency and incontinence. "Psychiatric medications" such as anti-depressants and anti-anxiety medications and "neurological medications" such as anti-seizure medications can also be associated with cognitive impairment.
Many medicines can cause cognitive impairment, especially in elderly patients. Perhaps the most frequent offenders are drugs used to control bladder urgency and incontinence. "Psychiatric medications" such as anti-depressants and anti-anxiety medications and "neurological medications" such as anti-seizure medications can also be associated with cognitive impairment.
If a physician
evaluates a person with cognitive impairment who is on one of these
medications, the medication is often gently tapered and/or discontinued to
determine whether it might be the cause of the cognitive impairment. If it is
clear that the cognitive impairment preceded the use of these medications, such
tapering may not be necessary. On the other hand, "psychiatric,"
"neurological," and "incontinence" medications are often
appropriately prescribed to patients with Alzheimer's disease. Such patients
need to be followed carefully to determine whether these medications cause any
worsening of cognition.
Psychiatric disorders:
In older persons, some forms of depression can cause problems with memory and concentration that initially may be indistinguishable from the early symptoms of Alzheimer's disease. Sometimes, these conditions, referred to as pseudodementia, can be reversed. Studies have shown that persons with depression and coexistent cognitive (thinking, memory) impairment are highly likely to have an underlying dementia when followed for several years.
In older persons, some forms of depression can cause problems with memory and concentration that initially may be indistinguishable from the early symptoms of Alzheimer's disease. Sometimes, these conditions, referred to as pseudodementia, can be reversed. Studies have shown that persons with depression and coexistent cognitive (thinking, memory) impairment are highly likely to have an underlying dementia when followed for several years.
Substance Abuse:
Abuse of legal and/or illegal drugs and alcohol abuse is often associated with cognitive impairment.
Abuse of legal and/or illegal drugs and alcohol abuse is often associated with cognitive impairment.
Metabolic Disorders:
Thyroid dysfunction, some steroid disorders, and nutritional deficiencies such as vitamin B12 deficiency or thiamine deficiency are sometimes associated with cognitive impairment.
Thyroid dysfunction, some steroid disorders, and nutritional deficiencies such as vitamin B12 deficiency or thiamine deficiency are sometimes associated with cognitive impairment.
Trauma:
Significant head injuries with brain contusions may cause dementia. Blood clots around the outside of the brain (subdural hematomas) may also be associated with dementia.
Significant head injuries with brain contusions may cause dementia. Blood clots around the outside of the brain (subdural hematomas) may also be associated with dementia.
Toxic Factors:
Long term consequences of acute carbon monoxide poisoning can lead to an encephalopathy with dementia. In some rare cases, heavy metal poisoning can be associated with dementia.
Long term consequences of acute carbon monoxide poisoning can lead to an encephalopathy with dementia. In some rare cases, heavy metal poisoning can be associated with dementia.
Tumors:
Many primary and metastatic brain tumors can cause dementia. However, many patients with brain tumors have no or little cognitive impairment associated with the tumor.
Many primary and metastatic brain tumors can cause dementia. However, many patients with brain tumors have no or little cognitive impairment associated with the tumor.
The Importance of Comprehensive Clinical Evaluation
Because many other
disorders can be confused with Alzheimer's disease, a comprehensive clinical
evaluation is essential in arriving at a correct diagnosis.
Such an assessment should include at least three major components;
1) a thorough general medical workup,
2) a neurological examination including testing of memory and other functions of thinking , and
3) a psychiatric evaluation to assess mood, anxiety, and clarity of thought.
Such an assessment should include at least three major components;
1) a thorough general medical workup,
2) a neurological examination including testing of memory and other functions of thinking , and
3) a psychiatric evaluation to assess mood, anxiety, and clarity of thought.
Such an evaluation
takes time - usually at least an hour.
In the United States healthcare system, neurologists, psychiatrists, or geriatricians frequently become involved. Nonetheless, any physician may be able to perform a thorough evaluation.
In the United States healthcare system, neurologists, psychiatrists, or geriatricians frequently become involved. Nonetheless, any physician may be able to perform a thorough evaluation.
The American Academy
of Neurology has published guidelines that include imaging of the brain in the
initial evaluation of patients with dementia.
These studies are either a noncontrast CT scan or an MRI scan.
Other imaging procedures that look at the function of the brain (functional neuroimaging), such as SPECT, PET, and fMRI, may be helpful in specific cases, but generally are not needed.
However, in many healthcare systems outside of the United States, brain imaging as not a standard part of the assessment for possible Alzheimer's disease.
These studies are either a noncontrast CT scan or an MRI scan.
Other imaging procedures that look at the function of the brain (functional neuroimaging), such as SPECT, PET, and fMRI, may be helpful in specific cases, but generally are not needed.
However, in many healthcare systems outside of the United States, brain imaging as not a standard part of the assessment for possible Alzheimer's disease.
Despite many attempts,
identification of a blood test to diagnose Alzheimer's disease has remained
elusive. As of June 2007, such testing is neither widely available nor
recommended.
What is the prognosis for a person with Alzheimer's disease?
Alzheimer's disease is
invariably progressive.
Different studies have stated that Alzheimer's disease progresses over two to 25 years with most patients in the eight to 15 year range.
Nonetheless, defining when Alzheimer's disease starts, particularly in retrospect, can be very difficult. Patients usually don't die directly from Alzheimer's disease.
They die because they have difficulty swallowing or walking and these changes make overwhelming infections, such as pneumonia, much more likely.
Different studies have stated that Alzheimer's disease progresses over two to 25 years with most patients in the eight to 15 year range.
Nonetheless, defining when Alzheimer's disease starts, particularly in retrospect, can be very difficult. Patients usually don't die directly from Alzheimer's disease.
They die because they have difficulty swallowing or walking and these changes make overwhelming infections, such as pneumonia, much more likely.
Most persons with
Alzheimer's disease can remain at home as long as some assistance is provided
by others as the disease progresses.
Moreover, throughout much of the course of the illness, individuals maintain the capacity for giving and receiving love, sharing warm interpersonal relationships, and participating in a variety of meaningful activities with family and friends.
Moreover, throughout much of the course of the illness, individuals maintain the capacity for giving and receiving love, sharing warm interpersonal relationships, and participating in a variety of meaningful activities with family and friends.
A person with
Alzheimer's disease may no longer be able to do math but still may be able to
read a magazine with pleasure.
Playing the piano might become too stressful in the face of increasing mistakes, but singing along with others may still be satisfying. The chessboard may have to be put away, but playing tennis may still be enjoyable.
Thus, despite the many exasperating moments in the lives of patients with Alzheimer's disease and their families, many opportunities remain for positive interactions.
