Related Resources For Alzheimer’s
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Mental Activity To Support Cognition
Many patients with normal cognition or those with mild impairment are concerned that they may develop AD. Many experts believe that mentally challenging activities, such as doing crossword puzzles and brainteasers, may reduce the risk in such patients. Whether such activities might slow the rate of disease progression in patients who already have AD is not known. Clinical trials are under way to determine the effect these cognitive activities have on AD progression.
Mental activities should be kept within a reasonable level of difficulty. Activities should preferably be interactive, and they should be designed to allow the patient to recognize and correct mistakes. Most important, these activities should be administered in a manner that does not cause excessive frustration and that ideally motivates the patient to engage in them frequently. Unfortunately, little standardization or rigorous testing has been done to validate this treatment modality.
Some investigators have attempted various forms of cognitive retraining, also known as cognitive rehabilitation. The results of this approach remain controversial, and a broad experimental study needs to be performed to determine whether it is useful in AD.
Initiating Monitoring And Maintaining Safe Pharmacologic Treatment For Bpsd
Selection of the right drug and the proper dosage should be guided by the nature of the patient’s symptoms . A drug should be continued as long as it is effective, but no longer than needed. Its efficacy can be gauged more easily if realistic goals have been set and target behaviors specified before initiating treatment. Achieving significant efficacy may require a few weeks of treatment. Rapidly switching from one agent to another deprives the patient of an adequate trial. Recent data on beneficial effects of ChEIs and antidepressants on behavioral disturbances including psychotic symptoms and agitation suggests that the intuitive approach of treating agitated AD patients experiencing psychotic symptoms with antipsychotics may not be the safest approach for many patients.
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Switching From One Chei To Another
There is some preliminary evidence that if a patient does not respond to one ChEI, switching to another may be beneficial . Switches can also be performed to cope with side effects . In general it is not difficult to switch from one drug to another among the 3 ChEIs . Combination of ChEI is not recommended. Standard dose escalation using monthly titration is recommended. Preliminary data indicate that for patients experiencing no safety/tolerability problems on a ChEI, another ChEI can be administered the following day with no washout period . If the patient is experiencing safety/tolerability problems with a ChEI, a washout period of 7 days, or until symptoms resolve, is recommended before switching to another ChEI . As yet, no guidelines for switching from one ChEI to another have been published.
Discussion Of Future Financial Health Care And End
Physicians should help both the family and patient to establish medical and legal advance directives for patients with AD and should recommend updating the patient’s will early in the course of treatment . Open discussions regarding role and responsibility changes within the family system should be encouraged. Assignment of health care proxy, durable power of attorney, and discussion of end-of-life issues, including living wills, should be addressed while the patient is competent to make informed decisions regarding these concerns. It is important to introduce the topic of advance directives sooner rather than later. The unpredictability of serious events such as hip fracture, pneumonia, etc., drive home the point that the discussion should take place before the crisis occurs. Discussions about advance planning do not have to be lengthy or conclusive. But the topic should be an agenda item in encounters with patients with dementia, much like nutrition and safety are.
Strategy 3a: Ensure Receipt Of Culturally Sensitive Education Training And Support Materials
Caregivers report that they feel unprepared for some of the challenges of caring for a person with Alzheimer’s disease — for example, caring for a loved one with sleep disturbances, behavioral changes, or in need of physical assistance can be an enormous challenge.25 Giving caregivers the information and training that they need in a culturally sensitive manner helps them better prepare for these and other challenges. The actions to achieve this strategy include identifying the areas of training and educational needs, identifying and creating culturally-appropriate materials, and distributing these materials to caregivers.
Action 3.A.1: Identify culturally sensitive materials and training
HHS will review culturally sensitive AD resources and identify areas where new resources need to be developed. HHS and private entities will develop relevant new culturally sensitive AD resources as needed.
Action 3.A.2: Distribute materials to caregivers
HHS will work with its agencies, other federal departments, and state and local networks and tribal governments to distribute training and education materials. This will include dissemination through the Aging Network, the public health network, and public websites.
Action 3.A.3: Utilize health information technology for caregivers and persons with AD
Developing A Treatment Plan
Psychologists may work with individuals with dementia and their families independently through a private practice or as part of a health care team. Psychologists will work with the individual and family to develop strategies to improve quality of life and manage emotions related to the dementia diagnosis.
In working with a psychologist, an individual with dementia and those who provide care for them may discuss what is already being done well to manage the dementia and which behaviors may be improved. The psychologist may ask the individual or caregiver to do homework like practicing memory tools. Memory tools can help individuals become more organized to better manage their symptoms of memory loss. These tools might include:
- Using an alarm as a reminder to take medicine
- Using a calendar, to-do list, and journal combo as a memory substitute
- Establishing routines to identify, plan, and carry out pleasant activities that are within the capacity of the care recipient
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Treatment For Moderate To Severe Alzheimers
A medication known as memantine, an N-methyl D-aspartate antagonist, is prescribed to treat moderate to severe Alzheimers disease. This drugs main effect is to decrease symptoms, which could enable some people to maintain certain daily functions a little longer than they would without the medication. For example, memantine may help a person in the later stages of the disease maintain his or her ability to use the bathroom independently for several more months, a benefit for both the person with Alzheimer’s and caregivers.
