Management of Chronic Disease: Alzheimer's Disease and Dementia

This portfolio provides a comprehensive assessment of dementia, including epidemiology, etiology, pathophysiology, memory loss, impacts of memory loss, nursing management, and assessment tools for Alzheimer's disease and dementia.

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Management of chronic Disease
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Management of chronic Disease 2
Table of Contents
1.0 Introduction..........................................................................................................................3
1.1 Epidemiology...................................................................................................................3
1.2 Aetiology..........................................................................................................................3
1.3 Search Criteria..................................................................................................................4
2.0 Portfolio Entry 1...................................................................................................................4
2.1 Pathophysiology...............................................................................................................4
2.2 The Process of Atrophy in Alzheimer’s Disease..............................................................5
3.0 Portfolio Entry 2...................................................................................................................5
3.1 Memory Loss (Alzheimer’s Disease)...............................................................................5
3.2 Impacts of Memory Loss on the Patient...........................................................................6
3.2.1 Emotions and feelings................................................................................................6
3.2.2 Confidence and self-esteem.......................................................................................6
3.2.3 Stigma........................................................................................................................6
3.2.4 Loss of spousal bond..................................................................................................7
3.3 Assessment Tool for Memory Loss (Alzheimer’s disease)..............................................7
3.3.1 The ABC Dementia Scale (ABC-DS).......................................................................7
4.0 Nursing Management of Alzheimer’s Disease....................................................................9
4.1 Person-Centred Approach................................................................................................9
4.2 The key Concepts of a Person-Centred approach...........................................................10
5.0 Portfolio Entry 3.................................................................................................................12
Conclusion................................................................................................................................12
References................................................................................................................................13

Management of chronic Disease 3
1.0 Introduction
Dementia is a clinical syndrome characterized by an overall decline of mental functioning
with regard to its various aspects such as cognitive and emotional (Ikejima et al., 2009). The
condition is a description of a group of clinical syndromes. The term dementia means a long-
term period of mental handicap and distress for the patient, in addition to extreme pressure
and fiscal burden on the family of the patient, the society and the providers. This portfolio
provides a comprehensive assessment of dementia.
1.1 Epidemiology
Dementia has become one of the major problems in public health, financial, societal and
political domains, and one that has received a lot of attention from researchers.
Approximately 47.47 million people across the world were diagnosed with dementia in 2015,
with this number expected double by 2030 and 135.46 million in 2050 (Prince, Wimo,
Guerchet, All, Wu, 2015). The prevalence of the condition increased to 6.99% from 4.98% in
East Africa and to 4.76% from 2.07% in the Sub-Saharan African regions. The primary
influencing factor of dementia is an aging population. There is an overwhelming increase of
population aging especially in the average and low-income countries, by 2050 the highest
prevalence rates of the illness is expected to in such regions.
1.2 Aetiology
Dementia is a result of a deterioration in the cognitive abilities that ruins routine activities.
Dementia comprises of different syndromes that are often characterized by isolated loss of
memory; some others also are typical of cognitive symptoms such as impairment of language,
mood disorders, weak regulation of skilled movements and challenges in planning and
execution. The different causes of dementia are typical of different anomalies to the structure
and function of the brain resulting in varying symptoms (Rizzi, Rosset, & Roriz-Cruz, 2014).
Majority of the dementias are perceived to be neurodegenerative diseases. In other words,
they mirror a substantial loss of the structure of the neuron alongside its function that is not
associated with any other known condition. Such disorders are usually attributed to the build-
up of abnormal proteins or normal proteins in the forms that are abnormal. The most
prevalent neurodegenerative dementia is Alzheimer’s disease which is the leading cause of
over 50% of all global dementia cases. Others include Frontotemporal lobar degeneration,
Lewy Body disease, and Parkinson’s disease. The neurodegenerative dementias are often
perceived to be permanent, and no known intervention that can reverse the loss of brain cells