Challenge, frustration, closeness, anger, warmth, sadness, and satisfaction may all be experienced by those who work to help the person with Alzheimer's disease. For more, please read the Caregiving and Alzheimer's Disease: Caregiving Challenges articles.
Playing the piano might become too stressful in the face of increasing mistakes, but singing along with others may still be satisfying. The chessboard may have to be put away, but playing tennis may still be enjoyable.
Thus, despite the many exasperating moments in the lives of patients with Alzheimer's disease and their families, many opportunities remain for positive interactions.
Challenge, frustration, closeness, anger, warmth, sadness, and satisfaction may all be experienced by those who work to help the person with Alzheimer's disease. For more, please read the Caregiving and Alzheimer's Disease: Caregiving Challenges articles.
The reaction of a
patient with Alzheimer's disease to the illness and his or her capacity to cope
with it also vary, and may depend on such factors as lifelong personality
patterns and the nature and severity of stress in the immediate
environment.
Depression, severe uneasiness, paranoia, or delusions may accompany or result from the disease, but these conditions can often be improved by appropriate treatments. Although there is no cure for Alzheimer's disease, treatments are available to alleviate many of the symptoms that cause suffering.
Depression, severe uneasiness, paranoia, or delusions may accompany or result from the disease, but these conditions can often be improved by appropriate treatments. Although there is no cure for Alzheimer's disease, treatments are available to alleviate many of the symptoms that cause suffering.
What treatment and management options are available for Alzheimer's disease?
The management of
Alzheimer's disease consists of medication based and non-medication based
treatments.
Two different classes of pharmaceuticals are approved by the FDA for treating Alzheimer's disease:
Neither class of drugs has been proven to slow the rate of progression of Alzheimer's disease.
Nonetheless, many clinical trials suggest that these medications are superior to placebos (sugar pills) in relieving some symptoms.
Two different classes of pharmaceuticals are approved by the FDA for treating Alzheimer's disease:
- cholinesterase inhibitors and
- partial glutamate antagonists.
Neither class of drugs has been proven to slow the rate of progression of Alzheimer's disease.
Nonetheless, many clinical trials suggest that these medications are superior to placebos (sugar pills) in relieving some symptoms.
Cholinesterase inhibitors
In patients with
Alzheimer's disease there is a relative lack of a brain chemical
neurotransmitter called acetylcholine.
(Neurotransmitters are chemical messengers produced by nerves that the nerves use to communicate with each other in order to carry out their functions.)
Substantial research has demonstrated that acetylcholine is important in the ability to form new memories.
The cholinesterase inhibitors (ChEIs) block the breakdown of acetylcholine.
As a result, more acetylcholine is available in the brain, and it may become easier to form new memories.
(Neurotransmitters are chemical messengers produced by nerves that the nerves use to communicate with each other in order to carry out their functions.)
Substantial research has demonstrated that acetylcholine is important in the ability to form new memories.
The cholinesterase inhibitors (ChEIs) block the breakdown of acetylcholine.
As a result, more acetylcholine is available in the brain, and it may become easier to form new memories.
Four ChEIs have been
approved by the FDA, but only
Several studies suggest that the progression of symptoms of patients on these drugs seems to plateau for six to 12 months, but inevitably progression then begins again.
- donepezil hydrochloride (Aricept),
- rivastigmine (Exelon), and
- galantamine (Razadyne - previously called Reminyl) are used by most physicians because
- the fourth drug, tacrine (Cognex) has more undesirable side effects than the other three.
Several studies suggest that the progression of symptoms of patients on these drugs seems to plateau for six to 12 months, but inevitably progression then begins again.
Of the three widely
used
It is not known whether rivastigmine and galantamine are also effective in severe Alzheimer's disease, although there does not appear to be any good reason why they shouldn't.
- AchEs, rivastigmine and galantamine are only approved by the FDA for mild to moderate Alzheimer's disease, whereas
- donepezil is approved for mild, moderate, and severe Alzheimer's disease.
It is not known whether rivastigmine and galantamine are also effective in severe Alzheimer's disease, although there does not appear to be any good reason why they shouldn't.
The principal side
effects of ChEIs involve the gastrointestinal system and include nausea, vomiting, cramping, and diarrhea.
Usually these side effects can be controlled with change in size or timing of the dose or administering the medications with a small amount of food. Between 75% and 90% of patients will tolerate therapeutic doses of ChEIs.
Usually these side effects can be controlled with change in size or timing of the dose or administering the medications with a small amount of food. Between 75% and 90% of patients will tolerate therapeutic doses of ChEIs.
Partial glutamate antagonists
Glutamate is the major
excitatory neurotransmitter in the brain.
One theory suggests that too much glutamate may be bad for the brain and cause deterioration of nerve cells.
Memantine (Namenda) works by partially decreasing the effect of glutamate to activate nerve cells.
It has not been proven that memantine slows down the rate of progression of Alzheimer's disease.
Studies have demonstrated that some patients on memantine can care for themselves better than patients on sugar pills (placebos).
Memantine is approved for treatment of moderate and severe dementia, and studies did not show it was helpful in mild dementia.
It is also possible to treat patients with both AchEs and memantine without loss of effectiveness of either medication or an increase in side effects.
One theory suggests that too much glutamate may be bad for the brain and cause deterioration of nerve cells.
Memantine (Namenda) works by partially decreasing the effect of glutamate to activate nerve cells.
It has not been proven that memantine slows down the rate of progression of Alzheimer's disease.
Studies have demonstrated that some patients on memantine can care for themselves better than patients on sugar pills (placebos).
Memantine is approved for treatment of moderate and severe dementia, and studies did not show it was helpful in mild dementia.
It is also possible to treat patients with both AchEs and memantine without loss of effectiveness of either medication or an increase in side effects.
Non-medication based treatments
Non-medication based
treatments include maximizing patients' opportunities for social interaction
and participating in activities such as walking, singing, dancing
that they can still enjoy.
Cognitive rehabilitation, (whereby a patient practices on a computer program for training memory), may or may not be of benefit. Further studies of this method are needed.
Cognitive rehabilitation, (whereby a patient practices on a computer program for training memory), may or may not be of benefit. Further studies of this method are needed.
Treatment of psychiatric symptoms
Symptoms of
Alzheimer's disease include agitation, depression, hallucinations, anxiety, and sleep disorders.
Standard psychiatric drugs are widely used to treat these symptoms although none of these drugs have been specifically approved by the FDA for treating these symptoms in patients with Alzheimer's disease.
If these behaviors are infrequent or mild, they often do not require treatment with medication.
Non-pharmacologic measures can be very useful.
Standard psychiatric drugs are widely used to treat these symptoms although none of these drugs have been specifically approved by the FDA for treating these symptoms in patients with Alzheimer's disease.
