#96154: Alzheimer Disease

According to the Centers for Disease Control and Prevention (CDC), approximately 121,500 patients with AD died in 2019, making it the fifth leading cause of death in adults 65 years of age or older [4]. Using mortality data provided by the National Vital Statistics System, a CDC analysis showed that the age-adjusted AD death rate per 100,000 population increased from 16.5 in 1999 to 25.4 in 2014 [172]. Rates were higher among women compared with men and among non-Hispanic White individuals compared with other racial/ethnic populations [172]. However, the findings in this report, which are derived from death certificates that list AD as the underlying cause of death, may underestimate the actual number of Alzheimer deaths in the United States. Other organizations approximate the annual number of deaths directly caused or attributable to AD at 500,000 to 700,000; it is thought that the true number lies somewhere between the death certificate data and these higher numbers. Between 2000 and 2019, the annual number of deaths from AD more than doubled, increasing 145%, while the number of deaths from heart disease decreased 7.3% [4]. The AD death rate in 2023 was 37 per 100,000 population.

Approximately 1 million new cases of AD develop each year [4]. As the aging population increases, so will these numbers. Barring effective new treatments, there will be an estimated 13.8 to 16 million patients with AD in 2060 [4].

As noted, the economic impact of AD is staggering. In 2023, the national cost of caring for persons with AD and other dementias is expected to reach $345 billion [4]. Projected costs for 2050 are nearly $1 trillion annually (in 2022 dollars). Of the $345 billion annual direct and indirect costs of care, [4]:

With the help of family and friends, individuals with dementia often live at home. However, as the disease progresses, more care is needed. Depending on the severity of the disease progression, home care workers may be hired or the individual may be placed in a nursing home or assisted living residence. The only federal program that covers long-term nursing home care is Medicaid; however, in order to receive these benefits, the individual must be considered low income and have low assets [4]. Typically, income and assets dwindle and most individuals eventually qualify for Medicaid. Long-term care or private insurance may cover long-term nursing home care, but only if the policies are purchased before the onset of disease. These types of policies are only offered by a few insurers, have very high premiums, and are unaffordable for most. (Private insurance funding accounts for only 4% of total residential facility care costs.) The vast majority of nursing home residents with AD and other dementias depend on Medicaid to pay for their care [4]. However, even with Medicare coverage, families incur high out-of-pocket expenses as a result of premiums, deductibles, co-payments, and other healthcare costs not covered by Medicare [4].

AD sufferers often have comorbidities, including hypertension, congestive heart disease or failure, osteoarthritis, diabetes, peripheral vascular disease, chronic obstructive pulmonary disease, thyroid disease, and stroke. The cost of care for Medicare beneficiaries who suffer from AD and a comorbid condition is significantly higher, sometimes more than double the cost of care for Medicare beneficiaries without AD [4]. Hospitalization is also more likely for these patients than for those with the same condition but without AD.

Patients are not the only ones affected by AD. More than 11 million family members, friends, and neighbors provide unpaid care for patients with AD that, by one estimate, totals $239,000 per patient annually [4]. Nearly half of all informal care is for patients with dementia. Interventions that assist caregivers to cope and prevent caregiver burnout are as essential as interventions for the patient.

The patient with AD endures a continuing loss of mental acuity while the family witnesses the slow deterioration of their loved one. There are devastating mental, emotional, and physical changes that result in total dependence, and the need for care continues until death. In the earlier stages, the patient may wander and get lost or get up frequently during the night. The sense of self is slipping away, but the patient is helpless to do anything about it. Familiar routine tasks become monumental chores, causing frustration and humiliation when they cannot be completed. In the later stages, maximum assistance with all activities of daily living is required.

Family members experience the same roller coaster ride of emotions as they too become frustrated, resentful, and often fatigued as they try to provide for the needs of their loved one. Marriages suffer as adult children, sometimes with children of their own, try to care for aging parents, or as one aging spouse feels responsible to meet every need of his or her increasingly dependent partner. Role reversals are common within a marriage or between parent and child. Caregivers have to take on the responsibilities previously assumed by the patients in addition to providing routine care. Caregivers must be strong, considerate, and able to anticipate problems. The support and care of friends may gradually subside as the situation continues for years.

Genes are comprised of four nucleotides in a wide variety of combinations, each of which directs the manufacture of a different protein. Even slight changes in a gene's DNA sequence can produce a faulty protein, which can lead to cell breakdown and eventually disease.

In addition to age and a positive family history of dementia, there are genetic risk factors for AD. Early-onset AD is an autosomal dominantly inherited disorder associated with gene mutations that alter production, assembly, and/or clearance of amyloid beta protein in the brain. Three well-characterized genotypes are mutations that encode for amyloid precursor protein (APP), presenilin-1, and presenilin-2 [12]. APP is a protein from which beta-amyloid, the chief component of plaques seen in the brains of patients with AD, is formed [4,8]. Mutations of the presenilin 1, presenilin 2, and APP genes leading to AD occur principally on chromosomes 1, 14, and 21 [127,155].

Genetic predisposition to late-onset AD has been linked to the APOE gene. Every person inherits one of three alleles of the APOE gene from each parent: e2, e3, or e4 in some combination (pairs). APOE3 is the most common allele found in the general population, with 50% to 60% of individuals having one or two copies. The APOE4 allele, either single (heterozygous) or as a pair (homozygous), is found in 5% to 35% of the population and is associated with an increased risk for AD compared with those individuals carrying APOE3 or APOE2 alleles [4,127]. Carrying one copy of the APOE4 allele confers a 3- to 4-fold increased risk; inheriting two copies of APOE4 allele confers an 8- to 12-fold increased risk of developing AD [4,13]. There is evidence that the APOE2 allele may be protective against AD or at least help the maintenance of cognition with age [12,78,127].

Although it is possible to determine the APOE gene profile in connection with a strong family history of AD, carrying the e4 allele does not mean that an individual is certain to develop AD. The pathogenesis of AD is complex and other factors come into play, such as age, gender, race, lifestyle (e.g., engagement in regular physical exercise), and vascular disease.

Using data from multiple genome-wide association studies, researchers have identified other genes that may increase an individual's risk of late-onset AD, including bridging integrator 1 (BIN1), clustering gene (CLU), phosphatidylinositol binding clathrin assembly protein (PICALM), and complement receptor 1 (CR1) [127]. These studies have been made possible by the completion of the Human Genome Project in 2003 and the International HapMap Project in 2005. Research into the relationship between these genes and AD is in its infancy.

Although it is generally known what changes occur in the brain of people with AD, it is still not clear why these events occur in certain individuals. There are nongenetic factors related to AD, and research is being conducted to investigate these factors and to develop new theories about the processes involved in triggering the onset of the disease.

An area of investigation concerns a theory of aging that pertains to certain types of molecules, specifically free radicals that are a product of normal metabolism. These substances assist healthy cells in some functions (including signaling and homeostasis), but as discussed, an overabundance of free radicals can injure cells. The oxidative damage due to free radicals may contribute to the development of AD. Because brain cells have a high rate of metabolism and a long life span, they are vulnerable to oxidative stress.

Another area of investigation concerns the possible role of inflammation in the pathogenesis of plaque formation within the brain. Activation of the immune system leads to production of gene products that promote inflammation (i.e., inflammatory mediators). Various compounds involved in the inflammatory process have been found in the plaques of patients with AD [8]. One study has shown indirect evidence that use of nonsteroidal anti-inflammatory drugs (NSAIDs), particularly ibuprofen, may have a protective effect against AD [69].

Chronic conditions that lead to cerebrovascular disease, such as hypertension, diabetes, and obesity, appear to influence susceptibility for developing AD. Of interest is the impact of oxygen and glucose deprivation on neuronal function, amyloid accumulation, and other pathophysiologic features of AD. It has been suggested that limited degrees of brain ischemia may not be sufficient to cause dementia but may play a role in augmenting the pathologic changes and lowering the threshold for clinical expression of AD [8].

Most major vascular risk factors, including hypertension, diabetes, smoking, obesity, and hypercholesterolemia, particularly when present in midlife, have been associated with increased risk of dementia and AD later in life [4]. Less clear is whether these risk factors directly promote the neurodegenerative features (i.e., amyloid deposition) specific for AD or merely augment cognitive decline indirectly as a byproduct of enhanced atherosclerotic cerebrovascular disease. A prospective cohort study of 326 middle-aged community-based participants without dementia, followed for 20 years, found that the presence of two or more vascular risk factors was significantly associated with elevated brain amyloid deposition later in life [173]. In this study, the mean age of participants was 52 years at the time of vascular risk assessment in 1987­–1989, and 76 years at the time of brain imaging (PET scan) in 2011­–2013. Vascular risk factors at baseline included body mass index ≥30, current smoking, hypertension, diabetes, and hypercholesterolemia. The risk of amyloid deposition in late life correlated with the number of vascular risk factors present in midlife. Thirty-one percent of individuals with no risk factors in midlife had elevated brain amyloid deposition, compared with 61% of individuals with at least two vascular risk factors. The authors postulated that some aspect of subclinical cerebrovascular disease might increase the propensity for amyloid deposition in the brain or that vascular disease at the arteriolar level might result in reduced clearance of amyloid from the brain [173].

In a prospective analysis of 223 older adults in the Harvard Aging Brain Study, vascular risk was associated with cognitive decline and beta-amyloid deposition in the brain during a 3.7-year period of observation [174]. The rapidity of cognitive decline correlated with the magnitude of the vascular risk score and the burden of beta-amyloid. The interaction of the vascular risk score and amyloid burden with time was significant, suggesting a synergistic effect. These results highlight the importance of addressing vascular risk factors in midlife as part of a strategy to delay cognitive decline in older adults.

Researchers have also studied the role of circulating sex hormone levels in the development of AD. Some data show a correlation between decreased levels of circulating testosterone and AD in men [90]. Depletion of testosterone levels in the brain is a normal consequence of male aging. Because levels of the hormone decrease prior to the development of AD, it is not believed to be a consequence of the disease but rather a possible contributor to its development [92]. The mechanism by which the depletion may affect or cause AD has not been established. However, it has been hypothesized that low testosterone levels may increase brain levels of beta-amyloid [92]. There are also some preliminary studies examining the ability of estrogen to prevent the hyperphosphorylation of tau and, by extension, AD [96]. More research regarding the role of sex hormones in the development of AD is necessary before definitive recommendations may be made.

The prevalence AD is higher among women than men [4]. Two-thirds of AD diagnosed in the United States are in women, a difference that cannot be accounted for by longer lifespan. At the cellular level, this difference appears to be driven by how well the aging brain is able to adapt to gradual loss of estrogen-controlled glucose utilization for energy needs. Studies have shown that estrogenic control of brain glucose metabolism is dismantled during perimenopause, resulting in a hypometabolic state and shift to free fatty acids as the source of energy for cellular mitochondrial function. The risk of developing neurodegenerative disease later in life may be influenced by how well the aging brain adapts to this transition in cellular metabolism [175]. In some women, the hypometabolic state that follows decline in estrogen-controlled glucose utilization by the brain may lead to loss of white matter, beta-amyloid deposition, and disruption of synaptic plasticity [176]. Metabolic studies in the mouse AD model and human cells indicate that brain adaptation to an alternate free fatty acid energy source occurs more readily in men than women [177].