Memantine is believed to work by regulating glutamate, an important brain chemical. When produced in excessive amounts, glutamate may lead to brain cell death. Because NMDA antagonists work differently from cholinesterase inhibitors, the two types of drugs can be prescribed in combination.
The FDA has also approved donepezil, the rivastigmine patch, and a combination medication of memantine and donepezil for the treatment of moderate to severe Alzheimers.
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Drugs For Memory And Cognition
Certain medications can temporarily relieve and help manage dementia symptoms related to memory and cognitive function.
- Cholinesterase inhibitors, including donepezil , rivastigmine , and galantamine , attempt to slow the rate of memory decline in dementia patients. These drugs work by preventing the breakdown of acetylcholine, a chemical that helps brain cells communicate with each other. This type of medication is most often used to treat people with mild to moderate Alzheimers disease. Side effects of cholinesterase inhibitors include weight loss and digestive problems, such as nausea, vomiting, and diarrhea.
- Memantine helps protect against further brain cell damage in patients who have vascular dementia. This drug regulates glutamate, a chemical messenger in the brain associated with learning and memory. Dizziness is a common side effect of memantine. Memantine is approved for the treatment of moderate to severe Alzheimers disease.
Regarding aducanumab, theres still a lot of science that needs to be done, Hashmi says.
Research Involving Genetics Of Ad
A 30-year-old woman with a genetic disorder linked to early onset of AD has become the first to successfully undergo in vitro fertilization with preimplantation genetic diagnosis of the embryos to avoid passing the defect on to her children . PGD, prenatal diagnosis, preimplantation embryo selection, and presymptomatic testing has been offered to families of patients who have early-onset familial AD. Complex legal and ethical issues surrounding these interventions need to be addressed before these interventions can be routinely recommended. There is great potential for stem cell treatment of patients with AD, but ethical issues will need to be addressed before fetal stem cell research can be carried out.
Help With Legal Needs
Families who cannot afford a lawyer can still prepare documents and express their wishes in advance. Samples of basic health planning documents are available online. Area Agency on Aging officials may provide legal advice or help. Other possible sources of legal assistance and referrals include state legal aid offices, state bar associations, local nonprofit agencies, foundations, and social service agencies.
Visit the National Hospice and Palliative Care Organization for free sample documents.
For help with legal advice, contact the Eldercare Locator.
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Planning For The Future After A Dementia Diagnosis
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If you or a loved one has been diagnosed with Alzheimers disease or a related dementia, it may be difficult to think beyond the day to day. However, taking steps now can help prepare for a smoother tomorrow.
Over time, the symptoms of Alzheimers and related dementias will make it difficult to think clearly. Planning as early as possible enables you to make decisions and communicate those decisions to the right people.
Below are important legal documents to consider, and resources and tips that can help with planning ahead for health care, financial, long-term care, and end-of-life decisions.
Treatment Of Behavioral And Psychological Symptoms Of Ad
The most challenging aspect of AD care is management of behavioral and psychological signs and symptoms of dementia . BPSD are common, serious problems that affect the quality of life of both patient and caregiver and that frequently result in premature institutionalization. The majority of BPSD in AD are of clinical significance based on their severity and because of co-occurrence of multiple symptoms . BPSD are associated with more rapid rates of cognitive and functional decline. BPSD include agitation, aggression, delusions, hallucinations, depression, apathy, sleep disturbances, and sexually inappropriate behaviors . These difficulties occur in 90% of patients at some point in the course of the disease and have been described in all dementing illnesses. Many clinical practice guidelines have addressed the treatment of these disturbances, noting that even modest improvement in these behaviors can markedly improve quality of life for both patient and caregiver. Practice guidelines frequently recommend starting with behavioral and environmental approaches, followed by a wide variety of pharmacologic interventions, including antipsychotics, antidepressants, and anticonvulsants. For a comprehensive review of management of BPSD in patients with AD, the reader is referred to the review article on recognition and management of behavioral disturbances in dementia by the authors .
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Caring For The Caregiver
Many caregivers are reluctant to ask for help. It is important that health care providers ask the caregivers if they need assistance and validate their feelings. Clinicians must be prepared to help the caregivers deal with anger, denial, anxiety, guilt, grief, and clinical depression as they adjust to the progression of the disease. The grief and adjustment process for a caregiver is complex and cyclical, potentially reactivated by the additional impairments at each new stage of the illness. Family and caregiver interventions will help not only the caregivers but also the patients with AD by preventing premature institutionalization . Educational program, training program, support, and respite services directed toward caregivers of dementia patients may improve their coping skills and reduce stress .