If these behaviors are infrequent or mild, they often do not require treatment with medication.
Non-pharmacologic measures can be very useful.
Nevertheless,
frequently these symptoms are so severe that it becomes impossible for
caregivers to take care of the patient, and treatment with medication to
control these symptoms becomes necessary.
Agitation is common, particularly in middle and later stages of Alzheimer's disease. Many different classes of agents have been tried to treat agitation including:
Agitation is common, particularly in middle and later stages of Alzheimer's disease. Many different classes of agents have been tried to treat agitation including:
·
antipsychotics,
·
mood-stabilizing anticonvulsants,
·
trazodone (Desyrel),
·
anxiolytics, and
·
beta-blockers.
Studies are
conflicting about the usefulness of these different drug classes.
It was thought that newer, atypical antipsychotic agents such as
might have advantages over the older antipsychotic agents because of their fewer and less severe side effects and the patients' ability to tolerate them.
However, more recent studies have not demonstrated superiority of the newer antipsychotics.
Some research shows that these newer antipsychotics may be associated with increased risk of stroke or sudden death than the older antipsychotics, but many physicians believe this question is still not resolved.
It was thought that newer, atypical antipsychotic agents such as
- clozapine (Clozaril),
- risperidone (Risperdal),
- olanzapine (Zyprexa, Zydis),
- quetiapine (Seroquel), and
- ziprasidone (Geodon)
might have advantages over the older antipsychotic agents because of their fewer and less severe side effects and the patients' ability to tolerate them.
However, more recent studies have not demonstrated superiority of the newer antipsychotics.
Some research shows that these newer antipsychotics may be associated with increased risk of stroke or sudden death than the older antipsychotics, but many physicians believe this question is still not resolved.
Apathy and difficulty
concentrating occur in most Alzheimer's disease patients and should not be
treated with antidepressant medications.
However, many Alzheimer's disease patients have other symptoms of depression including sustained feelings of unhappiness and/or inability to enjoy their usual activities.
Such patients may benefit from a trial of antidepressant medication.
Most physicians will try selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft), citalopram (Celexa), or fluoxetine (Prozac), as first-line agents for treating depression in Alzheimer's disease.
However, many Alzheimer's disease patients have other symptoms of depression including sustained feelings of unhappiness and/or inability to enjoy their usual activities.
Such patients may benefit from a trial of antidepressant medication.
Most physicians will try selective serotonin reuptake inhibitors (SSRIs), such as sertraline (Zoloft), citalopram (Celexa), or fluoxetine (Prozac), as first-line agents for treating depression in Alzheimer's disease.
Anxiety is another
symptom in Alzheimer's disease that occasionally requires treatment.
Benzodiazepines such as diazepam (Valium) or lorazepam (Ativan) may be associated with increased confusion and memory impairment.
Non-benzodiazepine anxiolytics, such as buspirone (Buspar) or SSRIs, are probably preferable.
Benzodiazepines such as diazepam (Valium) or lorazepam (Ativan) may be associated with increased confusion and memory impairment.
Non-benzodiazepine anxiolytics, such as buspirone (Buspar) or SSRIs, are probably preferable.
Difficulty sleeping (insomnia) occurs in many
patients with Alzheimer's disease at some point in the course of their disease.
Many Alzheimer's disease specialists prefer the use of sedating atypical antidepressants such as trazodone (Desyrel).
However, other specialists may recommend other classes of medications.
Sleep improvement measures, such as sunlight, adequate treatment of pain, and limiting nighttime fluids to prevent the need for urination, should also be implemented.
Many Alzheimer's disease specialists prefer the use of sedating atypical antidepressants such as trazodone (Desyrel).
However, other specialists may recommend other classes of medications.
Sleep improvement measures, such as sunlight, adequate treatment of pain, and limiting nighttime fluids to prevent the need for urination, should also be implemented.
Potential and future therapies for Alzheimer's disease
A variety of clinical
research trials are underway with agents that try either to decrease the amount
of Aβ1-42 produced or increase the amount of Aβ1-42
removed.
It is hoped that such therapies may slow down the rate of progression of Alzheimer's disease. As of June 2007, it is not known how well such therapies may work.
It is hoped that such therapies may slow down the rate of progression of Alzheimer's disease. As of June 2007, it is not known how well such therapies may work.
Caring for the caregiver and Alzheimer's disease resources
Caring for the
caregiver is an essential element of managing the patient with Alzheimer's
disease. Caregiving is a distressing
experience. On the other hand, caregiver education delays nursing home placement
of Alzheimer's disease patients.
The 3Rs - Repeat, Reassure, and Redirect - can help caregivers reduce troublesome behaviors and limit the use of medications.
The short-term educational programs are well liked by family caregivers and can lead to a modest increase in disease knowledge and greater confidence among caregivers.
Educational training for staffs of long-term care facilities can decrease the use of antipsychotics in Alzheimer's disease patients.
The 3Rs - Repeat, Reassure, and Redirect - can help caregivers reduce troublesome behaviors and limit the use of medications.
The short-term educational programs are well liked by family caregivers and can lead to a modest increase in disease knowledge and greater confidence among caregivers.
Educational training for staffs of long-term care facilities can decrease the use of antipsychotics in Alzheimer's disease patients.
Caregivers should be
directed to support services, particularly the Alzheimer's Association
(1-800-272-3900, www.alz.org/chapter/).
Alzheimer's Disease At A Glance
·
Alzheimer's disease is a brain disease of unknown cause that
leads to dementia.
·
Most patients with Alzheimer's disease are over 65 years of age.
·
There are 10 classic warning signs of Alzheimer's disease:
memory loss, difficulty performing familiar tasks, problems with language,
disorientation to time and place, poor or decreased judgment, problems with
abstract thinking, misplacing things, changes in mood or behavior, changes in
personality, and loss of initiative.
·
Patients with symptoms of dementia should be thoroughly
evaluated before they become inappropriately or negligently labeled Alzheimer's
disease.
·
Although there is no cure for Alzheimer's disease, treatments
are available to alleviate many of the symptoms that cause suffering.
·
The management of Alzheimer's disease consists of medication
based and non-medication based treatments organized to care for the patient and
family. Treatments aimed at changing the underlying course of the disease
(delaying or reversing the progression) have so far been largely unsuccessful.
Medicines that restore the defect, or malfunctioning, in the chemical
messengers of the nerve cells have been shown to improve symptoms. Finally,
medications are available that deal with the psychiatric manifestations of
Alzheimer's disease.
·
National Institute on Aging home safety
for people with Alzheimer's disease
·
Introduction
·
Caring for a person with Alzheimer's disease is a challenge that
calls upon the patience, creativity, knowledge, and skills of each caregiver.