Management of chronic Disease 4
(Stephan & Brayne, 2008). In some instances, patients may be diagnosed with the late-life
cognitive decrease of dementia which is secondary to some other condition. Such dementia
cases can be reversed by utilizing the actual treatment of the underlying disease.
1.3 Search Criteria
The researcher used keywords in searching for the recent and most appropriate articles,
books, and government websites for the literature review. The keywords include dementia,
epidemiology, and etiology of dementia, pathophysiology of dementia, Alzheimer disease,
dementia symptoms, types of dementia, impacts of Alzheimer disease, nursing management
of Alzheimer disease, holistic approach, AD impacts, and dementia assessment tools in
addition to other terms related to dementia. The researcher also used Google Scholar,
PubMed, NCBI, and BMJ as search engines to locate for both primary and secondary
research articles to be examined in the study. A total of 40 abstracts were identified and after
the screening, filtering and quality appraisal, 27 studies were chosen for review. The total
number of themes identified in the study were six namely epidemiology, etiology,
pathophysiology, Memory Loss (Alzheimer’s Disease), The ABC Dementia Scale (ABC-
DS), and the Person-Centred Approach.
2.0 Portfolio Entry 1
2.1 Pathophysiology
The most common cause of dementia is Alzheimer’s disease (AD) which accounts for almost
60 to 80 percent of all forms of the condition (Alzheimer's Association, 2017). The
pathology of Alzheimer’s disease at initial stages involves the continual loss of brain tissue.
With each progression of the disease, there is the death of neurons which follows a specific
pattern. The initial symptoms of the disease are memory loss, especially short-term recall
(Jack et al., 2013). The parts of the brain that are associated with memory are the cortex more
particularly the hippocampus (Schuff et al., 2009). The commencement of preclinical AD
takes place in the entorhinal cortex, which links the hippocampus, a section of the brain
whose function is memory formation, which is both long-term and short-term memory. Some
researches have indicated that neuronal loss (ascertained by deterioration in specific areas)
may begin some years before the appearance of symptoms of memory loss (Padurariu,
Ciobica, Mavroudis, Fotiou, & Baloyannis, 2012; Seeley, 2008). An example of such studies

Management of chronic Disease 5
is magnetic resonance imaging. As the brain continues to deteriorate, the vacuum that is
formerly filled with brain tissue is supplied by the cerebrospinal fluid.
During the transition of AD stages from minor to moderate, the patients undergo severe
memory loss such as having hard times remembering very familiar names and confusion
about accustomed locations. There is also a deterioration in the ability to execute complex
thoughts such as challenges in balancing the cashbook or food preparation, and alternations in
one’s personality and moods. The decline in the brain may extend to the other parts of the
cerebral cortex (Fjell et al., 2014). During the advanced phases of AD development, there is a
deterioration of the cortex in the specific areas responsible for speech, thinking, sensory
processing, and cognisant thought (Kalpouzos, Persson & Nyberg, 2012). The symptoms of
the AD also becomes severe at an advanced stage due to the continued brain atrophy. These
signs include damaged long-term memory, weight loss, incontinence, seizures, failure to
identify close relatives or family members, a lot of complaints, and lack of ability to sit up.
2.2 The Process of Atrophy in Alzheimer’s Disease
At the very initial phase, three neuropathologic marks define the disease: neuronal atrophy,
intracellular neurofibrillary tangles (NFTs), and amyloid plaques. Alois Alzheimer was the
first to discover plaques and NFTs of a demented patient in a 1906 autopsy. Plaques and
NFTs emerge during the natural aging and in some other neurodegenerative conditions. The
plaques and NFTs in AD, are confined to specific brain sections that relate to clinical
symptoms (Chételat et al., 2010). It is believed that the beta-amyloid plaques are the ones that
are primarily responsible for AD pathogenesis, alongside other numerous and different
pathophysiologic process that ensue, commonly termed as an amyloid cascade (Reitz, 2012).
The pathophysiologic cascade of AD is intricate but each encounter of different pathologic
process or a neurotransmitter results in the prospective detection of new healing objectives.
3.0 Portfolio Entry 2
3.1 Memory Loss (Alzheimer’s Disease)
The most common symptom of dementia is memory loss which is caused by Alzheimer’s
disease. Therefore this section will consider Alzheimer’s disease as the leading symptom of
dementia. Dementia is caused by a decline in intellectual function of which its most
significant element is the memory. This affects the patient in several ways.

