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Source: Slattum PW, Swerdlow RH, Massey Hill A. Alzheimer’s Disease. In: DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM, eds. Pharmacotherapy: A Pathophysiologic Approach. 8th ed. http://www.accesspharmacy.com/content.aspx?aid=7984697. Accessed May 25, 2012.

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  • Progressive dementia leading to loss of cognitive, analytical, and physical functioning

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  • Unknown

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  • Intracellular neurofibrillary tangles, extracellular neuritic plaques, degeneration of neurons and synapses, cortical atrophy
  • β-Amyloid protein aggregation leading to plaque formation, hyperphosphorylation of tau protein, inflammatory processes, vasculature injury, depletion of neurotrophin and neurotransmitters
  • Loss of cholinergic activity and serotonergic neurons
  • Increased activity of monoamine oxidase type B
  • Abnormal glutamate pathways of cortex and limbic structures.

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  • Affects approximately 5.3 million Americans.
  • Number of patients is projected to be 13.2 million by 2050.
  • Most cases present in persons over age 65 years, but 5% occur in younger persons.

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  • Hypertension
  • Elevated LDL cholesterol
  • Low HDL cholesterol
  • Diabetes mellitus

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Symptoms

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  • Cognitive
    • Memory loss
    • Aphasia
    • Apraxia
    • Agnosia
    • Disorientation
    • Impaired executive function
  • Noncognitive
    • Depression
    • Hallucinations/delusions
    • Behavioral disturbances (aggression, hyperactivity, uncooperativeness, wandering)
  • Functional: Inability to care for self
  • Stages:
    • Mild (Mini-Mental Status Examination [MMSE] score 26–18):
      • Difficulty remembering recent events
      • Declining ability to manage finances, prepare food, and perform other household activities
      • May get lost while driving.
      • Begins to withdraw from difficult tasks and give up hobbies.
      • May deny memory problems.
    • Moderate (MMSE score 17–10):
      • Requires assistance with activities of daily living (ADLs).
      • Frequently disoriented to time. Severely impaired recall for recent events.
      • May forget details of past life and names of family and friends.
      • Functioning may fluctuate.
      • Loses ability to drive safely.
      • Generally denies problems.
      • May become suspicious or tearful. Agitation, paranoia, and delusions are common.
    • Severe (MMSE score 9–0):
      • Loses ability to speak, walk, and feed self.
      • Incontinent of urine and feces.
      • Requires constant care.

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Means of Confirmation and Diagnosis

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  • History and physical examination with neurologic and psychiatric exams, standardized rating assessments, functional evaluation, caregiver interview
  • Information about prescription drug use; alcohol/substance use; history of trauma, depression, or head injury
  • Rule out medication use as contributor to symptoms (anticholinergics, sedatives, hypnotics, opioids, antipsychotics, anticonvulsants).
  • Folstein MMSE to help establish history of deficits in two or more areas of cognition and establish a baseline

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Laboratory Tests

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  • Vitamin B12 and folate levels to rule out deficiency
  • Thyroid function tests to rule out hypothyroidism
  • Complete blood count, serum electrolytes, liver function tests

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Imaging

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  • CT or MRI scans may aid diagnosis.

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Differential Diagnosis

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  • Maintain functioning as long as possible.
  • Treat psychiatric and behavioral sequelae.

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  • Managing blood pressure, cholesterol, and blood glucose may prevent worsening dementia.
  • Pharmacotherapy is symptomatic to improve or maintain cognition.

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