We hope that this booklet will help you cope with some of these challenges and
develop creative solutions to increase the security and freedom of the person
with Alzheimer's in your home, as well as your own peace of mind.
·
This booklet is for those who provide in-home care for people
with Alzheimer's disease or related disorders. Our goal is to improve home
safety by identifying potential problems in the home and offering possible
solutions to help prevent accidents.
·
We begin with a checklist to help you make each room in your
home a safer environment for the person with Alzheimer's. Next, we hope to increase
awareness of the ways specific impairments associated with the disease can
create particular safety hazards in the home. Specific home safety tips are
listed to help you cope with some of the more hazardous behaviors that may
occur as the disease advances. We also include tips for managing driving and
planning for natural disaster safety. The information ends with a list of
resources for family caregivers.
·
What is Alzheimer's
Disease?
·
Alzheimer's disease is a progressive, irreversible brain disease
that destroys memory and thinking skills. Estimates vary, but experts suggest
that as many as 5.1 million Americans has the disease, which affects people of
all racial, economic, and educational backgrounds. Although Alzheimer's
primarily affects people age 60 or older, it also may affect people in their
50s and, rarely, even younger.
·
Alzheimer's disease is the most common cause of dementia in adults. Dementia
is a loss of memory and intellect that interferes with daily life and
activities. Dementia is not a disease; rather, it is a group of symptoms that
may accompany certain diseases and conditions. Other symptoms include changes
in personality, mood, or behavior.
·
Other causes of irreversible dementia include vascular dementia
and alcohol
abuse. The recommendations
in this booklet deal primarily with common problems in Alzheimer's, but they
also may be helpful for people with other types of dementia.
What are the Symptoms of Alzheimer's disease?
There is no
"typical" person with Alzheimer's. There is tremendous variability
among people with Alzheimer's in their behaviors and symptoms. At present,
there is no way to predict how quickly the disease will progress in any one
person or the exact changes that will occur. We do know, however, that many of
these changes will present problems for caregivers. Therefore, knowledge and
prevention are critical to safety.
People with
Alzheimer's disease have memory problems and cognitive impairment (difficulties
with thinking and reasoning), and eventually they will not be able to care for
themselves. They often experience confusion, loss of judgment,
and difficulty finding words, finishing thoughts, or following directions. They
also may experience personality and behavior changes. For example, they may
become agitated, irritable, or very passive. Some people with Alzheimer's may
wander from home and become lost. Others may not be able to tell the difference
between day and night—they may wake up, get dressed, and start to leave the
house in the middle of the night thinking that the day has just started. People
with Alzheimer's also can have losses that affect vision, smell, or taste.
These disabilities are
very difficult, not only for the person with Alzheimer's, but for the
caregiver, family, and other loved ones as well. Caregivers need resources and
reassurance to know that while the challenges are great, specific actions can
reduce some of the safety concerns that accompany Alzheimer's disease.
General Safety Concerns
People with
Alzheimer's disease become increasingly unable to take care of themselves.
However, the disease progresses differently in each person. As a caregiver, you
face the ongoing challenge of adapting to each change in the person's behavior
and functioning. The following general principles may be helpful.
1.
Think prevention. It is very difficult to predict what a person with Alzheimer's
might do. Just because something has not yet occurred does not mean it should
not be cause for concern. Even with the best-laid plans, accidents can happen.
Therefore, checking the safety of your home will help you take control of some
of the potential problems that may create hazardous situations.
2.
Adapt the environment. It is more effective to change the environment than to change
most behaviors. While some Alzheimer's behaviors can be managed with special
medications prescribed by a doctor, many cannot. You can make changes in an
environment to decrease the hazards and stressors that accompany these
behavioral and functional changes.
3.
Minimize danger. By minimizing danger, you can maximize independence. A safe
environment can be a less restrictive environment where the person with
Alzheimer's disease can experience increased security and more mobility.
Is it Safe to Leave the Person With Alzheimer's disease Alone?
This issue needs
careful evaluation and is certainly a safety concern. The following points may
help you decide.
Does the person with
Alzheimer's:
·
become confused or unpredictable under stress?
·
recognize a dangerous situation, for example, fire?
·
know how to use the telephone in an emergency?
·
know how to get help?
·
stay content within the home?
·
wander and become disoriented?
·
show signs of agitation, depression, or withdrawal when
left alone for any period of time?
·
attempt to pursue former interests or hobbies that might now
warrant supervision, such as cooking, appliance repair, or woodworking?
You may want to seek
input and advice from a health care professional to assist you in these
considerations. As Alzheimer's disease progresses, these questions will need
ongoing evaluation.
Home Safety Room-By-Room
Prevention begins with
a safety check of every room in your home. Use the following room-by-room
checklist to alert you to potential hazards and to record any changes you need
to make. You can buy products or gadgets necessary for home safety at stores
carrying hardware, electronics, medical supplies, and children's items.
Keep in mind that it
may not be necessary to make all of the suggested changes. This booklet covers
a wide range of safety concerns that may arise, and some modifications may
never be needed. It is important, however, to re-evaluate home safety
periodically as behavior and abilities change.
Your home is a
personal and precious environment. As you go through this checklist, some of
the changes you make may impact your surroundings positively, and some may
affect you in ways that may be inconvenient or undesirable. It is possible,
however, to strike a balance. Caregivers can make adaptations that modify and
simplify without severely disrupting the home. You may want to consider setting
aside a special area for yourself, a space off-limits to anyone else and
arranged exactly as you like. Everyone needs private, quiet time, and as a
caregiver, this becomes especially crucial.
A safe home can be a
less stressful home for the person with Alzheimer's, the caregiver, and family
members. You don't have to make these changes alone. You may want to enlist the
help of a friend, professional, or community service such as the Alzheimer's
Association.
Throughout the Home
·
Display emergency numbers and your home address near all
telephones.
·
Use an answering machine when you cannot answer phone calls, and
set it to turn on after the fewest number of rings possible. A person with
Alzheimer's disease often may be unable to take messages or could become a
victim of telephone exploitation. Turn ringers on low to avoid distraction and
confusion. Put all portable and cell phones and equipment in a safe place so
they will not be easily lost.
·
Install smoke alarms and carbon monoxide detectors in or near
the kitchen and all sleeping areas. Check their functioning and batteries frequently.
·
Avoid the use of flammable and volatile compounds near gas
appliances. Do not store these materials in an area where a gas pilot light is
used.
·
Install secure locks on all outside doors and windows.
·
Hide a spare house key outside in case the person with
Alzheimer's disease locks you out of the house.
·
Avoid the use of extension cords if possible by placing lamps
and appliances close to electrical outlets. Tack extension cords to the
baseboards of a room to avoid tripping.
·
Cover unused electrical outlets with childproof plugs.
