In the present essay we would like to touch upon the issue of healthcare for older people and treating patients with Alzheimer’s disease in particular. We consider the community’s mental health maintaining an especially relevant topic nowadays as the number of elderly people with mental health problems increases constantly from year to year, and the health condition of the whole nation today depends on the ability of the Health Department to provide a full range of high quality preventive and care services for sick people. Since the disease is incurable and its outcomes make patient’s life very complicated because of losing basic and fundamental abilities, the role of professional skilled nurses becomes essential in treating people with dementia.
Alzheimer’s disease (senile dementia of Alzheimer’s type) is the most common form of dementia, an incurable degenerative disease, first described in 1906 by German psychiatrist Alois Alzheimer. As a rule, it is found among people over 65, but there is an early Alzheimer’s disease – a rare form of the disease. An estimated worldwide incidence in 2006 was 26.6 million people and the number of patients might grow four-fold by 2050. This pathology is found 3-5 times more frequently among women, than among men. Alzheimer’s disease refers to diseases, which impose the most severe financial burden on society in the developed countries (Nordqvist 2009;).
Alzheimer’s disease is characterized by the development of amyloid plaques and neurofibrillary tangles in brain tissue. Protein of amyloid plaques blocks certain receptors in brain, interrupting the signals responsible for processing information and working with memory. Its first manifestations are impaired memory, which are soon complemented with speech disorders by type of acoustic-mnestic aphasia. Patients cannot remember the right word, and replace it with another one with not suitable meaning (Europa).
It also affects visual-spatial sphere. One is disoriented in the area, forgets the way home, and does not recognize friends and even relatives. In the end, the skills of any action are lost: patients are unable to dress themselves, wash, and eat. There are personality changes, depression, psychotic disorders. Patients lose ability to self-care and require constant care. In 10% of cases epileptic seizures emerge. In connection with the inability to perform purposeful actions in extensive stage of the disease patients are immobilized, therefore they usually die from pneumonia. Average life expectancy of such patients is about 8 years (Graham 2009).
Since memory impairment is the first complaint of patients with Alzheimer’s disease, it is important to be able to assess it.
Age memory impairment is diagnosed in 40% of people aged over 65. But only 1% of them develop dementia. A slight decline of cognitive functions is observed in 10% of elderly people. Approximately 15% of them develop Alzheimer’s disease. Patients with mild memory impairment are most promising for pharmacotherapy (Waldemar & Burns 2009).
Where possible, in case of dementia neurovisualisation is needed. Magnetic resonance imaging is carried out in order to exclude focal changes and to identify specific signs of illness. In some countries, genetic testing is widespread, which can detect genes and mutations responsible for the development of this pathology.
Treatment of patients with Alzheimer’s disease involves pharmacological intervention and rational therapy. The drugs used in the treatment of this disease include acetylcholinesterase inhibitors, selegiline (MAO-B inhibitors), nootropics, vitamin E, nonsteroidal anti-inflammatory drugs and estrogen (for women during menopause) (Feldman 2007).
Scientists are actively seeking for the new drugs, currently the clinical trials of more than 10 medicines are completed. The point of application of most of them is the cholinergic system. In preclinical studies drugs are evaluated that affect the way of amyloid formation and protect the brain from its toxic effects. Perhaps in the future there will be a massive survey of the population aged 40-50 years, when amyloid plaques are beginning to appear in the cortex of the temporal region (Lanctot, Rajaram & Herrmann 2009).
Till the present time the full understanding of causes and course of Alzheimer’s disease has not been reached. The surveys suggest an association of disease with the accumulation of plaques and tangles in the brain tissues. Modern therapies only alleviate some symptoms, but do not yet allow slowing down or halting the development of the disease. Many promising therapies have reached the stage of clinical trials, the number of which was over 500 in 2008, but it is unclear whether their effectiveness will be proved. There were suggested many ways to prevent Alzheimer’s disease, but their impact on the course of the disease and its severity is not evidenced.
Old age is a major risk factor as it is reflected in the statistics: for every 5 years after the age of 65 rate risk increases twice.
Clinical diagnosis of Alzheimer’s disease is usually based on the patient’s history, his family history and clinical observations considering the characteristic neurological and neuropsychological symptoms and excluding alternative diagnoses. In order to distinguish the disease from other types of pathologies and dementia, sophisticated methods of medical imaging can be used – computed tomography, magnetic resonance imaging, photon-emission computed tomography or positron emission tomography. For a more accurate assessment of the state intellectual functions are tested, including memory.
In the diagnosis of Alzheimer’s disease might be helpful neuropsychological screening test, in which patients are copying shapes, remember the words, read and do arithmetic. Neuropsychological tests, for example, MMSE, are widely used to assess cognitive impairment, emerging during the disease. To obtain reliable results a more detailed set of tests is required, especially in the early stages of the disease. For the differential diagnosis of Alzheimer’s disease and other diseases advanced neurological research is important (Gauthier 2006).