The biologic sex difference in the risk of late-onset AD has been investigated clinically by means of a carefully designed protocol that included laboratory, neuropsychological, and multimodality imaging to assess brain biomarkers [178]. In total, 121 adults (85 women and 36 men) 40 to 65 years of age with normal cognition were enrolled. After adjusting for modality-specific confounders, the female group showed higher beta-amyloid deposition, lower brain glucose metabolism, and lower MRI gray and white matter volumes compared with the male group. Among participants in the female group, menopausal status was the predictor most consistently and strongly associated with the observed brain biomarker differences, followed by hormone therapy, hysterectomy status, and thyroid disease. These results indicate that sex differences in the development of the AD endophenotype are closely linked to hormonal factors associated with menopause. The authors concluded that the preclinical phase of AD may be early in the female aging process and coincides with the endocrine transition of perimenopause, emphasizing that the window of opportunity for preventive measures in women is early in the endocrine aging process [176,178].

A possible connection between herpes simplex virus-1 (HSV1) and AD has been explored. Researchers have found that the virus is able to enter the brain in later life as the immune system weakens, causing inflammation, oxidative damage, and increases in beta-amyloid and tau, especially in individuals with the APOE4 allele [147]. HSV1 is found in a high proportion of the brains of elderly individuals with and without AD, but certain individuals, such as those with the APOE4 allele, will suffer greater viral damage [147]. Interestingly, the APOE4 allele is also a risk factor for symptomatic, HSV1 reactivation (i.e., "cold sores"). It should be noted that while the presence and activation of HSV1 in the brain is apparently common in the elderly, herpes simplex encephalitis, a serious brain disease, is an exceedingly rare, separate condition.

Researchers at Brown University and Rhode Island Hospital have proposed that AD is a neuro-endocrine disorder "associated with brain-specific perturbations in insulin and insulin growth factor (IGF) signaling mechanisms;" essentially, they hypothesize that AD is a distinct type of diabetes, termed "type 3 diabetes" [148]. Animal experiments have demonstrated that many of the hallmark signs of AD can be reproduced by artificially reducing insulin and IGF levels, but additional research with human subjects is necessary before a link can be definitively proven [61,149].

Aluminum, a metal associated with chronic toxicity, was linked with AD in early studies. High concentrations of aluminum have been found in the brains of some individuals with AD, but the exact nature of the correlation, if any, is unknown [96]. The accumulation of aluminum may be responsible for the changes within the brain, or it might be secondary to the cause(s) of AD. Some research suggests that exposure to aluminum in municipal drinking water (used as a clearing agent during treatment) possesses greater potential for chronic toxicity than exposure from other sources, such as aluminum cookware, and that high intake of aluminum from tap water may be a risk factor for AD [144,145]. Other researchers speculate that fluoride ingestion (at exposure levels experienced by regular drinking water consumption in fluoridated municipalities and toothpaste use) greatly enhances aluminum's neurodegenerative effects [146]. Higher levels of silicon intake are thought to protect against aluminum toxicity. Research into the possible role of aluminum in the development of AD is ongoing.

In addition to aluminum, other transition metals (e.g., copper, zinc, iron) are implicated as causative factors for AD [144,151]. Oxidative stress, induced from either excesses or deficiencies of these metals, is theorized as being pathogenic. Iron overload, copper depletion, and zinc overload/depletion have been found in AD brains by various research groups. However, these findings were called into question by a 2011 meta-analysis that discovered citation bias towards irreproducible research, especially regarding iron overload [151]. Concrete evidence for transition metal pathogenesis is currently lacking.

While scholars agree that there may be several environmental factors for AD, no exposures, including pesticides, general air pollutants, lead, and other toxins, have been definitively linked to AD. Taking proactive steps to prevent oxidative damage, improve vascular health, and create a healthier lifestyle overall, seems to be the best defense against many environmental risks.

The lack of conclusive evidence for environmental causes of AD extends to various nutritional factors[79,127]. However, a relationship between AD and certain deficiencies has been suggested. Low vitamin E intake, or low intake of all tocopherols from food sources, has been associated with an increased risk of AD in some studies[37,38,41]. Oxidative damage, a major component of AD progression, is greatly reduced in individuals with adequate dietary vitamin E/tocopherol intake, and although other antioxidants and antioxidant cofactors are thought to have a protective effect, consistent data regarding the efficacy of vitamin C, flavonoids, and carotenoids, for example, is lacking. Research so far has shown that vitamin E supplementation does not offer protection equivalent to dietary intake of vitamin E, although it has been suggested that supplementation levels used in studies were too low or that the supplements (usually containing onlyα-tocopherol) did not replicate the full range of tocopherols available in foods[41]. The Academy of Nutrition and Dietetics' food and nutrition guideline for patients with AD recommends against supplementation with any antioxidants, mainly because of the risk of side effects and lack of efficacy in randomized controlled trials and reviews, even at levels above the recommended daily allowance[35].

Low vitamin B12, B6, and folate levels are also suspected of increasing AD risk, but the association is unproven. These vitamins are cofactors for the methylation of homocysteine, and high levels of homocysteine are thought to contribute to cognitive decline [41]. Supplementation with B12, B6, and folate has been associated with a protective effect in some studies [41].

Fat composition is also suspect. High saturated or trans fat intake and low polyunsaturated and monounsaturated fat intake can cause hypercholesterolemia, a risk factor for AD [153]. Omega-3 fatty acids (especially docosahexaenoic acid, or DHA) are protective against inflammation, oxidative damage, and synaptic loss. Individuals consuming one fish meal per week are better protected against dementia than those eating fish less often [153]. There is consistently strong evidence regarding the protective effect of omega-3 fatty acids for the prevention of AD [41].

A meta-analysis of 16 prospective studies examining the association between physical activity and dementia, AD, and Parkinson disease showed that brisk physical activity is inversely associated with risk of dementia [170]. Further evidence of the neuroprotective effects of exercise is provided by a meta-analysis indicating that aerobic exercise in midlife is associated with a significant reduction in risk for later mild cognitive impairment [171].

There is increasing evidence that individuals who do not engage in regular mental, social, and physical activities (and possibly a combination of all three) are at heightened risk for AD [153]. Social activities and interactions provide opportunities for exercise, which maintains vascular health, and intellectual stimulation and problem solving, which maintain cognition. Individuals with large social networks perform better on tests of cognition despite having similar amounts of brain lesions as individuals with few social contacts. It is not known which specific component of leisure, work, and/or mental activities in late life prevent or delay AD; however, researchers have noted a protective effect when greater mental complexity is required throughout life at work and if cognitive/social/physical activities are maintained during mid-life [153].

An analysis of data from two longitudinal studies of health and aging demonstrated the potential impact of a healthy lifestyle on lowering the risk of AD [179]. In this study, a cohort of 2,765 participants older than 65 years of age were selected on the basis of available lifestyle data at baseline and periodic assessment for AD. A healthy lifestyle score was defined in relation to five factors: nonsmoking, light-to-moderate alcohol consumption, high-quality diet intervention, ≥150 minutes/week moderate- or vigorous-intensity physical activity, and engagement in late-life cognitive activities, giving an overall score ranging 0 to 5. During a median follow-up of 5.8 to 6.0 years, 608 (22%) of the participants developed incident AD. Compared with participants with 0 to 1 healthy lifestyle score, the risk of AD was 37% lower in those with 2 to 3 healthy lifestyle factors and 60% lower in those with 4 or 5 healthy factors.

The acquisition of a memory depends on several mechanisms. Information is received from the environment, and the senses perceive it, interpret it, and respond to it. There are three stages involved in this process.

Information is acquired during the first stage; the information is taken in through the senses, perceived, and understood. If the information is visual, it enters the brain through electrical impulses coming from the retina, traveling through the optic nerve and into the cerebral cortex. A limited amount of this information is retained in short-term memory. Like a clipboard on a computer, the contents of short-term memory are constantly being lost and replaced with other information unless the contents are restored through repetition. For example, when a telephone number is looked up, it is usually remembered long enough to complete the call. This information will soon be forgotten if it is not used again for several days or weeks. However, if the number is dialed every day or several times per week for several weeks, it becomes firmly entrenched in the brain as long-term memory for the duration of use. There is a limited storage capacity for short-term memory.

The second stage of memory is retention. Important information is placed in long-term memory, where the storage involves associations with words, images, or other experiences. This information can be recalled days, weeks, or years later. For a memory to be retained, it must be transferred from short-term to long-term memory. Physical changes take place in the brain to facilitate this transfer.

Retrieval of information occurs in the third stage. Information is stored at an unconscious level and is later recalled, bringing it into the conscious mind. The accuracy and availability of the memory depends on how well the information was processed in stage two (retention). Some memories are easily recalled, others seem temporarily unavailable, and some seem to disappear from the mind completely.

There are many types of memory. How the information is used depends on how the memory was formulated. Episodic memory pertains to remembering specific events associated with a particular time and place. Episodic memory requires no effort at learning. Remembering the details of a child's birth, one's wedding, or perhaps a catastrophic event are other examples of episodic memory.

Semantic memory requires the conscious involvement of the learner. The knowledge is not associated with a particular time or place but is learned at some point in time. Skills such as using a telephone book, balancing a bank statement, cooking from a recipe, and reading a road map are examples of semantic type memories.

Implicit memory is information learned without the conscious involvement of the individual. It is established through early and frequent repetition. Reciting the Pledge of Allegiance and singing "Happy Birthday" are the result of implicit memory. Social customs and manners, such as saying please and thank you, develop through implicit memory.

Motor memory is required for tasks utilizing motor skills, such as riding a bicycle, jumping rope, and dancing. Once learned, these skills are rarely lost even if not used for some time.

Affective memory refers to feelings and emotions. Listening to a song may evoke memories of a person, place, or event. The aroma of a certain perfume may bring to mind a specific person. Cooking odors may elicit the memory of family holiday meals. Meeting a person for the first time may bring forth feelings of dislike until one realizes that the person resembles someone from the past.

Semantic memory is the first type affected in the person with AD [131]. The individual may notice that tasks that were once simple to perform are causing increasing frustration. Motor memory is eventually lost as activities requiring fine and gross motor skills become more and more difficult to access. Implicit memory often remains intact as long as the individual can communicate. Anyone who has worked with those with advanced AD has experienced the surprise of hearing a person in the later stages singing a favorite hymn during church service or an old song during a sing-a-long. There is some evidence that affective memory remains intact far into the disease.