·
Place red tape around floor vents, radiators, and other heating
devices to deter the person with Alzheimer's from standing on or touching them
when hot.
·
Check all rooms for adequate lighting.
·
Place light switches at the top and the bottom of stairs.
·
Stairways should have at least one handrail that extends beyond
the first and last steps. If possible, stairways should be carpeted or have
safety grip strips. Put a gate across the stairs if the person has balance
problems.
·
Keep all medications (prescription and over-the-counter) locked.
Each bottle of prescription medicine should be clearly labeled with the
person's name, name of the drug, drug strength, dosage frequency, and
expiration date. Child-resistant caps are available if needed.
·
Keep all alcohol in a locked cabinet or out of reach of the
person with Alzheimer's. Drinking alcohol can increase confusion.
·
If smoking is permitted, monitor
the person with Alzheimer's while he or she is smoking. Remove matches,
lighters, ashtrays, cigarettes, and other means of smoking from view. This
reduces fire hazards, and with these reminders out of sight, the person may
forget the desire to smoke.
·
Avoid clutter, which can create confusion and danger. Throw out
or recycle newspapers and magazines regularly. Keep all areas where people walk
free of furniture.
·
Keep plastic bags out of reach. A
person with Alzheimer's disease may choke or suffocate.
·
Remove all guns and other weapons from the home or lock them up.
Installing safety locks on guns or remove ammunition and firing pins.
·
Lock all power tools and machinery in the garage, workroom, or
basement.
·
Remove all poisonous plants from the home. Check with local
nurseries or contact the poison control center (1-800-222-1222) for a
list of poisonous plants.
·
Make sure all computer equipment and accessories, including
electrical cords, are kept out of the way. If valuable documents or materials
are stored on a home computer, protect the files with passwords and back up the
files. Password protect access to the Internet, and restrict the amount of
online time without supervision. Consider monitoring computer use by the person
with Alzheimer's, and install software that screens for objectionable or
offensive material on the Internet.
·
Keep fish tanks out of reach. The combination of glass, water,
electrical pumps, and potentially poisonous aquatic life could be harmful to a
curious person with Alzheimer's disease.
Outside Approaches to the House
·
Keep steps sturdy and textured to prevent falls in wet or icy
weather.
·
Mark the edges of steps with bright or reflective tape.
·
Consider installing a ramp with handrails as an alternative to
the steps.
·
Eliminate uneven surfaces or walkways, hoses, and other objects
that may cause a person to trip.
·
Restrict access to a swimming pool by fencing it
with a locked gate, covering it, and closely supervising it when in use.
·
In the patio area, remove the fuel source and fire starters from
any grills when not in use, and supervise use when the person with Alzheimer's
is present.
·
Place a small bench or table by the entry door to hold parcels
while unlocking the door.
·
Make sure outside lighting is adequate. Light sensors that turn
on lights automatically as you approach the house may be useful. They also may
be used in other parts of the home.
·
Prune bushes and foliage well away from walkways and doorways.
·
Consider a NO SOLICITING sign for the front gate or door.
Entryway
·
Remove scatter rugs and throw rugs.
·
Use textured strips or nonskid wax on hardwood and tile floors
to prevent slipping.
Kitchen
·
Install childproof door latches on storage cabinets and drawers
designated for breakable or dangerous items. Lock away all household cleaning
products, matches, knives, scissors, blades, small appliances, and anything
valuable.
·
If prescription or nonprescription drugs are kept in the
kitchen, store them in a locked cabinet.
·
Remove scatter rugs and foam pads from the floor.
·
Install safety knobs and an automatic shut-off switch on the
stove.
·
Do not use or store flammable liquids in the kitchen. Lock them
in the garage or in an outside storage unit.
·
Keep a night-light in the kitchen.
·
Remove or secure the family "junk drawer." A person
with Alzheimer's may eat small items such as matches, hardware, erasers,
plastics, etc.
·
Remove artificial fruits and vegetables or food-shaped kitchen
magnets, which might appear to be edible.
·
Insert a drain trap in the kitchen sink to catch anything that
may otherwise become lost or clog the plumbing.
·
Consider disconnecting the garbage disposal. People with
Alzheimer's may place objects or their own hands in the disposal.
Bedroom
·
Anticipate the reasons a person with Alzheimer's disease might
get out of bed, such as hunger, thirst, going to the bathroom, restlessness,
and pain. Try to meet these needs by offering food and fluids and scheduling
ample toileting.
·
Use a night-light.
·
Use a monitoring device (like those used for infants) to alert
you to any sounds indicating a fall or other need for help. This also is an
effective device for bathrooms.
·
Remove scatter rugs and throw rugs.
·
Remove portable space heaters. If you use portable fans, be sure
that objects cannot be placed in the blades.
·
Be cautious when using electric mattress pads, electric
blankets, electric sheets, and heating pads, all of which can cause burns and fires. Keep
controls out of reach.
·
If the person with Alzheimer's disease is at risk of falling out
of bed, place mats next to the bed, as long as they do not create a greater
risk of accident.
·
Use transfer or mobility aids.
·
If you are considering using a hospital-type bed with rails
and/or wheels, read the Food and Drug Administration's up-to-date safety
information at FDA Medical Devices, Hospital Beds
Bathroom
·
Do not leave a severely impaired person with Alzheimer's alone
in the bathroom.
·
Remove the lock from the bathroom door to prevent the person
with Alzheimer's from getting locked inside.
·
Place nonskid adhesive strips, decals, or mats in the tub and
shower. If the bathroom is uncarpeted, consider placing these strips next to
the tub, toilet, and sink.
·
Use washable wall-to-wall bathroom carpeting to prevent slipping
on wet tile floors.
·
Use a raised toilet seat with handrails, or install grab bars
beside the toilet.
·
Install grab bars in the tub/shower. A grab bar in contrasting
color to the wall is easier to see.
·
Use a foam rubber faucet cover (often used for small children)
in the tub to prevent serious injury should the person with Alzheimer's fall.
·
Use a plastic shower stool and a hand-held shower head to make
bathing easier.
·
In the shower, tub, and sink, use a single faucet that mixes hot
and cold water to avoid burns.
·
Set the water heater at 120 degrees Fahrenheit to avoid scalding
tap water.
·
Insert drain traps in sinks to catch small items that may be
lost or flushed down the drain.
·
Store medications (prescription and nonprescription) in a locked
cabinet. Check medication dates and throw away outdated medications.
·
Remove cleaning products from under the sink, or lock them away.
·
Use a night-light.
·
Remove small electrical appliances from the bathroom. Cover
electrical outlets.
·
If a man with Alzheimer's disease uses an electric razor, have
him use a mirror outside the bathroom to avoid water contact.
Living Room
·
Clear electrical cords from all areas where people walk.