Conversation with family members is also used in evaluating the disease, because relatives can provide important information about the level of patient’s everyday human activity and the gradual decline of his mental abilities. Psychological tests are also used to identify depression, which may accompany a disease like Alzheimer’s and cause cognitive decline (Caracciolo & Bartorelli 2005).
Equipment for single photon emission computerized tomography (SPECT) and positron emission tomography (PET) if available can be used to confirm the diagnosis in conjunction with other evaluation methods, including an analysis of the mental status.
Since Alzheimer’s disease cannot be cured, the available therapies can only to a certain degree effect the symptoms, but are essentially palliative measures. The entire set of measures can be divided into pharmacological, psychosocial measures and measures to care for the sick (Alzheimer Europe).
Currently four types of drugs are approved for the treatment of cognitive disorders in Alzheimer’s disease – three cholinesterase inhibitors and memantine, NMDA-antagonist. But there are no drugs, the effects of which would indicate slowing or stopping the development of Alzheimer’s disease (Campbell & Gowran 2007).
A special sensory room (snoezelen) is used to emotionally-oriented care for people suffering from dementia. Psychosocial intervention supplements the pharmacological one and can be divided into the following approaches: behavioural, emotional, cognitive, and stimulating-oriented (Hope & Waterman 2004).
The effectiveness of intervention has not yet been elucidated in the scientific literature; moreover, the approach is not applied to Alzheimer’s disease, but to dementia in general.
Behavioural intervention is aimed at the definition of causes and consequences of problematic behaviour and work on their correction. When using this approach no improvement in the overall level of functioning has been marked, but it might mitigate some specific problems such as incontinence.
Regarding the impact of techniques of this trend on other behavioural problems not enough quality data has been collected.
Interventions that affect the emotional sphere include reminiscence therapy (RT), validation therapy, supportive psychotherapy, sensory integration (snoezelen), and simulated presence therapy (SPT). Some clinical specialists believe that supportive therapy provides benefit when trying to help minor sick patients to adapt to the disease. With reminiscence therapy (RT) patients discuss their experiences face to face with a therapist or in a group, often with photographs, household items, old music, and archival audio recordings and other familiar items from the past. This method may have positive effects on thinking and mood of the patient.
Simulated presence based on theories of attachment, supposes playing the tapes with the voices of the relatives. According to preliminary data, patients undergoing SPT, become calmer. Validation therapy is based on the recognition of reality and truth of personal experience of another person, and during sensory integration sessions the patient performs exercises designed to stimulate the senses. However, there is little data in support of these two methods (Sun 2009).
Orienteering in reality, cognitive retraining and other cognitive-oriented therapies are applied in order to reduce the cognitive deficits. Orienteering in reality suggests providing information about time, location and identity of the patient in order to facilitate his understanding of the situation and his own place in it. In turn, cognitive retraining is carried out to improve the abilities of disturbed patient who is given tasks that require mental effort.
Stimulant therapies include art therapy, music therapy, as well as types of therapy, when patients interact with animals, do exercises and any other restorative activity. Stimulation, according to research, has a moderate influence on behaviour and mood, and even less on the level of functioning. In any case, such therapy is conducted primarily to improve the daily lives of patients.
Caring and nursing the patient is extremely important because the disease is incurable and degenerative. This role is often played by a spouse or close relative. Such a heavy burden greatly affects the social, psychological, economic and other aspects of human life of a person caring for the sick (Chalfont 2007).
The nurse ensures the infectious safety of patients, carries out all phases of nursing process in caring for patients (patient’s state assessment, interpretation of the records, planning care, etc.), performs preventive, therapeutic and diagnostic procedures, prescribed by the doctor, assists the doctor during treatment diagnostic manipulations and operations, provides emergency assistance, inserts drugs into patients, conducts health education on health promotion and disease prevention, promotion of healthy lifestyles.
The nursing interventions during Alzheimer’s disease include those for memory disorders, language difficulties, and problems of visuospatial function, which are common cognitive defects among older people with dementia. Thus, in order to maintain memory ability nurses can use written reminders, memory places for keeping everyday items, phone reminders, specific exercises for training memory. Treating patients with language difficulties nurses help them find the correct word in a conversation, encourage reading and oral communication. Dealing with older people having impaired visuospatial functioning nurses ensure patients’ security by maintaining a usual environment, explaining all the actions to avoid patient’s disorientation, miscomprehension and fear (Alzheimer Europe).
In the early and moderate stages of the disease patient’s safety can be improved and care simplified by making changes in the patient’s environment and lifestyle. Such measures include the transition to a simple daily routine, attaching safety locks, sticking labels to household supplies with an explanation of how to use them. The patient may lose the ability to feed himself; in this case feeding through a tube may be required. In this case, family members and service workers face the ethical question of how long should such feeding continue; is it effective from the medical point of view? Sometimes it is necessary to physically fix the patient to protect him from harming himself or others (Cummings, Gauthier, & Scheltens 2005).
As the disease develops various complications may emerge, such as diseases of the teeth and mouth, bedsores, malnutrition, hygiene problems, respiratory, eye or skin infections. They can be avoided with careful nursing, but when they occur, professional intervention is required. Facilitating care for the patient in front of approaching death is the main task at the last stage of the disease (Smith 2005).