During an interview, no memory problems are evident, and no memory problems are identified by the patient. There may be measurable biomarkers indicating changes; however, no diagnostic criteria have been developed for use by clinicians. This stage exists as a placeholder for future biomarker diagnostics.

Patient complains of memory lapses (e.g., forgetting familiar words and names, the location of keys, eyeglasses, or other everyday objects). These problems are not evident during a medical examination or readily apparent to friends, family, or co-workers. Patients in this stage may be experiencing normal age-related decline or early signs of AD.

During a detailed medical interview or in clinical testing, problems with memory or concentration may be measurable or discernible. Patients, friends, family, or co-workers begin to notice deficiencies. Common difficulties include:

Early-stage AD or MCI can be diagnosed in some, but not all, individuals with these symptoms.

At this stage, the patient interview detects clear-cut deficiencies in the following areas:

Major gaps in memory and deficits in cognitive function are observed by an acquaintance and are apparent during an assessment. Some assistance with day-to-day activities becomes essential. At this stage, individuals may:

Memory difficulties have significantly worsened, and noticeable personality changes may have emerged. Family members or caregivers relate that the affected individual needs extensive help with daily activities. At this stage, individuals may:

During an intensive interview, the patient may only be able to speak a few words. This is the final stage of the disease. Individuals lose the ability to respond to their environment, the ability to speak, and, ultimately, the ability to control movement. At this last stage, individuals will:

Delirium is defined as "an acute change in cognition and a disturbance of consciousness, usually resulting from an underlying medical condition or from medication or drug withdrawal"[83]. Delirium may be related to an acute or chronic medical condition or may be substance induced. While delirium is often a forerunner of underlying disease, delirium may also have a psychosocial/environmental cause associated with the death of loved ones, sensory deprivation, or overstimulation and changes in the degree of personal control[24]. The incidence is highest among the elderly and is often misdiagnosed or missed entirely. In individuals with pre-existing dementia, it may be mistakenly assumed that the signs and symptoms are evidence of natural disease progression (Table 3). Knowing the patient's history of onset and type of disease progression is helpful in identifying delirium[83].

Pneumonia and urinary tract infections are common causes of delirium in the older population. Elderly people do not always present the typical signs of inflammatory response, such as elevated temperature and physical pain or discomfort. Confusion may be the only sign that an infection is present. The confusion generally dissipates with appropriate treatment.

Some medications may also be a cause of delirium, including [9]:

The diagnosis of depression may be difficult to make in people with multiple medical conditions. Depression is present in 25% of individuals diagnosed with AD[133]. Left undiagnosed and untreated, depression results in an earlier onset of behavioral disturbances, cognitive deficits, and mental suffering. Depression may also be responsible for earlier admission into a long-term care facility. Depression is often recurrent and thus may be a potentially chronic illness[26]. The fifth revised edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) criteria for major depression are summarized in Table 4.

Misdiagnosing dementia as depression may result in an exacerbation of the disease, because antidepressants with anticholinergic properties may worsen the confusion and memory impairment. In people with coexisting AD and depression, failure to identify and treat the depression may cause additional physical and emotional discomfort. The clinical interview is the foundation for evaluating and diagnosing depression in older adults. Self-report questionnaires can assist in screening for depression. The 30-item Geriatric Depression Scale (GDS-30) and the Center for Epidemiological Studies Depression Scale Revised (CESD-R) have proven to be reliable and valid.

It has been noted that "memory difficulty, agitation, disrupted sleep-wake cycle, and personality changes (e.g., apathy, increased dependence) are classic symptoms of AD that may be mistaken for depressive signs of poor concentration, decreased interest, changes in psychomotor activity, sleep disturbance, and fatigue" [16].

The DSM-5-TR requires the following signs to be present before a diagnosis of major neurocognitive disorder (commonly referred to as dementia) is made [20]:

Dementia is not diagnosed if the symptoms occur only during the course of delirium or another mental disorder. Delirium may be superimposed on a pre-existing dementia, in which case both diagnoses are given. A specific diagnosis of AD is considered only when all other etiologies for the dementia have been ruled out.

A complete and thorough medical history is imperative to making an accurate diagnosis. The family history may identify genetic or familial illness. Testing for impaired vision and hearing should be included. People with hearing impairments often deny the problem and will answer questions inappropriately, thus appearing confused. Visually impaired people may have problems controlling their environment and may also appear disoriented. Determine the onset and progression of the disease—whether abrupt or gradual. Identify whether the manifestations fluctuate, are gradually worsening, or if there is a stair-step progression.

The aging process causes diminished liver and kidney function. This loss may interfere with the absorption and metabolism of medications. Adverse effects of drugs such as cimetidine, digoxin, and diazepam are often noted through behavioral changes. A thorough assessment of the medication regimen should be included in the history. It is necessary to question the patient or family regarding the use of:

Nutritional and hydration status can also affect cognition. Dehydration may be attributed to the fact that thirst is not sharply experienced by the elderly. Fear of incontinence also hinders the consumption of adequate fluids. Nutritional disorders, such as anemia, hypoglycemia, hyperglycemia, hypoproteinemia, and vitamin deficiencies, often present clinical manifestations similar to AD. Caretakers should be instructed to keep a food diary for three days so dietary intake can be evaluated. Poor nutrition is not uncommon among elder adults and may be related to economic factors, health problems that diminish appetite, living alone and having no motivation to cook, or functional deficits that affect the ability to purchase or prepare food. An informant should supplement the clinical history, and clinicians should use any of the informant-based questionnaires when possible [159].

A functional assessment, to investigate the ability to complete activities of daily living, should be included in the diagnostic evaluation [159]. These activities include bathing, dressing, eating, and mobility within the home [2]. Instrumental activities of daily living include preparing meals, shopping, managing money, using the telephone, completing housework, and taking medications. Various tools are available that measure the person's ability to perform instrumental activities (e.g., Cognitive Performance Test, Executive Function Performance Test, Kitchen Task Assessment) [23]. These tests are also useful in determining whether or not someone can live independently or the degree of assistance that is required. Activities to consider include [23]:

Full neurologic and physical exams are required [159]. The neurologic exam consists of testing speech, sensation, coordination, muscle strength, eye movement, and reflexes [157]. Other etiologies associated with neurologic dysfunction (e.g., Parkinson disease, stroke, hypothyroidism, vitamin B12 deficiency, tumors) should be ruled out.

There are many physical disorders that can cause a decrease in the cognitive function of elderly persons. Some may be elicited or suggested by a complete physical examination. The physical examination should determine if fever is present, because many infectious processes (e.g., urinary tract infections) are known to have cognitive and/or psychological manifestations in the elderly. The assessment of cardiac status should include observation of the pulse rate and rhythm, cardiac auscultation, and blood pressure measurements while the patient is sitting and standing. The thyroid gland should be palpated to note enlargement or the presence of nodules. Pulmonary auscultation is performed to listen for rales and rhonchi and to observe the patient's ease of breathing. Examination of the abdomen for masses and organomegaly can be accomplished easily, as can an assessment of renal pain by palpating and percussing the appropriate regions of the body. Listening for bruits over the carotid arteries and palpation of all major pulses are necessary to help evaluate vascular status. Electrocardiogram and chest x-ray may be useful.

All comorbid conditions must also be identified. The following tests are generally considered mandatory at the initial evaluation, both to rule out other etiologies and to establish a diagnosis of dementia [159]:

CSF testing with routine cell count, protein, glucose, and protein electrophoresis may be included for patients with atypical presentation or who are suspected of having chronic meningitis or certain other neurologic diseases (e.g., Creutzfeldt-Jakob disease)[159]. In patients with rapidly progressive dementia, CSF 14-3-3 or total tau measurement is recommended to identify Creutzfeldt-Jakob disease. Electroencephalography may also be useful with atypical presentations or when Creutzfeldt-Jakob disease or transient epileptic amnesia is suspected[159].

In 2022, the U.S. Food and Drug Administration (FDA) permitted marketing of the first in vitro diagnostic test to detect amyloid plaques associated with AD[187]. The Lumipulse Gβ-Amyloid Ratio (1-42/1-40) test is intended to be used in patients 55 years of age and older presenting with cognitive impairment who are being evaluated for AD and other causes of cognitive decline. The test measures the ratio of beta amyloid 1-42 and 1-40 concentrations in CSF. The specificity is roughly equivalent to PET scan results. This test is not intended to be used as a standalone diagnostic assay or for screening; further, false-positive results are possible[187].

Mental status examinations alone are not definitive for establishing a diagnosis of AD; however, they are central to the diagnostic process and provide important information for developing a more complete clinical picture. Additionally, assessment offers a baseline for monitoring the progression of the disease and can be used to reassess mental status in people who have delirium or depression upon initial evaluation. All behavioral and psychological symptoms should be assessed and documented. Delayed recall tests are particularly useful [159].

There are several mental status examinations that can be used, including the Mini-Mental State Examination, the Blessed Information-Memory-Concentration Test, the Blessed Orientation-Memory-Concentration Test, the Short Test of Mental Status, and the Mini-Cog. One study found that compared with the more commonly used Mini-Mental State Examination, the Short Test of Mental Status was slightly more sensitive in identifying individuals with cognitive impairment and was significantly better at documenting MCI due to AD and predicting progression to AD [158]. When administering and interpreting any of these tests, one must be sure to consider the presence of sensory impairments, physical disabilities, and the age, educational level, and cultural influences of the individual being studied [82].

Neuropsychological testing may be appropriate when the mental status test is abnormal but the functional test is normal; when a family member expresses concern or dementia is suspected and results of mental status tests are within the normal range; when the patient has an advanced academic degree; or when the patient's occupation indicates high premorbid intelligence [16]. Preferably, a specialist in neuropsychology should be employed.

When mental status test results indicate cognitive impairment, the results of neuropsychological testing must be considered with the results of other assessments and the patient's history when any of the following circumstances apply:

Communication with patients regarding personal and family history is a necessary step in identifying dementia and obtaining and accurate diagnosis. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient's lack of proficiency in the English language, an interpreter is required.

Brain imaging should be included in the evaluation of patients suspected of having AD. The imaging modality of choice is MRI, which is able to assess with considerable accuracy the integrity of intracerebral structures as well as the size of the hippocampus [76]. It has been found that the volume of the hippocampus is diminished in patients with AD, compared with non-affected individuals, and that persons with some degree of atrophy are more liable to develop AD. MRI is also sensitive for detecting cerebral atrophy, vascular disease, and other structural abnormalities that may indicate contributing factors or an alternative diagnosis for dementia. Non-contrast computed tomography (CT) can also help in the diagnosis by identifying structural changes, such as infarcts or mass lesions, that may be the cause of cognitive changes [159,160].