·
Remove scatter rugs or throw rugs. Repair or replace torn
carpet.
·
Place decals at eye level on sliding glass doors, picture
windows, or furniture with large glass panels to identify the glass pane.
·
Do not leave the person with Alzheimer's disease alone with an
open fire in the fireplace. Consider alternative heating sources.
·
Keep matches and cigarette lighters out of reach.
·
Keep the remote controls for the television, DVD player, and
stereo system out of sight.
Laundry Room
·
Keep the door to the laundry room locked if possible.
·
Lock all laundry products in a cabinet.
·
Remove large knobs from the washer and dryer if the person with
Alzheimer's tampers with machinery.
·
Close and latch the doors and lids to the washer and dryer to
prevent objects from being placed in the machines.
Garage/Shed/Basement
·
Lock access to all garages, sheds, and basements if possible.
·
Inside a garage or shed, keep all potentially dangerous items,
such as tools, tackle, machines, and sporting equipment either locked away in
cabinets or in appropriate boxes/cases.
·
Secure and lock all motor vehicles and keep them out of sight if
possible. Consider covering vehicles, including bicycles, that are not
frequently used. This may reduce the possibility that the person with
Alzheimer's will think about leaving.
·
Keep all toxic materials, such as paint, fertilizers, gasoline,
or cleaning supplies, out of view. Either put them in a high, dry place, or
lock them in a cabinet.
·
If the person with Alzheimer's is permitted in a garage, shed,
or basement, preferably with supervision, make sure the area is well lit and
that stairs have a handrail and are safe to walk up and down. Keep walkways
clear of debris and clutter, and place overhanging items out of reach.
Home Safety Behavior-By-Behavior
Although a number of
behavior and sensory problems may accompany Alzheimer's disease, not every
person will experience the disease in exactly the same way. As the disease
progresses, particular behavioral changes can create safety problems. The
person with Alzheimer's may or may not have these symptoms. However, should
these behaviors occur, the following safety recommendations may help reduce
risks.
Wandering
·
Remove clutter and clear the pathways from room to room to
prevent falls and allow the person with Alzheimer's to move about more freely.
·
Make sure floors provide good traction for walking or pacing. Use
nonskid floor wax or leave floors unpolished. Secure all rug edges, eliminate
throw rugs, or install nonskid strips. The person with Alzheimer's should wear nonskid
shoes or sneakers.
·
Place locks high or low on exit doors so they are out of direct
sight. Consider installing double locks that require a key. Keep a key for
yourself, and hide one near the door for emergency exit purposes.
·
Use loosely fitting doorknob covers so that the cover turns
instead of the actual knob. Due to the potential hazard they could cause if an
emergency exit is needed, locked doors and doorknob covers should be used only
when a caregiver is present.
·
Install safety devices found in hardware stores to limit how
much windows can be opened.
·
If possible, secure the yard with fencing and a locked gate. Use
door alarms such as loose bells above the door or devices that ring when the
doorknob is touched or the door is opened.
·
Divert the attention of the person with Alzheimer's disease away
from using the door by placing small scenic posters on the door; placing
removable gates, curtains, or brightly colored streamers across the door; or
wallpapering the door to match any adjoining walls.
·
Place STOP, DO NOT ENTER, or CLOSED signs on doors in strategic
areas.
·
Keep shoes, keys, suitcases, coats, hats, and other signs of
departure out of sight.
·
Obtain a medical identification bracelet for the person with
Alzheimer's with the words "memory loss" inscribed along with an
emergency telephone number. Place the bracelet on the person's dominant hand to
limit the possibility of removal, or solder the bracelet closed. Check with the
local Alzheimer's Association about the Safe Return program.
·
Place labels in garments to aid in identification.
·
Keep an article of the person's worn, unwashed clothing in a
plastic bag to aid in finding someone with the use of dogs.
·
Notify neighbors of the person's potential to wander or become
lost. Alert them to contact you or the police immediately if the individual is
seen alone and on the move.
·
Give local police, neighbors, and relatives a recent photo of
the person with Alzheimer's, along with the person's name and pertinent
information, as a precaution should he or she become lost. Keep extra photos on
hand.
·
Consider making an up-to-date home video of the person with
Alzheimer's disease.
·
Do not leave a person with Alzheimer's who has a history of
wandering unattended.
Rummaging/Hiding Things
·
Lock up all dangerous or toxic products, or place them out of
the person's reach.
·
Remove all old or spoiled food from the refrigerator and
cupboards. A person with Alzheimer's may rummage for snacks but may lack the
judgment or taste to rule out spoiled foods.
·
Simplify the environment by removing clutter or valuable items
that could be misplaced, lost, or hidden by the person with Alzheimer's
disease. These include important papers, checkbooks, charge cards, and jewelry.
·
If your yard has a fence with a locked gate, place the mailbox
outside the gate. People with Alzheimer's often hide, lose, or throw away mail.
If this is a serious problem, consider obtaining a post office box.
·
Create a special place for the person with Alzheimer's to
rummage freely or sort (for example, a chest of drawers, a bag of selected
objects, or a basket of clothing to fold or unfold). Often, safety problems
occur when the person with Alzheimer's becomes bored or does not know what to
do.
·
Provide the person with Alzheimer's a safe box, treasure chest,
or cupboard to store special objects.
·
Close access to unused rooms, thereby limiting the opportunity
for rummaging and hiding things.
·
Search the house periodically to discover hiding places. Once
found, these hiding places can be discreetly and frequently checked.
·
Keep all trash cans covered or out of sight. The person with
Alzheimer's disease may not remember the purpose of the container or may
rummage through it.
·
Check trash containers before emptying them in case something
has been hidden there or accidentally thrown away.
Hallucinations, Illusions, and Delusions
Due to complex changes
occurring in the brain, people with Alzheimer's may see or hear things that
have no basis in reality. Hallucinations involve hearing, seeing, smelling, or
feeling things that are not really there. For example, a person with
Alzheimer's may see children playing in the living room when no children exist.
Illusions differ from hallucinations because the person with Alzheimer's is
misinterpreting something that actually does exist. Shadows on the wall may
look like people, for example. Delusions are false beliefs that the person
thinks are real. For example, stealing may be suspected but cannot be verified.
It is important to
seek medical evaluation if a person with Alzheimer's has ongoing disturbing
hallucinations, illusions, or delusions. Discuss with the doctor any illnesses
the person has and medicines he or she is taking. An illness or medicine may
cause hallucinations or delusions. Often, these symptoms can be treated with
medication or behavior management techniques. With all of these symptoms, the
following environmental adaptations also may be helpful.
·
Paint walls a light color to reflect more light. Use solid
colors, which are less confusing to an impaired person than a patterned wall.
Large, bold prints (for example, florals in wallpaper or drapes) may cause
confusing illusions.