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3.2 Impacts of Memory Loss on the Patient
3.2.1 Emotions and feelings
Individuals diagnosed with memory loss due to Alzheimer’s disease often experience
changes in their emotional responses. The patients are not able to usually manage their
feelings and the manner in which they express them. For instance, patients diagnosed with
memory loss are easily irritable, become moody and end up overreacting to small matters.
Hurt et al. (2010) found out that patients diagnosed with memory loss were less interested in
normal life activities and were distant from them.
As a result, the patients become difficult to deal with and are sometimes neglected by
caregivers. This ends up making them feel lonely and further worsens their already affected
emotions and feelings. According to Lyketsos et al. (2011), the demented patients were easily
agitated or tearful when faced with a situation in which they could not discern due to the
decline of their factual memories.
3.2.2 Confidence and self-esteem
The loss of memory in demented patients may spark a feeling of insecurity and loss of self-
confidence in themselves and their capabilities. This can also be as a result of their inability
to be in control of their memory and trust their judgment. Furthermore, the aspect of not
being treated equally like others may hurt the self-esteem of a demented patient. The study by
Geda et al. (2013) also found out that the impact of memory loss on other aspects of one’s
individual life may have an indirect effect on one's self-esteem. Negative impacts of memory
loss on one’s financial status, employment status, and in relationships may also lead to low
self-esteem.
3.2.3 Stigma
Memory loss due to Alzheimer’s disease is attached to the issue of stigma as it does affect not
only the patient but also families and friends. Memory loss as a result of cognitive
impairment leads to the loss of independence and ultimately stigmatization and social
segregation irrespective of their care needs. Demented patients characterized by memory loss
experience separation and sometimes make a laughing stock for their inability to remember
basic things such as names of family members of familiar locations. Studies have found that
the emotional and psychosocial effects on demented patients are majorly caused by stigma
(Urbańska, Szcześniak, & Rymaszewska, 2015). Family members and confidants also
contribute to the stigma by feeling embarrassed and thus limiting their association with the
patient.

Management of chronic Disease 7
3.2.4 Loss of spousal bond
Memory loss in a spouse diagnosed with Alzheimer's disease leads to the decline or loss of
the essential relationship that formerly existed in their marital association. The decline in
mental health has directly been linked to relational deprivation as pointed out by spousal
caregivers (Ferrara, 2008). While there is the physical presence of the demented patient, the
loss of her or his personality due to memory loss weakens the marital bond which is two way
and is dependent on intimacy and emotional associations (Pinquart & Sörensen, 2011).
3.3 Assessment Tool for Memory Loss (Alzheimer’s disease)
3.3.1 The ABC Dementia Scale (ABC-DS)
The ABC-DS comprises of 13 test items, with each having nine phases of systematic
categorical scales. The 13 items assess activities of daily living (ADL), behavioral and
psychological symptoms of dementia (BPSD), and cognitive function (C). The thirteen test
items are categorized into six domains with each having varying questions (Mori et al.,
2018).
Domains of the ABC Dementia Scale
 Activities of Daily Living
This is the first domain which contains the first to the fourth items. The first test item is on
daily activities and seeks to ascertain the behavior of the patient when undertaking routine
duties such as changing clothes. The second item of question focus on motivation and aims at
determining the willingness with which the patient conducts the daily activities of life.
Communication is the third test item which identifies the ease with which the patient
communicates with people. The fourth test item under the first domain of activities of daily
living tests on the ability of the patient to undertake intricate activities such as the use of
electric machines such as an iron box or TV (Kikuchi, Mori, Wada-Isoe, Umeda-Kameyama,
& Kagimura, 2018).
 Cognitive function
This is the second domain in the ABC-DS, and it consists of test questions five and six. This
domain addresses two main problems; the ability of the patient to accurately remember an
immediate activity such as where she/he placed her things. Secondly, the domain tests the
patient’s ability to recall daily events.