Single photon emission tomography (SPECT) and PET are noninvasive imaging techniques that provide information about cerebral function and regional cerebral blood flow. Cerebral glucose metabolism can be studied with PET using fluorodeoxyglucose [160]. The ability to image the regional metabolism of the brain and locate areas of diminished function has been of particular importance in advancing the ability to diagnose AD. These techniques help to differentiate AD from other causes of dementia but should not be used as the primary imaging measure [8,80,81,85,159]. One of the benefits of these tests is the ability to help identify people in the early stages of AD or those with MCI who may benefit from treatments that are now being offered or may soon be developed.

While advances in several imaging techniques are being explored, one study has examined the use of PET in conjunction with a radioactive tracer. This tracer, known as Pittsburgh Compound B, adheres to amyloid clumps in the brain, which are then easily detected by PET scans. Due to the rapid loss of radioactivity in the tracer compound, other tracing elements were compared. AD subjects retained the tracers, while control subjects had a rapid loss of the compounds. It has been found that AD, MCI, and healthy control groups are strongly distinguished using Pittsburgh Compound B PET, and are even more clearly distinguished when combined with the results of fluorodeoxyglucose PET [160].

A novel tracer compound, 18F-AV-45, is currently being researched as an alternative to Pittsburgh Compound B [88]. In several small-scale studies, it has shown a high affinity for beta-amyloid plaque binding in AD brains and stained areas match reliably with postmortem exams.

Patients and family members should be encouraged to make long-term plans after a diagnosis of AD. When the diagnosis is made early in the course of the disease, the patient can and should fully participate. Decisions can be given some thought if they are made before a crisis occurs. The patient and family must be aware of the need for advance planning as a mechanism for protecting the individual's self-determination. The Patient Self-Determination Act (PSDA), legislated in 1990, is legally recognized in all states. The PSDA recognizes advance directives (the durable power of attorney and in some states, the living will) as legal documents providing direction when the patient is unable to make decisions. In some states, do not resuscitate (DNR) must be also written in the medical orders for those in healthcare facilities even if the advance directives contain this statement. Various states require that DNR orders must also be posted by or on the patient's bed. In the absence of advance directives, it may be necessary to initiate guardianship when the patient becomes incompetent. After a competency hearing, the judge decides incompetency based on the criteria of that state. The judge assigns a guardian to oversee the patient and his or her estate. Guardianship can protect a vulnerable person, but the process may be lengthy and complicated [28].

In the absence of directives or in controversial situations with institutionalized individuals, the facility's bioethics committee may be required to intervene. The bioethics committee can assist healthcare providers to develop guidelines for decision making.

The family or caretaker(s) may wish to consult with an attorney or financial advisor. This is especially important if the patient is financially responsible for a spouse or dependents. The family and patient may wish to establish a trust or appoint a durable power of attorney. The care of a person with AD is expensive and can bankrupt an individual and impoverish his or her dependents. Most individuals will eventually require the services of a long-term care facility. It is a rare family that has the time, energy, and emotional strength to provide continuing care throughout the course of the illness. The cost and method of payment for such services must be considered. Knowledge about using appropriate community services can delay the need for placement of the affected person in a long-term care facility.

It may be tempting for a busy and harried staff or family caregiver to rely on the use of medications or physical restraints in an effort to reduce the problems associated with wandering or agitated patients; however, there are serious ethical issues related to the use of restraints. Healthcare facilities traditionally relied on restraints to protect those in their care and to avoid liability for injury. In 1989, the U.S. Senate Special Committee on Aging sponsored the national symposium "Untie the Elderly: Quality Care Without Restraints." A statement by Alan R. Hunt, Esq., addresses the issue of liability [30]:

It is clear that to be restrained severely diminishes quality of life. This is in addition to the harmful effects of both physical and chemical restraints. The improper application of physical restraints may impede circulation, inhibit breathing, and predispose the patient to muscle atrophy, pressure ulcers, and incontinence [139,140]. The use of restraints increases disorientation and anxiety in many confused individuals. Restraints have not been proven to prevent falling and injury but have been shown to increase the risk of injury and death [140]. It is recommended that restraints only be used for medical emergencies [139].

A physical restraint is defined by the federal government as "any manual method or physical or mechanical device, material, or equipment attached or adjacent to the client's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body" [29]. To address concerns regarding the costs associated with eliminating restraints, an analysis of nearly 12,000 nursing home residents was completed in 1993, and the data showed that eliminating the use of restraints was less costly than continued use [136]. Nursing homes across the country have made significant progress in this endeavor [140]. The use of restraints in U.S. nursing homes has declined from 40% in the 1980s to 16% in the 2000s [140].

Chemical restraints are used short-term (6 to 12 weeks) in some cases for those who show anger and aggression symptoms, while other patients receive long-term treatment with psychotropic medications in an attempt to permanently alter these behaviors. There is growing evidence that long-term use of atypical antipsychotic drugs, in particular, is not beneficial and is associated with serious side effects, including increased falls, tardive dyskinesia, cerebral cell apoptosis, accelerated cognitive decline, stroke, and even death [161,162,163]. One small-scale study found that the three-year survival rate of patients with AD previously on a short-course of an atypical antipsychotic was double that of patients being continually administered the active medication [163].

It is beneficial to have a discussion involving the family, patient, and the facility regarding the use of restraints. The nonuse of restraints is a decision based on a consideration of independence and mobility versus the risk of incidents. The family should be informed of the interventions that will be implemented to maintain safety. The family should report any accident the patient has had while in their care. Families that include patients with AD at home should inform their neighbors and the local police department of the situation so they may help if necessary.

In a care facility, knowledgeable staff can plan a therapeutic physical environment that is safe, warm, and comfortable. Maintaining such an environment will diminish disruptive behaviors, thus reducing or eliminating the need for physical and chemical restraints [139,162]. Caregivers are elements of the environment and must be prepared to participate in the effort to create the appropriate milieu. The entire staff can be educated in the rationale for a restraint-free environment and how to implement interventions to prevent falls. Staff input in identifying and meeting the needs of all inpatients is encouraged. Employees from all departments should be aware of which people are at risk for falls. All employees must share responsibility for monitoring those at risk as they move about the building.

The physical environment should be evaluated for potential dangers. This is especially important when the patient is at home. A safe environment allows the patient freedom to move about, maximizing independence as long as possible. There are several ways to reduce the risk of trauma and injury related to poisoning, thermal injuries, lacerations, and falls. Remove or lock up:

Place guards over:

Reduce the risk for falls:

Reduce risks associated with wandering behavior:

Devices used to prevent patients from leaving the building that allow for freedom of movement:

Those with memory deficits should be provided with identification bracelets such as MedicAlert. Have recent snapshots of patients available and always know what they are wearing.

Unmet needs can cause the patient with AD to become agitated and anxious. Patients may be unaware of the source of discomfort or be unable to respond to the cues resulting from unmet needs. A routine should be established that will avoid problems resulting from thirst, hunger, lack of sleep and rest, inadequate exercise, and irregular elimination patterns. It is necessary to correct underlying physiologic problems such as infections, dehydration, urinary retention, fecal impaction, hypoxia, or blood sugar imbalance. The staff should be aware if the patient has taken a laxative or is on diuretics and monitor the reaction to other drugs affecting behavior. In addition, they should: provide measures to relieve fear and anxiety; avoid situations that can trigger emotional outbursts; correct sensory deficits with glasses and hearing aids; plan varied activities appropriate for each person's abilities and interests; and give positive reinforcement at every opportunity.

Clothing, grooming, and personal appearance can affect the self-esteem of patients even though they are disoriented. Poorly fitting attire can cause falls. It is important that patients wear clothing that is familiar and comfortable. Women who have always worn dresses or men who wore dress shirts and ties every day may react negatively to being dressed in jogging suits. Patients should be provided with well-fitting shoes with nonslip soles; shufflers, especially, need nonslip shoes that glide well on the floor. Shoelaces should be avoided when possible. Socks, nylons, and pants must fit properly. Prevent patients from ambulating in a long robe. In general, it helps to maintain a neat, attractive appearance.

Avoiding an overstimulating environment helps to prevent agitation, as does minimizing noise and commotion. Television can be disorienting to those who cannot distinguish between television and reality. Lowering the volume on telephones and communication systems may diminish patient agitation.

Older people in general require increased illumination, so bright, diffused lighting without glare is helpful. People with AD may become frightened by shadows produced by inconsistent light sources. Non-glare glass should be used on all pictures and artwork. Drawing the blinds or drapes at sundown helps to prevent reflections from the glass at night.

The area of care should present an inviting environment with judicious decorating, such as artwork that is familiar and objective (e.g., still life, landscape, seascape). Abstract patterns may further confuse or dazzle the disoriented person. Avoid patterns on floors and walls. Patients with AD may try to "pick" flowers off the wallpaper or may try to walk around or jump over "holes" in the floor created by different colors in the pattern. Mirrors may frighten some who are no longer able to recognize themselves; others find comfort in the reflection.

Orientation clues for those who are able to utilize the information are also useful. These include items such as clocks and calendars with large numbers, activity boards, reminders of special events, and seasonal and holiday decorations. Redundant cueing with pictures, words, and colors are helpful. A picture with the name of the person on the door may help him or her find the right room. This idea may also be used for bathrooms.

Areas of small, comfortable seating groups draw the people in and encourage them to reach out and touch objects. Placing safe, familiar objects around may promote reminiscence. A patient may be happy using a manual carpet sweeper or browsing through a catalog of old objects.

There is conflicting evidence regarding the clinical benefit of other therapies, including B vitamins, testosterone, ginkgo biloba, selegiline, and statins. Vitamin E, estrogen, and NSAIDs are generally regarded as being non-effective [79,159].

B vitamin and folic acid supplementation have been studied in an attempt to reduce homocysteine levels in patients with AD. Improvements in cognition remain unproven, although homocysteine levels were found to diminish with consumption of vitamin combinations [87,98,99].

The use of hormone therapy has been debated in relation to developing AD. Estrogen replacement therapy for women has been studied and is considered generally ineffective [79]. Testosterone therapy for men, however, has shown mixed effects on cognition, with some research studies showing improved cognition [58,60]. Part of this benefit may be the result of improvements in cardiovascular risk factors, and it is important to note that testosterone replacement is associated with increased risks of benign prostatic hypertrophy, liver toxicity, and erythrocytosis.

Ginkgo biloba is an herbal product with an unclear mechanism of action, but it may have antioxidant and anti-inflammatory effects, positively influence neurotransmitter levels, and have a protective effect on the energy metabolism of nerve cells when oxygen and glucose levels are low [97]. A certain extract of ginkgo (EGb 761) was shown in one study to produce a slight improvement in cognitive scores in patients with AD [6,87]. However, another study found no marked improvement in patients with AD who received a daily dose of 120 mg of high-purity ginkgo biloba for six months [100]. Although ginkgo biloba would be a cost-effective treatment modality if effective, more research is needed to support its efficacy [97,100]. As of 2014, it is not recommended [159].