·
Make sure there is adequate lighting, and keep extra bulbs handy
in a secured place. Dimly lit areas may produce confusing shadows or difficulty
with interpreting everyday objects.
·
Reduce glare by using soft light or frosted bulbs, partially
closing blinds or curtains, and maintaining adequate globes or shades on light
fixtures.
·
Remove or cover mirrors if they cause the person with
Alzheimer's disease to become confused or frightened.
·
Ask if the person can point to a specific area that is producing
confusion. Perhaps one particular aspect of the environment is being
misinterpreted.
·
Vary the home environment as little as possible to minimize the
potential for visual confusion. Keep furniture in the same place.
·
Avoid violent or disturbing television programs. The person with
Alzheimer's may believe a story is real.
·
Do not confront the person with Alzheimer's who becomes
aggressive. Withdraw and make sure you have access to an exit as needed.
Special Occasions/Gatherings/Holidays
When celebrations,
special events, or holidays include large numbers of people, remember that
large groups may cause a person with Alzheimer's disease some confusion and anxiety. The person with
Alzheimer's may find some situations easier and more pleasurable than others.
·
Large gatherings, weddings, family reunions, or picnics may
cause anxiety. Consider having a more intimate gathering with only a few people
in your home. Think about having friends and family visit in small groups
rather than all at once. If you are hosting a large group, remember to prepare
the person with Alzheimer's ahead of time. Try to have a space available where
he or she can rest, be alone, or spend some time with a smaller number of
people, if needed.
·
Consider simplifying your holidays around the home and remember
that you already may have more responsibilities than in previous years. For
example, rather than cooking an elaborate dinner at Thanksgiving or Christmas,
invite family and friends for a potluck dinner. Instead of elaborate
decorations, consider choosing a few select items to celebrate holidays. Make
sure holiday decorations do not significantly alter the environment, which
might confuse the person with Alzheimer's disease.
·
Holiday decorations, such as Christmas trees, lights, or
menorahs, should be secured so that they do not fall or catch on fire. Anything
flammable should be monitored at all times, and extra precautions should be
taken so that lights or anything breakable are fixed firmly, correctly, and out
of the way of those with Alzheimer's disease.
·
As suggested by most manufacturers, candles of any size should
never be lit without supervision. When not in use, they should be put away.
·
Try to avoid clutter in general, especially in walkways, during
the holidays.
Impairment of the Senses
Alzheimer's disease
can cause changes in a person's ability to interpret what he or she can see,
hear, taste, feel, or smell. The person with Alzheimer's should be evaluated
periodically by a physician for any such changes that may be correctable with
glasses, dentures, hearing aids, or
other devices.
Vision
People with
Alzheimer's may experience a number of changes in visual abilities. For
example, they may lose their ability to comprehend visual images. Although
there is nothing physically wrong with their eyes, people with Alzheimer's may
no longer be able to interpret accurately what they see because of brain
changes. Also, their sense of perception and depth may be altered. These
changes can cause safety concerns.
·
Create color contrast between floors and walls to help the
person see depth. Floor coverings are less visually confusing if they are a
solid color.
·
Use dishes and placemats in contrasting colors for easier
identification.
·
Mark the edges of steps with brightly colored strips of tape to
outline changes in height.
·
Place brightly colored signs or simple pictures on important
rooms (the bathroom, for example) for easier identification.
·
Be aware that a small pet that blends in with the floor or lies
in walkways may be a hazard. The person with Alzheimer's disease may trip over
the pet.
Smell
A loss of or decrease
in smell often accompanies Alzheimer's disease.
·
Install smoke detectors and check them frequently. The person
with Alzheimer's disease may not smell smoke or may not associate it with
danger.
·
Keep refrigerators clear of spoiled foods.
·
Touch
·
People with Alzheimer's may experience loss of sensation or may
no longer be able to interpret feelings of heat, cold, or discomfort.
·
Adjust water heaters to 120 degrees Fahrenheit to avoid scalding
tap water. Most hot water heaters are set at 150 degrees, which can cause
burns.
·
Color code separate water faucet handles, with red for hot and
blue for cold.
·
Place a sign on the oven, coffee maker, toaster, crock-pot,
iron, and other potentially hot appliances that says DO NOT TOUCH or STOP! VERY
HOT. The person with Alzheimer's should not use appliances without supervision.
Unplug appliances when not in use.
·
Use a thermometer to tell you if bath water is too hot or too
cold.
·
Remove furniture or other objects with sharp corners or pad the
corners to reduce potential for injury.
Taste
People with
Alzheimer's may lose taste sensitivity. As their judgment declines, they also
may place dangerous or inappropriate things in their mouths.
·
Keep all condiments such as salt, sugar, or spices hidden if you
see the person with Alzheimer's using excess amounts. Too much salt, sugar, or
spice can be irritating to the stomach or cause other health problems.
·
Remove or lock up medicine cabinet items such as toothpaste,
perfume, lotions, shampoos, rubbing alcohol, and soap, which may look and smell
like food to the person with Alzheimer's.
·
Consider a childproof latch on the refrigerator, if necessary.
·
Keep the toll-free poison control number (1-800-222-1222) by the
telephone. Keep a bottle of ipecac (vomit-inducing agent) available, but use
only with instructions from poison control or 911.
·
Keep pet litter boxes inaccessible to the person with
Alzheimer's disease. Do not store pet food in the refrigerator.
·
Learn the Heimlich maneuver or other techniques to use in case
of choking. Check with your local Red Cross chapter for more information and
instruction.
·
If possible, keep a spare set of dentures. If the person keeps
removing dentures, check for correct fit.
Hearing
People with Alzheimer's
disease may have normal hearing, but they may lose their ability to interpret
what they hear accurately. This loss may result in confusion or
overstimulation.
·
Avoid excessive noise in the home such as having the stereo and
the TV on at the same time.
·
Be sensitive to the amount of noise outside the home, and close
windows or doors, if necessary.
·
Avoid large gatherings of people in the home if the person with
Alzheimer's shows signs of agitation or distress in crowds.
·
If the person wears a hearing aid, check the batteries and
functioning frequently.
Driving
Driving is a complex
activity that demands quick reactions, alert senses, and split-second decision
making. For a person with Alzheimer's disease, driving becomes increasingly
difficult. Memory
loss, impaired judgment,
disorientation, impaired visual and spatial perception, slow reaction time,
certain medications, diminished attention span, and inability to recognize cues
such as stop signs and traffic lights can make driving particularly hazardous.
People with
Alzheimer's who continue to drive can be a danger to themselves, their
passengers, and the community at large. As the disease progresses, they lose
driving skills and must stop driving. Unfortunately, people with Alzheimer's
often cannot recognize when they should no longer drive. This is a tremendous
safety concern. It is extremely important to have the impaired person's driving
abilities carefully evaluated.