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 Behavioral and Psychological Symptoms of Dementia
Having ascertained the behavioral and cognitive activities of the patient, the third domain
examines any possible existence of dementia symptoms. Three main symptoms that are
assessed include cooperativeness, irritability, and restlessness, representing test items seven
to nine respectively. Irritability is examined by observing the patients feelings to
unsatisfactory things, cooperativeness is monitored by observing the patient’s response when
asked something, and lastly, restlessness is assessed based on the patient's conduct when
required to sit still (Kikuchi et al., 2018).
 Cognitive Function
The cognitive function includes the tenth test item which focuses on the patient’s behavioral
response after taking medication.
 Activities of daily living
This is the fifth domain with test items twelve and thirteen. The focus of this assessment is on
the routine activities of the patient such as meals and toilets. The eleventh test item examines
the feeling of the patient after taking meals whereas the twelfth test item examines the extent
of care required by the demented patient when using the toilet.
 Cognitive function
This is the sixth domain containing the thirteenth last test item and focuses on care-burden.
The question seeks to find out the frequency with which the caregivers attend to the patient.
Advantages of ABC Dementia Scale
Clinicians can utilize the ABC-DS tool to assess patients for a short time. Medical
practitioners often use assessment tool such as the HDS-R and the MMSE which examine
only the cognitive function. On the other hand, the ABC-DS tool can assess a patient in three
areas namely BPSD, ADL function, and cognitive function within 10 minutes. The ABC-DS
assessment tool doesn’t need the clinician to decide on the seriousness of the patient’s AD
before evaluation, thus making it more reliable and minimizes any possible bias.
Furthermore, the tool includes illustrations, and it comes with guidelines that are easy to
comprehend. Therefore, there is no need for training the assessors how to use it. This
minimizes the costs and time that could have been used in training, and this implies that it can

Management of chronic Disease 9
also be used by junior staff. The outstanding benefit of the ABC-DS is its ability to predict
the total score concerning the Clinical Dementia Rating (CDR). This enables the assessor to
compare the outcomes with the predicted values and to ascertain the range, thus making the
outcomes more reliable. The ABC-DS is also important as an index for determining the shift
in medication because it can differentiate between the different progression levels of AD
(Mori et al., 2018).
Disadvantages of ABC Dementia Scale
Perhaps the major drawback of the ABC-DS model is that it was initially designed for the
Japanese population. This limits its generalizability in other settings of varying cultural
background unless its reliability and validity to the new population are first re-assessed
before being used. Another disadvantage of this tool is that it has been developed for the
major symptom of memory loss in AD patients and not for evaluating any other types of
dementia. This, therefore, limits its application to AD patients. Another limitation of the
ABC-DS assessment tool is that it was developed for use in patients who require medical
attention and not for any cognitively normal persons. This significantly limits its usability
since the AD symptom of memory loss is progressive and requires early detection before the
advanced stage which is irreversible (Mori et al., 2018).
4.0 Nursing Management of Alzheimer’s Disease
4.1 Person-Centred Approach
A person-centered approach to healthcare involves the planning and administration of care
services that focus at the individual patient and considers their environment (social, physical,
emotional and spiritual aspects of the patient) with the aim of meeting his/her needs. Person-
centered care is based on an interactive process where the dementia patients are actively
involved in their care in the entire progression levels of the illness, and family members have
a significant role to making sure that the health and well-being of one of them are fully
catered for. The overriding objective of person-centred care is to develop partnerships among
caregivers at the home center, dementia patients and their families that will culminate to the
best results and improve the quality of life of the patients and that of the caregivers.
Several studies have examined the effectiveness of the person-centered approach in the
healthcare sector (Kim & Park, 2017). The attitude of the healthcare staff towards patients
diagnosed with memory loss due to AD is critical in their treatment. If they are perceived to
be people who have lost their personality, then there are high chances of them being treated