Genetic predisposition is not a guarantee for the development of the disease. Everything that contributes to the health of the brain may delay the advance of dementia. Therefore it is necessary to avoid stress (chronic stress leads to poor memory), do exercises (physical activity improves cerebral blood flow, which in turn promotes the growth of nerve cells and stimulates mental function), take vitamins (consuming large amounts of fat and carbohydrates increases the risk of atherosclerosis and diabetes, which contributes to the emergence of dementia, and polyunsaturated fatty acids, antioxidants, like vitamins C and E have a protecting effect on the brain), perform intellectual activity (the risk of developing Alzheimer’s disease is much lower among intellectually active people), and it is also important to protect the head (patients who have suffered traumatic brain injury, as well as smokers have the probability of formation of Alzheimer’s disease 2 times higher) (Alzheimer Europe).
Realising that many serious diseases (including Alzheimer’s disease) are more frequent among older people, a National Service Framework (NSF) for Older People has been specially formed to meet the problems of older people in obtaining care and to provide the best quality services.
NSF deals with the cases significant for older people like stroke, falls and mental health problems related to ageing.
The four main tasks of the National Service Framework are as follows:
- To respect the individual, which means fighting age discrimination and ensuring that older patients are treated properly, considering their personal needs; providing a properly arranged, rational and interrelated approach to evaluating individual needs and to appointing specific services for them.
- To create an intermediate care to make it possible for older people to receive the necessary range of care services at home or in special care centres; to ensure patients’ independence by giving improved health services to avoid needless hospitalisation and efficient treatment to ensure quick discharge from hospital and to avoid untimely or unwarranted durable residential care.
- To provide evidence-based professional care because the UK trains high quality specialists for older people services in the world, whose effectiveness has been proved many times. Well-timed intervention based on proper patient state assessment reduces accelerates the recovery.
- To promote an active, healthy lifestyle among older people for they are willing to maintain their health and independence from the necessity to be constantly assisted by special services and their family members. Therefore, NSF with the support from councils has designed an organised programme of action directed to distribute the idea of active and healthy lifestyle for the well-being of older people (Department of Health).
All the above mentioned and other services are applied to help older people with serious diseases fight for their health and lead a full-sized life in appropriate conditions.
While nurses provide care services to maintain patients’ abilities to function independently and feel as comfortable as it is possible in their case, laboratory researchers work hard inventing and testing new medicines for stopping or slowing down the development of this serious mental disease. The number of new treatment methods increases each year and this gives hope that science is getting closer towards the solution of dementia problem and finding the way to stop or prevent its development.
Alzheimer’s Disease. Alzheimer Europe. <http://www.alzheimer-europe.org>.
Alzheimer Disease and Other Dementias. Public Health. Europa.<http://ec.europa.eu/health/ph_information/ dissemination/diseases/alzheimer_en.htm>.
Campbell, V.A., & Gowran, A. 2007. Alzheimer’s Disease; Taking the Edge Off With Cannabinoids? British Journal of Pharmacology (152). 655–662.
Caracciolo, F., & Bartorelli, L. 2005. Alzheimer: A Journey Together. Jessica Kingsley Publishers.
Chalfont, G. 2007. Design for Nature in Dementia Care. Jessica Kingsley Publishers.
Cummings, J.L., Gauthier, S., & Scheltens, P. 2005. Alzheimer’s Disease and Related Disorders Annual 5. Informa Healthcare.
Feldman, H. 2007. Atlas of Alzheimer’s Disease. 1st Ed. Informa Healthcare.
Gauthier, S. 2006. Clinical Diagnosis and Management of Alzheimer’s Disease: Third Edition. Informa Healthcare.
Graham, N., & Warner, J. 2009. Alzheimer’s Disease and Other Dementias (Understanding). Family Doctor Publications.
Hope, K.W., & Waterman, H.A. 2004. Using Multi-Sensory Environments (MSEs) with People with Dementia. University of Manchester. Dementia. 3(1). 45-68.
Lanctot, K.L., Rajaram, R.D., & Herrmann, N. 2009. Review: Therapy for Alzheimer’s disease: how effective are current treatments? Therapeutic Advances in Neurological Disorders. 2. 163-180.
National Service Framework for Older People. Department of Health. <http://www.dh.gov.uk/en/ publicationsandstatistics/publications/publicationspolicyandguidance/DH_4003066>.
Nordqvist, C. 2009. What Is Alzheimer’s Disease? What Causes Alzheimer’s Disease? Medical News Today.<http://www.medicalnewstoday.com/articles/159442.php.
Smith, T. 2005. Living with Alzheimer’s Disease. 2nd Ed. Sheldon Press.
Sun, M.-K. 2009. Research Progress in Alzheimer’s Disease and Dementia. Gazelle Distribution Trade.
Waldemar, G., & Burns, A. 2009. Alzheimer’s Disease (Oxford Neurology Library). OUP Oxford.