Selegiline is a monoamine oxidase type B inhibitor that possesses some anticholinergic properties [79]. A meta-analysis of 17 well-designed trials found that a 10 mg per day dose was associated with a four- to six-week improvement in cognition; however, no benefit was seen after six weeks. There is currently not enough evidence to support its use [79].

The use of statins has been shown to decrease the incidence of AD but not to improve the cognitive abilities of the elderly [87]. Poor vascular health is a risk factor for AD; however, it is unknown whether it is the cholesterol-lowering properties of these agents that results in the supposed effectiveness or whether it is due to the pleiotropic functions of statins [166]. There is currently not enough evidence to support their use [159].

For some time, it was believed that vitamin E could prevent or slow the progression of AD, due to a protective effect on neurons through a reduction of oxidative stress [6,87]. However, research has not supported this use. A 2008 meta-analysis found no evidence of vitamin E effectively preventing or treatment AD or MCI, and no guidelines support its use for AD prevention or treatment [55].

NSAIDs have been studied for both treatment and prevention of AD due to their anti-inflammatory qualities. Twin studies have shown that NSAIDs used continuously for more than two years during a person's lifetime can delay the onset or reduce the likelihood of developing AD [132]. Although certain NSAIDs have been shown in epidemiologic studies to reduce the risk of AD, they have not been proven effective as a form of treatment [101,102].

Because the accumulation of amyloid plaques and tau tangles in the brain are the key structural features of AD, drugs that decrease the amount of amyloid and tau present in the blood stream and/or CSF have been a significant area of research[90,104,105,106,107,108,109,110]. Despite the efficacy of various agents in clearing aggregated plaques, certain research has shown that the course of the disease is not significantly altered by their elimination[54]. Because plaques are considered a sign of later stages of the disease, serious neural pathology is believed to occur as the result of other disease processes or amyloid-induced toxicity[53]. Preliminary studies of a monoclonal beta-amyloid antibody, gantenerumab, have found a reduced deposition of beta-amyloid in treatment-group participants' brains on PET scans versus controls[51,90]. Trials assessing the efficacy of gantenerumab for prevention of AD in genetically susceptible individuals and treatment of existing AD are being conducted. A 2022 study involving nearly 1,800 adults with AD found that the expiramental drug lecanemab reduced markers of amyloid in early disease and resulted in moderately less decline on measures of cognition and function than placebo after 18 months[188]. However, lecanemab was associated with infusion-related reactions in 26.4% of the participants and amyloid-related imaging abnormalities with edema or effusions in 12.6%.

The results of large-scale randomized clinical trials to assess the efficacy of monoclonal antibody therapy for AD have not proved promising. Solanezumab is a humanized monoclonal antibody that binds to the mid-domain of the beta-amyloid peptide. It was designed to increase clearance of soluble beta-amyloid peptides from the brain before deposition of the toxic fibrillary form of the protein[180]. In a double-blind, placebo-controlled phase 3 trial, 2,194 patients with mild AD were assigned to receive intravenous solanezumab or placebo every 4 weeks for 76 weeks. The primary outcome was change from baseline to week 80 in the cognitive subscale of the AD Assessment Scale. Results showed that compared with placebo, solanezumab had no significant effect on cognitive decline[180].

Another humanized monoclonal antibody, donanemab, has been studied, most recently in a double-blind, placebo-controlled phase 3 trial, with results published in July 2023 [190]. This antibody is directed against "insoluble, modified, N-terminal truncated form ofβ-amyloid present only in brain amyloid plaques," and was shown to significantly slow clinical disease progression at 76 weeks. The trial had several limitations, but a study extension and other trials are planned with the hope of confirming the positive outcome seen with donanemab.

Disruption of the GABAergic and glutamatergic systems is associated with the behavioral and psychological symptoms of AD[63,92,94]. Evidence for a link between various mood disorders (including depression) and the heightened risk of developing dementia, related to disruption of GABA and l-glutamic acid levels in the central nervous system, is being sought[167]. While memantine has shown promise in regulating the glutamatergic system, it is hoped that future neuroprotective/neuromodulatory agents may be able to inhibit toxicity well before symptoms of AD. More research is clearly needed regarding the role of regulating the GABAergic and glutamatergic systems in AD treatment[93,167].

Depending upon the disease stage, 25% to 50% of patients with AD experience concomitant psychotic symptoms [70]. Although antipsychotics have been used in the management of AD, none have been approved specifically for this use. In 2005, the FDA warned the healthcare community regarding the increased risk of mortality in elderly patients receiving atypical antipsychotic medications for dementia-related psychosis. In 2008, the FDA added this warning to typical antipsychotic medications as well [135]. In addition to the increased risk of mortality and other serious side effects, antipsychotics diminish the patient's response to stimuli and may be considered a form of chemical restraint when the sedative properties of the drug are used to facilitate patient management [89]. Even with short-term use, antipsychotic medications are associated with many adverse effects in this population, including [134,137]:

A clinical need for the use of antipsychotic medications must be established. Psychotic behavioral disturbances, including agitation, hallucinations, delusions and paranoia, and physical and verbal aggressive behavior, may justify their use [49]. Wandering, impaired memory, depression, insomnia, and anxiety do not warrant their use unless patients present a danger to themselves or to others. Evidence suggests no single drug is more effective than any other, and when a drug is effective, it requires relatively low doses [134]. Greater clinical improvement has not been noted with higher doses [67]. The goal of the therapy is to find the dose at which the identified behaviors are eradicated without causing sedation [66]. Before antipsychotic medications are prescribed [66,152]:

Because age may alter the absorption, distribution, metabolism, and elimination of many medications, elderly individuals may be more sensitive to their effects [134]. The combination of drugs may also contribute to disorientation and confusion, and administration of multiple drugs increases the risk for adverse, interactional side effects. Ongoing evaluation is required to determine the effectiveness of these agents over time and to assess the need for their continued administration [152]. The APA recommends several actions regarding the use of antipsychotic medications [193]:

The concept of dignity is subjective and may have different meanings for each person. It is beneficial to have an understanding of what the patient was like before the illness. Remember that several aspects of individuality must be met:

Family and staff should consider the wishes of the patient before initiating a treatment that may prove to be more harmful than beneficial. For example, starting an IV for feeding or administering antibiotics for an infection may not be in the best interests of the patient if he or she must be restrained to prevent dislodging of the needle. Acknowledge the individual's autonomy. When a patient is too demented to make decisions, the family must consider what their loved one would have wanted rather than what they themselves want.

Be honest with patients with AD while being optimistic when answering questions. Let them know that although the disease is progressive and there is no cure, there are still treatment options. Honesty from caregivers often encourages patients to consider the future and to make decisions about what they want as their condition worsens.

Consistent caregivers should be familiar with:

Each activity of daily living requires a number of steps that must be completed in sequence in order to accomplish that particular task. The functional assessment identifies the steps of an activity of daily living that the individual can and cannot perform. Using this information, an approach can be developed that allows patients with AD the opportunity to perform the steps that they are capable of performing. For example, a patient may be able to brush his or her teeth if all the needed items are set out. It is possible for well-intentioned caregivers to enforce dependency by overhelping. When a patient begins to have problems completing a task, this approach may prevent premature deterioration.

Cueing is a process of giving hints or clues to facilitate independence. Verbal cues require the use of simple instructions given with each step of a task. For example, a caregiver may say, "Please put on your shirt" while handing the shirt to the individual. After the shirt is on, the caregiver may say, "Please button your shirt." Demonstrating the action by buttoning the first button provides an additional cue. Redundant cueing uses several methods, such as colors, words, and pictures to communicate information. A facility may have all bathroom doors painted the same color with the word bathroom on the door and a picture of a toilet.

Brief attention span and memory deficits can be helped by the use of distraction techniques. Looking through a picture book may distract the patient who complains of not having dinner immediately after eating. If a patient with AD has his or her hands full while shopping, it will be difficult or impossible for the patient to pick up unnecessary items from the shelves.

Determine whether the patient still writes checks with legible handwriting, adds and subtracts in order to balance a monthly statement, handles cash (i.e., paying for purchases and receiving change), or comprehends the routine of paying taxes. Does the patient have an awareness of the family's overall financial status?

As the patient begins to lose the ability to handle financial matters, family members must gradually assume responsibility for these tasks. Patients may make accusations that someone is stealing from them. Allow them to keep small sums of money in their pockets. Consultation with an attorney may be needed to assure fairness to the patient and to the family.

Losing a driver's license causes a considerable loss of independence. According to the Alzheimer's Association position statement on driving safety, a diagnosis of AD alone should not be considered grounds to revoke a patient's driving privileges [123]. Other factors must be present and considered, such as the degree of cognitive decline, comorbidities, and prescription of medications that may affect driving abilities [123,124]. Formal assessments, such as an on-the-road driving test, should be considered when appropriate [123]. Physicians carry the responsibility of recommending driving cessation in patients with AD when necessary. As some states have reporting laws, physicians should be aware of their own state's reporting laws. This situation is difficult, especially in the case of the patient who refuses to give up driving. There are several issues that physicians are faced with, including [124]:

Healthcare professionals should work with each patients' caregiver and family to explore all options, including taking away the car keys, disabling the car, or selling the car.

It is wise for patients with AD to inform their employers of the diagnosis. It may be possible to switch to a simpler job or one with fewer responsibilities as ability declines; retirement may also be an option. The family can investigate the availability of counseling through an employee assistance program or a social service agency. The family also must determine whether or not any benefits, like a pension or health insurance, will be available to the worker if employment is to be terminated. They should also contact the local Social Security office to find out whether the patient is eligible for benefits.

Patients with AD do not remember that they have to take a shower, brush their teeth, and shave. They may forget how to find the bathroom, how to turn the water on, or where their toothbrush is when they get there. Knowledge of how to get toothpaste onto the brush or how to use the razor may also be lost.

Even with reminders, patients often cannot attend to a task long enough to complete it. For example, they may start shaving or brushing their teeth and quit before they are finished.

Patients with AD may also have a figure-ground deficit, which means that when a number of items are laid out (e.g., toothbrush, toothpaste, razor), they are unable to distinguish one from another. The individual who perseverates may wash the same side of his or her face over and over, unable to move on to another part of the body. Sequencing deficits (the inability to complete the required steps in the correct order) are common in AD. For example, when dressing, patients may put underwear on top of outer clothing or try to put a sock on over a shoe.

Some individuals may suffer excess disability. This is defined as disability beyond that expected by the disease process itself. Treating the excess disability is a priority for people with AD. The condition may be caused by medication toxicity from drugs such as digoxin or phenytoin; other diseases, such as arthritis, cardiac disease, or coexisting mental illness; increased level of fatigue or stress; and vision or hearing impairments. Caregivers may unwittingly contribute to or hasten the onset of dependence by decreasing their expectations. Caregivers can over help because of their desire to spare their loved one. It can be due to impatience with the decreasing abilities, a lack of understanding of the disease, or because it is "just easier" to do it themselves [103].