Warning Signs of Unsafe Driving
Often, the caregiver
or a family member, neighbor, or friend is the first to become aware of the
safety hazards of someone with Alzheimer's behind the wheel. If a person with
Alzheimer's disease experiences one of more of the following problems, it may
be time to limit or stop driving.
Does the person with
Alzheimer's:
·
get lost while driving in a familiar location?
·
fail to observe traffic signals?
·
drive at an inappropriate speed?
·
become angry, frustrated, or confused while driving?
·
make slow or poor decisions?
Please do not wait for
an accident to happen. Take action immediately!
Explaining to the
person with Alzheimer's disease that he or she can no longer drive can be
extremely difficult. Loss of driving privileges may represent a tremendous loss
of independence, freedom, and identity. It is a significant concern for the
person with Alzheimer's and the caregiver. The issue of not driving may produce
anger, denial, and grief in the person with Alzheimer's, as well as guilt and
anxiety in the caregiver. Family and concerned professionals need to be both
sensitive and firm. Above all, they should be persistent and consistent.
The doctor of a person
with Alzheimer's disease can assist the family with the task of restricting
driving. Talk with the doctor about your concerns. Most people will listen to
their doctor. Ask the doctor to advise the person with Alzheimer's to reduce
his or her driving, go for a driving evaluation or test, or stop driving
altogether. An increasing number of States have laws requiring physicians to
report Alzheimer's and related disorders to the Department of Motor Vehicles.
The Department of Motor Vehicles then is responsible for retesting the at-risk
driver. Testing should occur regularly, at least yearly.
When dementia impairs
driving and the person with Alzheimer's disease continues to insist on driving,
a number of different approaches may be necessary.
·
Work as a team with family, friends, and professionals, and use
a single, simple explanation for the loss of driving ability such as: "You
have a memory problem, and it is no longer safe to drive," "You
cannot drive because you are on medication," or "The doctor has
prescribed that you no longer drive."
·
Ask the doctor to write on a prescription pad DO NOT DRIVE. Ask
the doctor to write to the Department of Motor Vehicles or Department of Public
Safety saying this person should no longer drive. Show the letter to the person
with Alzheimer's disease as evidence.
·
Offer to drive or ask a friend or family member to drive.
·
Walk when possible, and make these outings special events.
·
Use public transportation or any special transportation provided
by community organizations. Ask about senior discounts or transportation
coupons. The person with Alzheimer's should not take public transportation
unsupervised.
·
Park the car at a friend's home.
·
Hide the car keys.
·
Exchange car keys with a set of unusable keys. Some people with
Alzheimer's are in the habit of carrying keys.
·
Place a large note under the car hood requesting that any
mechanic call you before doing work requested by the person with Alzheimer's
disease.
·
Have a mechanic install a "kill switch" or alarm
system that disengages the fuel line to prevent the car from starting.
·
Consider selling the car and putting aside for taxi fares the
money saved from insurance, repairs, and gasoline.
·
Do not leave a person with Alzheimer's alone in a parked car.
Natural Disaster Safety
Natural
disasters
come in many forms and degrees of severity. They seldom give warning, and they
call upon good judgment and the ability to follow through with crisis plans.
People with Alzheimer's disease are at a serious disadvantage. Their
impairments in memory and reasoning severely limit their ability to act
appropriately in crises.
It is always important
to have a plan of action in case of fire, earthquake, flood, tornado, or other
disasters. Specific home safety precautions may apply and environmental changes
may be needed. The American Red Cross is an excellent resource for general
safety information and preparedness guides for comprehensive planning. If there
is a person with Alzheimer's in the home, the following precautions apply:
·
Get to know your neighbors, and identify specific individuals
who would be willing to help in a crisis. Formulate a plan of action with them
should the person with Alzheimer's be unattended during a crisis.
·
Give neighbors a list of emergency phone numbers of caregivers,
family members, and primary medical resources.
·
Educate neighbors beforehand about the person's specific
disabilities, including inability to follow complex instructions, memory loss,
impaired judgment, and probable disorientation and confusion. Give examples of
some of the simple one-step instructions that the person may be able to follow.
·
Have regular emergency drills so that each member of the
household has a specific task. Realize that the person with Alzheimer's disease
cannot be expected to hold any responsibility in the crisis plan and that
someone will need to take primary responsibility for supervising the
individual.
·
Always have at least an extra week's supply of any medical or
personal hygiene items critical to the person's welfare, such as:
§ food and water
§ medications
§ incontinence
undergarments
§ hearing aid batteries
Keep an extra pair of the person's eyeglasses on hand.
Be sure that the person with Alzheimer's wears an identification
bracelet stating "memory loss" should he or she become lost or
disoriented during the crisis. Contact your local Alzheimer's Association
chapter and enroll the person in the Safe Return program.
Under no circumstances should a person with Alzheimer's be left
alone following a natural disaster. Do not count on the individual to stay in
one place while you go to get help. Provide plenty of reassurance.
Who Would Take Care of the Person with Alzheimer's disease if Something Happened to You?
It is important to
have a plan in case of your own illness, disability, or death.
·
Consult a lawyer about setting up a living trust, durable power
of attorney for health care and finances, and other estate planning tools.
·
Consult with family and close friends to decide who will take
responsibility for the person with Alzheimer's. You also may want to seek information
about your local public guardian's office, mental
health
conservator's office, adult protective services, or other case management
services. These organizations may have programs to assist the person with
Alzheimer's in your absence.
·
Maintain a notebook for the responsible person who will assume caregiving. Such a notebook
should contain the following information:
§ emergency phone
numbers
§ current problem
behaviors and possible solutions
§ ways to calm the
person with Alzheimer's
§ assistance needed with
toileting, feeding, or grooming
§ favorite activities or
food
Preview board and care
or long-term care facilities in your community and select a few as
possibilities. Share this information with the responsible person. If the
person with Alzheimer's disease is no longer able to live at home, the
responsible person will be better able to carry out your wishes for long-term
care.
Conclusion
Home safety takes many
forms. This booklet focuses on the physical environment and specific safety
concerns. But the home environment also involves the needs, feelings, and
lifestyles of you the caregiver, your family, and the person with Alzheimer's
disease. Disability affects all family members, and it is crucial to maintain
your emotional and physical welfare in addition to ensuring a safe environment.
We encourage you to
make sure you have quiet time, time out, and time to take part in something you
enjoy. Protect your own emotional and physical health. Your local Alzheimer's
Association chapter can help you with the support and information you may need
as you address this very significant checkpoint in your home safety list. You
are extremely valuable. As you take on a commitment to care for a person with
Alzheimer's, please take on the equally important commitment to care for
yourself.
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