Special Care Dementia Unit
The social environment is also significant in mollifying the behavioral manifestations of dementia. If demented individuals are grouped together on a special care dementia unit, many symptoms may be minimized. Grouping demented patients together further eliminates the problem of demented patients disrupting the routine of cognitively intact individuals by wandering into their rooms, rummaging through their belongings, or approaching them repeatedly with questions and unwanted physical contact. Well-designed studies are needed to demonstrate the benefits of such units.
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Treatment For Dementia Behaviors
- Behavior management strategies can help caregivers provide a more structured environment, identify and avoid triggers for problematic behaviors, and learn how to gently redirect their family members attention. Doctors generally prefer to try non-drug strategies for difficult dementia behaviors first, Hashmi says.
- Medications such as sleep aids, mood stabilizers, antidepressants, anti-anxiety drugs, anticonvulsants, or antipsychotics may help control symptoms in some people. However, these medications can have serious side effects, so its important to discuss their safety and risks with an expert, says Hashmi. As geriatricians, we try to use these medications sparingly, he says. They need to be matched to the behavior. Its not one size fits all.
Strategy 4b: Work With State Tribal And Local Governments To Improve Coordination And Identify Model Initiatives To Advance Alzheimer’s Disease Awareness And Readiness Across The Government
State, tribal, and local governments are working to help address challenges faced by people with Alzheimer’s disease and their caregivers. Nineteen states and a handful of local entities have published plans to address AD that cover many of the same issues as the National Plan. Leveraging the available resources and programs across these levels of government will aid in the success of these efforts.
Action 4.B.1: Convene leaders from state, tribal, and local governments
HHS will convene national leaders from state, tribal, and local government organizations to identify steps for increasing AD awareness and readiness in their jurisdictions. These leaders will create an agenda for partnering and supporting the efforts described in this National Plan. HHS will engage key stakeholders from a range of constituencies whose participation is important for the success of this effort.
Action 4.B.2: Continue to convene federal partners
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How Common Is Alzheimers Disease
Alzheimers disease is the most common cause of dementia . Alzheimers disease is the sixth leading cause of death in the United States.
One in 10 people older than 65 and nearly half of people older than 85 have Alzheimers disease. Alzheimers disease can also affect people in their 40s. The percentage of people who have Alzheimers disease rises every decade beyond the age of 60. According to the Alzheimer’s Association, with the aging of the population and without successful treatment, there will be 14 million Americans and 106 million people worldwide with Alzheimers disease by 2050.
Which Medicines Are Used To Treat Alzheimers Disease
There is no cure for Alzheimers disease, but available medications temporarily slow the worsening of dementia symptoms and help with behavioral problems that may appear during the course of the disease.
Four medications representing two drug classes are currently approved by the Food and Drug Administration to treat the symptoms of Alzheimers disease. These drugs are the cholinesterase inhibitors and a NMDA antagonist.
Cholinesterase inhibitors. The cholinesterase inhibitors are all approved to treat the symptoms of mild to moderate Alzheimer’s disease . Cholinesterase inhibitors include:
These drugs work by blocking the action of acetylcholinesterase, the enzyme responsible for destroying acetylcholine. Acetylcholine is one of the chemicals that helps nerve cells communicate. Researchers believe that reduced levels of acetylcholine cause some of the symptoms of Alzheimer’s disease. By blocking the enzyme, these medications increase the concentration of acetylcholine in the brain. This increase is believed to help improve some memory problems and reduce some of the behavioral symptoms seen in patients with Alzheimers disease.
These medications do not cure Alzheimers disease or stop the progression of the disease. The most common side effects of these drugs are nausea, diarrhea, and vomiting. Some people may have loss of appetite, insomnia or bad dreams.
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Patient Selection Management Of Adverse Effects And Therapeutic Outcome
The course of AD tends to be slowly progressive, with a loss of 35 points per year on a standard assessment instrument such as the MMSE. Caregivers and patients must have realistic expectations these drugs’ effects are modest, and sometimes no symptomatic improvement is noted. In fact, a report of no change means that these drugs are helping, because without ChEI treatment, one would have seen a decline in functioning.
If a ChEI is stopped, rapid deterioration can occur in some patients. Also, reintroducing the drug after the AD patient has been taken completely off a ChEI may not yield the same benefit. By tapering the dosage slowly, we can detect early those patients who are going to lose function or show cognitive deterioration. If they do, then there exists a good reason not to take them off the drug. Only very early in the disease will the patient be able to self-report improvement or benefit. Many of the patients, by the time they are diagnosed, have already lost insight and are unable to appreciate the benefits of ChEIs.