When a behavior is disturbing to caregivers, the specific actions of the patient must be identified. Using subjective descriptions such as "He became violent" or "She is aggressive" provide no clues as to a possible cause or how to intervene. The statement "Mr. J said he didn't want a shower and bit me when I attempted to take him to the shower room," provides a starting point for problem resolution.

The next step is to evaluate the behavior by further investigation. In this situation, the problem may be directly related to the shower or it may be due to other factors. To determine triggers for problem behaviors, the following questions may be helpful:

With this information in hand, interventions can be developed.

There are clear-cut solutions to resolving problems caused by unmet needs or an upsetting environment. Other situations may require more deliberation. It may be helpful to discuss the problem with other staff members. Is the interaction between a patient and a particular staff member especially positive? Remember that it may be a housekeeper, a volunteer, or other individual who has the most substantial relationship with the individual. Try to identify the reasons and share this information so these approaches can be used consistently. Before establishing interventions, determine whether the safety or health of the patient or other individuals is at risk as a result of the behavior and whether the problem is truly a patient problem or a staff problem. In some cases, actions are only troubling to the staff and are not hindering the safety or health of anyone. For example, a patient with dementia who is masturbating in the privacy of his or her room is not a problem except to those members of the staff who consider it delinquent behavior.

Redirecting behaviors uses distraction techniques and patients' memory deficits, and short attention spans help to ensure the success of distraction. Used correctly, it avoids confrontation and the risk of catastrophic reactions.

The effective use of one's self as a therapeutic medium is the greatest intervention of all. Caregivers who are successful realize that the responses of the patient are frequently related to the approach of the caregiver. The most successful are those who are willing to "listen" to the patient's unspoken messages and use this information in their interactions. When a disturbing behavior occurs, they view it as a challenge for which they can find a solution rather than placing the responsibility for the behavior on the patient. They learn as much as they can about patients and their pasts through their contacts with the patients' families and others who know them.

As an example, Patient D was agitated one morning and repeatedly called out, saying, "I have to go outside." Because it was a beautiful spring morning, a nursing assistant wheeled Patient D to a window where he could view the trees and the blooming spring flowers. Patient D became more agitated and began pounding the table. Another nursing assistant who knew him suggested that he was upset because for several years he had been a gardener for a public park. The spring was his busiest time; sitting by the window reminded him that he had to get outside to "get his chores done." The nursing assistant also knew that he enjoyed ball games and moved him to the TV where he could watch his favorite team playing.

Caregivers with the therapeutic touch have the ability to go where the patient is at the present time. They can sing Christmas carols in the middle of July if that makes the patient happy. They know when hugs are appropriate and sense when a hand massage is in order. Most importantly, those who make use of "self" truly enjoy working with the patients and are proud of their accomplishments.

Shadowing occurs when the patient follows or "hovers" around the caregiver and may persist in talking or asking questions. Safety is not usually a concern related to shadowing. However, it can become irritating and annoying to the caregiver, particularly when it involves a family member at home. Remember that the caregiver represents security to the patient. The shadowing may be accompanied by agitated behavior that should be addressed. An assessment of the behavior will help determine if the behavior happens at a specific time of day or if it is triggered by certain people or environments.

Interventions for Shadowing

If certain people or environments trigger shadowing, then adjustments or avoidance is necessary. If the behavior happens at a certain time of day, an activity may be planned to keep the person occupied, such as dusting or winding a ball of yarn. The Alzheimer's Association suggests, "gum therapy" or "cereal therapy" if the person can safely chew and swallow. Chewing is another form of distraction and redirection of energies.

The Hartford Institute for Geriatric Nursing asserts that best practice in care of older adults with dementia involves: 1) identifying risk for wandering, including interviews with caregivers, 2) providing appropriate supervision, 3) reducing environmental triggers for wandering, and 4) using individualized nursing interventions to address the causes of wandering behavior.

(https://hign.org/consultgeri/try-this-series/wandering-hospitalized-older-adult Last Accessed: August 17, 2023)

Level of Evidence: Expert Opinion/Consensus Statement

Wandering is defined as ambulation that may appear aimless but often has a purpose. There are many unproven theories for wandering. The patient with AD may be looking for something or someone, or it may be a way of coping with stress or of alleviating feelings of loneliness and isolation. The perception of the caregiver, the type of wandering pattern, and the environment help determine whether wandering is considered a problem. Purposeful wandering occurs when the individual has intent for the movement. He or she may be walking to escape boredom or to exercise. Purposeful wanderers are usually predictable and consistently walk the same route. They do not attempt to leave the building, and they are "safe" wanderers. This type of wandering should be considered normal unless the pattern changes. When mobility skills begin to diminish, falling may become a problem. Aimless wandering is characterized by purposeless movement by a disoriented person who may enter other rooms or take another's belongings. The escapist usually has a destination, planning on "going home" or to some other familiar place.

An example is Patient W, who was very determined to leave the facility so he could visit his sister. When all the staff was busy, he managed to get the nurse's car keys from the counter in the nurse's station. He knew which car was hers and drove away from the premises. He was missed about 15 minutes later. When a search of the grounds and building proved fruitless and when the nurse noted her car missing, the police were notified. Following the staff's advice, the police found Patient W at his sister's house. He had driven 65 miles on an interstate highway without incident.

The most dangerous type of wandering is done by the critical wanderer. This individual tries to leave the premises but is unaware of the hazards involved. He or she may wander into the middle of a busy highway or into a pond of water without any comprehension of cause and effect.

Not all people with AD will wander. Those who may not have wandered at home may do so in the long-term care facility. The first two weeks after admission are critical. The staff should monitor the individual for specific behaviors. The goal is not necessarily to stop the wandering but to ensure the safety of the individual and to avoid intrusion on others.

Interventions for Wandering

Sundown syndrome occurs when the patient becomes restless in the evening or during the night. As with wandering, the cause is unknown. Experts feel it may be due to overfatigue, physical discomfort, reduced sensory stimulation, too much caffeine, shadows caused by the lighting, disturbing dreams or feelings of insecurity, or loneliness during the night.

Interventions for Sundowning

If these interventions fail and sundowning persists, repeat the bedtime routine (take the patient to the bathroom, provide a glass of warm milk, etc.). If all else fails, allow the patient to stay up in a recliner or beanbag chair by the nurse's station. The patient may willingly return to bed later. If in the patient's home, the caregiver may need to adapt the sleep/wake schedule to match the patient, or a sitter may be hired to remain with the patient while the caregiver sleeps.

Psychotropic medications may be needed for agitation, delusions, or hallucinations. Sleeping medications are not recommended. The effects are short-term and may add to confusion on awakening.

Persistent sundowning is a common reason for admission to the long-term care facility. The caregiver becomes stressed from lack of sleep. The situation may also become dangerous if the patient wanders outside, turns on the stove, or turns up the thermostat.

The degree to which rummaging, pillaging, and hoarding is a problem depends on whether the individual is at home or in a facility and whether or not it is infringing upon the rights of others. Consider Patient J, who goes from room to room aimlessly picking up items from others. She may take the items to her room or she may leave them in someone else's room. This is one of the most disturbing behaviors for other residents in the facility. The family of Patient F noted that she had over 200 rolls of toilet paper in her basement. Patient P had stacks of newspapers throughout the house, with only a narrow walkway going from room to room. Theorists believe these patients may be searching for something or attempting to maintain control of the environment.

Interventions for Rummaging, Pillaging, and Hoarding

In a dementia unit, patients may pillage from one another. This may present more of a problem to family than to the patient. In some facilities, the night-shift staff collects the items and returns them to the proper rooms.

Agitation is defined as improper behavior that may be verbal or physical and is not explained by an unmet need, confusion, or pain. Aggression is a hostile action directed toward other people, oneself, or objects. Agitation may be a result or a cause of many other behaviors associated with AD. Agitation may cause sundowning, shadowing, and/or wandering. It may result from delusions or hallucinations. Other causes of agitation include delirium, psychiatric disorders, medical problems, depression, drug side effects, sleep problems, and social and environmental factors. As the disease progresses, the AD sufferer's insecurity increases. The coping mechanisms used earlier to block out awareness of functional losses are no longer effective. Agitation may change to verbal or physical aggression if not managed appropriately. It is estimated that more than 75% of those with dementia will exhibit agitation [52].

Interventions for Agitated Behavior

Patient H, for example, is seated at the table waiting for breakfast. The dining room is a flurry of commotion. Several call-ins mean the nursing assistants are trying to hurry in an effort to catch up on the day's tasks. Patient H is showing signs of agitation. His breakfast has been served, and he is able to feed himself; however, he is not eating. The nurse approaches him and urges him to eat. "You have to eat; this food is good for you. Here, just take a bite of cereal." At the same time she is attempting to get him to drink by holding a glass of juice up to his mouth. He pushes the glass away, and the nurse responds, "Why did you do that? That wasn't nice. Here, you need to drink this juice." The nurse continues her attempts to coerce him to eat. Finally, Patient H slaps the glass out of the nurse's hand, spilling juice down the front of her uniform. The nursing assistant approaches Patient H when the nurse leaves to clean her uniform. He gently touches him on the hand and tells him that he is going to move him to a quieter place. The nursing assistant sits down next to Patient H and gains eye contact. He places a bowl of cereal in front of him but makes no attempt to coax him into eating. Patient H picks up the spoon and begins to eat his cereal. The nurse reports and documents that Patient H is "combative."

This scenario is an example of agitation changing to aggression. The interventions for agitation and aggression are the same. If those interventions are implemented during agitation, aggression can usually be avoided. Physical aggression often contains an element of danger. The patient may strike out at the caregiver or other residents. Occasionally, two patients will "feed into" one another, causing each person to become aggressive, striking one another if within close range. The only solution is to keep the two parties separated at all times. When a person is physically aggressive, assess the level of danger for the caregiver, the individual, and other residents. Avoid a "hands on" approach unless the situation is leading to immediate peril.

A catastrophic reaction is defined as an overstated emotional response triggered by task failure. The patient feels he or she is expected to perform beyond capacity and feels frustrated and angry. A catastrophic reaction may have components of agitation or aggression but does not necessarily have violent tendencies. Assess the situation in an effort to determine what may have precipitated the reaction; in this way, further incidents may be avoided. Regularly assess the individual's abilities so the staff does not expect more than the patient is capable of doing.

In an example of distraction, Patient G was told that she would have a new roommate. The medical condition of her present roommate necessitated moving her to a different level of care. After the new roommate was admitted, Patient G began pacing the hallway. She muttered over and over, "I can't do it. I can't take care of her. I can't do it." This continued as various staff members attempted to calm her. Taking her to her room was not a solution. Seeing her roommate in bed only increased her agitation. Her daughter later came to visit and suggested she take her mother out for a ride and some ice cream. This was successful. Upon her return, Patient G was calm and went to bed that night without further incident.