Management of chronic Disease 10
of the physical symptoms only. Studies have also ascertained that the most appropriate
interventions for AD patients diagnosed with memory loss are those that create and sustain
beneficial associations between the caregivers and the patients (Qiu, Kivipelto, & von
Strauss, 2009). Gozalo, Prakash, Qato, Sloane, and Mor (2014) found out that the
implementation of a person-centered approach for showering and bathing the AD patients at
moderate to severe phases reduced cases of anxiety, aggression, and distress compared to the
control group.
4.2 The key Concepts of a Person-Centred approach
 Dignity and Respect.
Persons with memory loss symptoms due to AD human beings who should be listened to and
their preferences honored as much as it is safe for them. The planning and the provision of
service health care for AD patients should incorporate their values, beliefs, and spiritual
inclinations.
 Sharing of Information
The caregiver staff should share unbiased information with the AD patients and their relatives
in a manner that is beneficial to enable them to make informed and timely decisions
regarding the patient.
 Participation
AD patients and families are assisted in engaging in the care and decision-making process.
The foundation of this holistic approach is to involve the patient in treatment irrespective of
their impairment. The objective is to emphasize the relationship of the individual without
neglecting family members.
Four Hallmarks of A Person-centred Approach
A person-centered approach considers four main areas to ensure that comprehensive care is
provided to the AD patients diagnosed with memory loss. These include environment,
communication, nutritional, and activities.
 Environmental
Studies have shown that some aspects of the environment can trigger adverse reactions and
behaviors of the AD patients. Padilla (2011) points out that ecological considerations should

Management of chronic Disease 11
include lighting, sounds, smells, safety, comfort, coming and getting out, and the necessity
for changes. There should be adequate lighting in the room for their safety, and harsh
fluorescent lighting and extreme overhead lighting which causes glare should be avoided.
The environment should be visually appealing but not over stimulating. Contrasting colors of
the items in the house should be used such as the color of the floor should vary with that of
the chairs and tables.
 Activities
The use of creative methods to draw the attention of AD patients is a holistic approach to
reducing behaviors such as depression, anxiety, boredom, reduces the burden and stress of the
caregiver, provides cognitive stimulation among others (Letts et al., 2011). Basic exercises,
the use of music or artistic opportunities are examples in which the patient can holistically be
engaged.
 Nutritional
Diet has a significant role in preserving muscle strength, body function, and health of the
internal organs. Fiber-rich foods should be encouraged as they promote bowel health. The old
patients diagnosed with AD are at high risk of being dehydrated due to lack of appetite for
foods that trigger fluid consumption (Fortes et al., 2015). Furthermore, the aging population
requires thorough nutritional support to maintain their wellbeing.
 Communication
High-stress levels and burden for caregivers have been attributed to a communication
breakdown between the caregivers and receivers (Egan, Bérubé, Racine, Leonard, & Rochon,
2010). The advancement of AD symptoms leads to the deterioration of verbal skills as a
result of the weakening of the functionality of the temporal lobe. Therefore, the exercise of
effective verbal and non-verbal communication skills will substantially reduce agitation and
frustration.
5.0 Portfolio Entry 3
Conclusion
The prevalence and incidence of dementia are on the increase worldwide. Different types of
dementia have been reported at different levels in varying locations. However, Alzheimer’s
disease (AD) is the leading cause of dementia primarily characterized by memory loss.

Management of chronic Disease 12
Dementia is a progressive disease which leads to the damage of brain cells leading to failure
of the cognitive function. AD impairs the normal life of a person because the individual is no
longer able to recall the necessary life activities or event such as familiar places or names of
close family members. This leads to negative emotions and feelings such as being overactive
to small issues, lack of interest in normal life activities and feeling lonely. Patients diagnosed
with memory loss due to AD also have low self-esteem and confidence and are stigmatized
due to their physical and cognitive impairment.
Pharmacological interventions in the management of dementia have been in use
notwithstanding the existence of the evidence of their ineffectiveness in the improvement in
the general quality life of the dementia patients. As a result, a palliative assessment tool
called the ABC-DS scale has been developed. The tool examines the daily activities of life,
behavioral and cognitive function of Dementia syndrome. Furthermore, a person-centered
approach for managing AD has been recommended by several studies as the most effective.
The model takes a holistic approach in four main areas namely environment, activities,
nutrition, and communication.
Based on the preceding literature review of dementia, I would like to make recommendations
for future nursing practice. Future research should develop an assessment tool for dementia
that addresses other types of the condition, unlike the ABC-DS approach that only addresses
Alzheimer’s disease. Additionally, the studies should emphasize the generalizability of the
model to different population settings. More studies should be done on the person-centered
approach to making it more effective. For instance, further studies should seek to find out a
specific component of the method that makes it more successful, the progressive phase of
dementia that is most suitable for person-centered approach, and the qualifications of the
caregiver to administer person-centered approach.

Management of chronic Disease 13
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