Delusions and hallucinations are psychotic symptoms of dementia. AD is not considered a psychiatric illness, but the patient may have concomitant psychiatric illness with AD. These manifestations may be triggered by medications, physiologic malfunction, environmental stress, or insecurity. As previously noted, delusions are fixed false ideas or beliefs and may result from the person's misinterpretation of a situation. One evening at an activity, Patient R kept talking about "the people over there who were having a party." Patient R was looking at the reflection in the window of the people in the room but misinterpreted what she saw. Hallucinations are sensory experiences that cannot be verified by anyone else. They may be auditory or visual and are usually disorganized and fragmented. An illusion is a misperception and is common among the general population; for example, one may bend over to pick up a piece of foil from the floor, thinking it is a dime.

Delusions and hallucinations may not need aggressive treatment unless they are bothersome to the patient who may then respond with aggression, fear, or violence. An assessment, as described earlier, may identify events that trigger these manifestations.

Interventions for Delusions and Hallucinations

Never argue or disagree with patients with AD about what they think they see or hear. They may become agitated and even violent. It is real to them and no amount of persuasion will change their minds. If a patient asks you, "Do you see that person over there?" saying, "I know you see something, but I don't see it" does not deny the truth. If the patient is upset or frightened, be calm and reassuring with statements such as, "I know you are frightened, but we will keep you safe." You are responding in a manner that will assist the patient and consider his or her feelings.

Check the environment for noises that may be misinterpreted and for lighting that may cast shadows. Assess for impaired hearing and vision because correcting deficits with hearing aids or glasses may improve the symptoms.

Consider whether the delusion has some basis in reality. In another example, it was reported by the nurse that Mrs. S was delusional; she insisted that she was going to California in a few days to visit her daughter. Three days later her son and daughter-in-law came to get her and flew with her to California. Similarly, the patient who claims her son is taking her money may be correct. These types of statements may be worthy of tactful investigation.

Consider whether the delusion is based on a past event from years ago. The person who talks about getting home to her children or getting up early to milk the cows may be reliving a happier time of life. These types of delusions are harmless. The staff should not feed into them, but it is important they understand that these beliefs are filling a need. In these situations, it is not the task of the staff to determine whose reality is appropriate.

Determine whether the delusion may be rooted in television. Patients with AD cannot always distinguish reality from fiction. Witnessing acts of violence on the screen can be frightening and upsetting.

Use distraction for delusions that appear distressful. Music, going for a walk, looking at pictures, or quiet conversation may be effective. Cover or remove mirrors if a patient becomes upset when the image is mistaken for that of someone else. Pharmacologic therapy must be considered when someone experiences frequent delusions or hallucinations that result in further behavior disturbances.

Mrs. R had been a businesswoman prior to retirement 15 years ago. She commuted to Chicago every workday for 30 years. For the last five years she has resided in a long-term care facility. Every morning she walks to the nurse's station to "buy a ticket" so she can take the train to work. For several days, the staff would intervene with RO. "Mrs. R, you are in the nursing home now. You are retired and no longer work in Chicago." Mrs. R's agitation would sometimes escalate to a catastrophic reaction. One day, the nurse gave Mrs. R a "ticket" without comment. Mrs. R took the ticket and walked away contented. This approach was incorporated into the care plan, and there have been no further incidents.

Mrs. S waits by the door every night for her husband to come home. Mr. S died 15 years ago, but his wife does not remember this. For a staff person to say, "Mrs. S, your husband died 15 years ago" would be upsetting and needless. The staff members allow her to sit, knowing that in a few minutes she will have forgotten why she is sitting there. She will soon get up and move on to something else.

Caregivers and staff must take every patient's unique situation into consideration. The benefits of attempting to make patients with AD aware of present reality should always be weighed against possible adverse effects. It is the caring of the staff, the ability to "go with the moment" and to connect with their patients by accepting them as they are, that enhances the patient's behavior.

At the beginning of the last stage, the patient may still be wandering but will exhibit significant changes in posture, gait, and balance. The hips appear to be internally rotated, causing a shuffling, scissor-type gait. Eventually, it will take two people to transfer and to assist the patient to walk. As mobility skills diminish, patients may be transferred out of bed with an automatic lifting device and placed in a recliner type chair. Supportive devices are needed to maintain body alignment and to relieve pressure. Contractures and rigidity will develop without appropriate intervention. In addition to frequent repositioning and adequate support, passive range of motion exercises should be completed two times per day, doing each motion at least three to four times.

Immobility and incontinence place the patient at risk for pressure ulcers. A Pressure Ulcer Risk Potential assessment will identify areas requiring aggressive intervention. As mobility skills diminish, it becomes exceedingly difficult to maintain a scheduled toileting routine. The use of incontinence briefs avoids the soiling of outer clothing and enables the individual to participate in activities geared to his or her cognitive level. The briefs should be checked every two hours and perineal care given with each incontinent episode. A skin barrier provides additional protection. Soaps can be irritating and difficult to remove from the skin; therefore, caregivers should carefully and regularly inspect the skin for signs of breakdown.

Adhering to a positioning schedule and doing range of motion exercises, as described, are additional preventive measures. Use a turning sheet to avoid friction when moving the patient in bed. High protein supplements given between meals may be necessary to maintain adequate nutritional status. The fragility of the patient's skin presents a risk of skin tears and easy bruising. The staff should be aware how to handle the person to avoid these injuries.

As AD progresses, nutritional intake becomes a major concern. Ideally, the family and patient will have made decisions regarding the use of enteral feeding tubes in the early stage of the disease, should it become an issue. If this is not the case, the family should be encouraged to consider the possibility so a mutually agreed upon decision can be made if the need arises.

Eating alterations are made throughout the course of the disease. Adaptive eating devices may allow the affected individual to maintain independent eating skills for a longer period of time. Spoons will replace knives and forks. Patients may be able to manage a smaller, plastic glass better than a larger one. A "sippy" type cup often works better than a straw. Providing nourishing finger foods allows patients to self-feed. Adding thickeners to liquids increases ease of drinking and swallowing. By the terminal stage of AD, pureed or chopped foods are usually needed and the patient must be fed.

Diminishing cognitive awareness leads to dysphagia, which increases the risk of aspiration. The visual and olfactory stimulation that activates the swallowing mechanism in the brain stem is no longer effective. An evaluation by a speech-language pathologist may identify specific interventions that the staff can implement.

General caregiver guidelines for feeding those at risk for aspiration include:

The manifestations of the terminal stage place the patient with AD at risk for urinary tract and respiratory tract infections. Adequate fluid intake is an effective preventive measure for both types of infection. Indwelling catheters are not recommended; their use often agitates the person, predisposing to urethral tears. Frequent changes of position and prevention of aspiration may preclude respiratory infections.

Severe cognitive impairment places the patient with AD at risk for sensory deprivation. Although the patient is minimally expressive, proper amounts of stimulation are needed to prevent continuous sleeping and agitation. The use of recliner type chairs enables dependent patients to be moved out of their room and to participate in appropriate activities. Listening to soothing music, hand massages, quiet talking, and olfactory stimulation with familiar odors are examples of sensory-centered activities.

As the family adjusts to the situation, they may need encouragement to think about the future and any legal actions that should be taken in regard to legal and financial planning. Eventually, patients with AD will be unable to manage their own affairs, but they are usually able to participate and help with decision making when done early in the course of the disease. To delay this process can result in many financial and legal problems.

Physicians and other healthcare professionals may be required to consider the admission of a patient with AD to an advanced healthcare facility.

Most families experience mixed emotions of relief and guilt when they realize they can no longer care for their loved one. The healthcare team must fully understand the impact of AD and institutionalization on the family so they can effectively help them deal with their grief. Intervention begins when the family visits the facility prior to admission. Their future adjustment may be influenced by what they observe during this time. Introduction to the staff gives the family the opportunity to identify key people in various departments. They should be provided information that describes the facility routine and a typical day. Most importantly, the family should be encouraged to communicate openly and honestly with staff. It is helpful if there is a specific person they can go to for discussion and answers. They should know that their feelings are normal and that staff is not judging them because of the patient's behavior.

Families may need suggestions for visiting. It is sometimes awkward to visit with a person who thinks the spouse is a sibling or the child is the spouse. The family is encouraged to bring old photos as a way of stimulating a response from the patient. The staff should direct them to other areas of the unit or building where they can take the patient when they come to visit and be invited to participate in care planning conferences and activities. Some families take great pleasure in feeding their loved ones, getting them ready for bed, or helping them bathe. On the other hand, there should be no pressure on those who choose not to help. Some families are exhausted from their caregiving demands prior to admission and welcome relief from further responsibilities.

Hospice agencies can be a tremendous help for those who qualify for the service. Care may be rendered at home or in a healthcare facility. Staff members are truly concerned with the total family unit. They are knowledgeable about community resources and can link the family to other services that they may require.

Respite care, or adult day care, may be a solution for spouses who are still employed. Care may be available 8 to 10 hours per day, 5 days per week. The recipient receives nourishing meals and snacks, and appropriate activities are offered. Other services may be available depending on the type of agency sponsoring the day care. Adult day care may be utilized for family caregivers who do not need full-time care but who would benefit from release of responsibilities once or twice per week, either for the entire day or a few hours.

Some nursing facilities offer temporary nursing care to allow caregivers to have freedom from care for a weekend or for a few weeks at a time. This allows the caregiver to take a vacation or to recuperate from illness.

Homemaker services are frequently available through family service organizations or nursing agencies. The homemaker provides no nursing care but will come to the home to prepare and serve a meal, do laundry and light housekeeping, run errands, or to stay with the patient while the caregiver performs those tasks. Home-delivered meals (Meals on Wheels) may be arranged in most communities where there is a documented need for such a service.

The Alzheimer's Association website also provides a wealth of information and education to patient's families and healthcare providers (http://www.alz.org). The Association also sponsors support groups located in every state. The Social Services department of hospitals and long-term care facilities can offer information about the availability of community services.

Meals should be served at the same time each day and in the same place. In the long-term care facility, having a specific seating arrangement and making sure all residents are seated before serving begins is helpful.

Remove items such as extra silverware and condiments from the table. It may become necessary to place only one food at a time in front of a specific resident. Too many foods can be confusing and frustrating.

The patient should be taken to the toilet before each meal and assisted with hand washing. Make sure the patient's mouth is clean and that dentures are in place and in good condition. Note whether he or she wears glasses or a hearing aid. Make sure the patient is in a comfortable position, in good body alignment with feet flat on the floor. In the last stage, pillows or supportive devices are often needed to support a patient's head. Transfer patients from wheelchairs to dining chairs for eating.

All caregivers should use the same or similar methods of assistance, such as verbal cues, hand-over-hand techniques, or demonstration. Light pressure on the lips may remind the patient to open his or her mouth. Monitor individuals at each meal because their ability often fluctuates. A given patient may be able to eat independently for one meal and require assistance or feeding at the next meal.

Avoid distractions by turning off radios and televisions in order to maintain a calm, quiet environment. Establish a cheerful dining room conducive to social interaction. Use tables that seat four to eight people. Place a clear plastic tablecloth over a colorful cloth or use plastic place mats. Having snapshots at the table may help ambulatory residents find their table. Set a small centerpiece in the middle of the table, but remove it if someone thinks it is edible. One study at a nursing home in Sweden noted significant improvements in behavioral symptoms (e.g., irritability, anxiety, depression) and nutritional intake when soothing music was played during meals [45].

Use plain dinnerware because plates with patterns can be confusing. Use dishes that are a different color from the tablecloth. Avoid the use of plastic eating utensils that can break in one's mouth. A spoon may work better than a fork. Use cups for soup to help facilitate patients' independence.

Use assistive devices to expedite mealtime. Plate guards prevent food from being scooped onto the table. Nonslip material or a wet washcloth under the plate prevents sliding. Convalescent feeding cups avoid dribbles and spills.

Serve familiar foods prepared in the usual way. Check the temperature of foods before serving them and debone all meats. Cut food into bite-sized pieces. Remove all wrappers, open all cartons, and pour beverages. Add condiments if the resident desires, then remove them from the table. Avoid tough, stringy, or dry foods. Crumbly foods such as hamburger are difficult to control in the mouth and may cause choking. Dry cereal in milk and soups containing pieces of food are confusing; patients may not know whether to chew or to swallow.

Meeting nutritional needs requires an interdisciplinary approach throughout the progression of the disease. The attending staff should consult with the dietician for suggestions about appealing, nutritious, and easy to handle foods. The speech-language pathologist can conduct a bedside swallow evaluation and instruct the staff on feeding techniques for the dysphagic individual. The benefits of assistive-eating devices can be evaluated by the occupational therapist. With accurate assessment and knowledgeable planning, the patient with AD can maintain adequate nutritional status throughout the course of the illness.

Dressing is a complex activity of daily living. To dress, one must have fine and gross motor skills, balance, the ability to sequence, and the ability to tell right from left and top from bottom. The task can be overwhelming for patients with advanced AD. If a patient can make choices, take him or her to the closet to pick out the clothing. If this is too complicated, hold out two garments and ask the patient to choose one. When patients can no longer cope, the caregiver must make the choice. Dressing is easier if the clothing is large enough and made of a soft, slick, stretchy fabric. Try to maintain the individual's dressing style. As patients become more dependent, it will be necessary to adapt clothing to their needs. To facilitate dressing/undressing, follow the guidelines that are appropriate for the individual's abilities:

Remember that putting on an article of clothing like underwear requires the patient to distinguish back from front, which foot to put in first and in which opening, and how to pull underwear up.

Adapt clothing to the individual's abilities as the disease progresses. Elastic waistbands and Velcro closures are easier to manage. Cardigan style tops may be easier than pullover styles for caregivers to handle.

Complete a bowel and bladder assessment to rule out reversible causes of incontinence and provide appropriate treatment if required. Incontinence resulting from the disease process cannot be reversed; however, adaptations can be made to prevent soiling.

Steps to modify the environment for the patient:

Behavioral interventions that the staff can implement [48]:

Eventually, the individual will become incontinent regardless of caregiver efforts. The use of adult diapers will prevent embarrassment from soiling clothing. Change the diapers frequently and provide adequate skin cleansing and drying to avoid skin breakdown. Giving the patients cranberry juice to drink may help eliminate odor and urinary tract infections.

Safety

Safety is the first concern when planning activities. Choose nontoxic supplies for activities such as painting or clay modeling. Avoid activities that require scissors or other potentially dangerous tools. Games that utilize many small pieces may be unsafe for patients with hyperorality. Food-related activities are popular, but staff members must be aware of dietary modifications (e.g., the use of thickeners or pureed foods) required by a person or any swallowing problems that may occur.

Monitor patients for agitation and signs of discomfort, incontinence, or choking, and initiate appropriate action if necessary. Utilize in-service opportunities to teach the activities staff how to respond to emergencies. They should also learn how to safely transfer patients from wheelchairs to dining chairs, how to assist with eating, and how to help their charges in the bathroom. Patients benefit tremendously when the staff has participated in AD classes and are knowledgeable in appropriate behavior management techniques.

Planning

Activities should be dignified, avoiding those that may be perceived as demeaning or childish. A well-planned and implemented program brings meaning, purpose, and joy to the patient's life. An assessment done upon admission will identify previous and current pastimes enjoyed by the person, and past roles and lifestyles can be validated. However, to ask someone to do a simplified version of a craft he or she once excelled in may not be successful. For example, an artist who is given a paint-by-number set or a child's coloring book may become frustrated and angry with the reminder that the mastery is disappearing. On the other hand, some skills remain even when patients are severely impaired. Given the opportunity, someone who enjoyed playing the piano may be able to sit down and render a familiar tune.

Activities that focus on routine daily tasks can improve the quality of life by maintaining these skills for a longer period of time. Combing hair, applying makeup, and polishing fingernails improve self-esteem and can delay functional loss. Household tasks are also effective activities.

Implementation of Activities

Activities should be:

It is important to allow for quiet time. It is not necessary for the patient to be busy all of the time, as overstimulation causes anxiety and fatigue.

Activities have a greater chance for success when all staff members appreciate their value. Not all patients with AD can attend events, so it may be helpful for the activity staff to tell the nursing personnel which people would benefit most from a particular session. These patients can then be dressed and be taken to the toilet in time to attend. In some dementia special care units, the nursing assistants are trained to plan and present the activities. This simplifies the amount of coordination that is required between departments.

Spiritual Activities

Participation in spiritual activities is very beneficial for those who were involved in religious activities in the past. The background and faith of the individual must be considered so the services are familiar and comforting. Clergy in the community may rotate their services to ensure that all faiths are represented during the year. Ask the members of the clergy to dress in their traditional garments. The environment can promote the feeling of a spiritual setting by holding services in a chapel or by utilizing items appropriate for specific religions, such as a cross or a rosary. Those who have received strength and reassurance in the past from their spiritual beliefs may continue to find support from such activities even into the later stages of AD. Religious services are most beneficial when the program is familiar; for example, well-known hymns and passages from religious text are comforting.

Music Activities

Singing, listening to music and dancing are entertaining for many patients. Musical programs may be either passive (listening) or active (singing or dancing). Consider the age and era of the audience when selecting the music. Adequate space and safe flooring are needed for dancing. Block out other environmental sounds to avoid excessive stimulation.

Arts and Crafts

Some patients enjoy arts and crafts that are within the realm of their abilities, and the end product gives a sense of accomplishment and productivity. Much planning and assistance may be required of the staff to avoid frustration. Arts and crafts are noncompetitive. There is no right or wrong, and one individual's product is not compared to anyone else's. A group activity provides the socialization and camaraderie of being in a group. For higher functioning individuals, consider quilting, woodworking, or ceramics. One facility adopted a project whereby the patients made rag dolls for children in a nearby pediatric chronic care hospital. Those in the advanced stages of AD may enjoy painting with their fingers, a large brush, or a sponge or working with clay. Art projects can also serve as communication tools, providing opportunities to control colors and designs.

An autobiography project may be satisfying to the patient and helpful to the staff. The project usually requires the help of the family. Photos from the person's past, up through the present time, are placed in a scrapbook with names printed underneath. Family members, friends, pets, and former homes may be included. The book should be readily accessible and can be used to help calm patients when they are anxious.

Pet Therapy

The therapeutic use of small animals provides sensory stimulation and encourages movement, reminiscence, social interaction, and opportunities for nonverbal communication. Pets provide unconditional affection and approval. Some facilities adopt one or more permanent pets. This requires preplanning and commitment on the part of the staff. Other facilities use an animal visitation program with pets provided at specific times by staff members, by volunteers, or from a local animal shelter. Everyone who wishes should have an opportunity to interact with the animal. Kittens or puppies are especially effective in drawing positive responses from those in the advanced stages of AD. Watching fish in an aquarium or listening to birds is often a pleasant pastime. Patients' allergies should be taken into consideration.

Horticulture

Horticulture activities are often familiar and have healing and therapeutic properties. With proper care, plants grow and produce new shoots, giving them the opportunity for nurturing and caring. Plants provide sensory stimulation when the patient feels the soil, sees and smells the blossoms, or tastes a tomato fresh from the vine. Plants can be correlated with seasons, with tulips and Easter lilies for spring and poinsettias for Christmas. Avoid poisonous or possibly harmful plants. Projects should be small and manageable. Hardy individual houseplants require little attention. Some facilities plant small outdoor raised gardens for those who enjoy more involvement. Plants can also be used as a foundation for other activities, such as reminiscing, as door prizes for patient-sponsored programs, or as gifts to family members. However, it is the process and not the end product that is the important feature of a horticulture program.

Physical/Recreational Activities

Regular physical exercise is beneficial for patients with AD. Consider wandering habits when planning programs to avoid physically exhausting the person. Physical activity facilitates bowel regularity, reduces tension, increases appetite, and may prevent complications associated with immobility. Exercise activities may include:

Intergenerational Programming

Interaction between children and patients can have many positive results for both generations. In one facility, a group of mothers and their preschool children and infants joined the residents once a month for morning exercises. In another facility, elementary school children each "adopted" a patient whom they visited weekly. It is better to avoid large groups of children at one time. Give the children prior instruction and encourage the participation of parents or teachers.

Community Activities

Activities outside of the facility require additional staff, a mode of transportation, and places to go that are accessible and accepted by the participants. Community activities are well worth the effort and planning. Staff members should identify restaurants, stores, museums, shopping malls, and other public places that will welcome patients with AD. Plan the outing for the time of day and day of the week that are the least busy, and choose places that have minimal stimulation. Make reservations when a restaurant outing is planned. Inform other staff members in advance which residents will be out of the building. For lengthy outings, it may be necessary to take patients' medications. Community outings can be very simple; examples include a ride through the country in the spring to see newly planted fields or in the fall to view changing colors, visiting the hometowns where patients once lived, going to a drive-in for an ice cream cone, or visiting a park. Going to country fairs, fishing at nearby lakes, having picnics, or attending theater productions requires more extensive planning but may be very enjoyable for those with early stage disease.

Individual Activities

Having items available for individual activities may soothe the patient's behavior. Boxes can be filled with objects that meet the individual's need to rummage. Picture books, greeting cards, playing cards, balls of yarn, and other small, safe items are suggested. Children's toys (e.g., abacus, clock, workbench, large strands of beads) may stimulate interest. Rocking is comforting to some patients; the availability of gliding rockers meets this need. Others may find comfort in stuffed animals or dolls. Some caregivers may feel this is demeaning. It is not the object that is demeaning, but rather the attitude of staff towards those who are attached to the objects. Whether or not it is appropriate depends on the response of the individual patient.