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KEY CONCEPTS

KEY CONCEPTS

  • image Alzheimer disease (AD) is the most common form of dementing illness, and the prevalence of AD increases with each decade of life.

  • image The etiology of AD is unknown, and current pharmacotherapy neither cures nor arrests the pathophysiology.

  • image Amyloid plaques and neurofibrillary tangles (NFTs) are the pathologic hallmarks of AD; however, the definitive cause of this disease is yet to be determined.

  • image Alzheimer disease affects multiple areas of cognition and is characterized by a gradual onset with a slow, progressive decline.

  • image A thorough physical examination (including neurologic examination), as well as laboratory and imaging studies, is required to rule out other disorders and diagnose AD before considering drug therapy.

  • image Pharmacotherapy for AD focuses on impacting three domains: (1) cognition, (2) behavioral and psychiatric symptoms, and (3) functional ability.

  • image Nondrug therapy and social support for the patient and family are the primary treatment interventions for AD.

  • image Cholinesterase inhibitors and memantine are used to treat cognitive symptoms of AD; other medications have been suggested to be beneficial because of their potential preventive or cognitive effects.

  • image Appropriate management of vascular disease risk factors may reduce the risk for developing AD and may prevent the worsening of dementia in people with AD.

  • image A thorough behavioral assessment and plan with careful examination of environmental factors should be conducted before initiating drug therapy for behavioral symptoms

PATIENT CARE PROCESS

Patient Care Process for Alzheimer Disease

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Collect

  • Patient characteristics (eg, age, sex)

  • Patient history (eg, past medical, family, social history)

  • Current medications including medications that may cause or worsen cognitive, neuropsychiatric, and/or functional symptoms (see list of common offending agents, in “Assess”)

  • Assessments for cognitive, noncognitive, and functional symptoms; for example:

    • Mini-Mental State Examination (cognition)

    • Neuropsychiatric Inventory (behavioral disturbances)

    • Bristol Activities of Daily Living Scale (function)

  • Laboratory data

    • Comprehensive metabolic panel, including electrolytes, glucose, and liver function tests

    • Complete blood cell count, serum B12 and thyroid function tests.

    • Rapid plasma reagin and human immunodeficiency virus testing

Assess

  • Risk factors for Alzheimer disease (eg, age, family history, low education level, smoking)

  • Cognitive symptoms (eg, memory loss, aphasia, apraxia, agnosia, disorientation, impaired executive function)

  • Neuropsychiatric symptoms (eg, depression, psychotic symptoms, behavioral disturbances)

  • Functional symptoms (eg, inability to care for self), including patient's ability to manage and self-administer their own medications

  • Medications that may cause or worsen cognitive, neuropsychiatric, and/or functional symptoms; for example:

    • Benzodiazepines and other sedative hypnotics

    • Anticholinergics

    • Opioid analgesics

    • Antipsychotics

    • Anticonvulsants

    • Skeletal muscle relaxants

  • Diseases or syndromes that may cause or worsen cognitive, neuropsychiatric, and/or functional symptoms

    • Alcohol or drug abuse

    • Depression

    • B12 or folate deficiency

    • Hypothyroidism

    • Electrolyte disturbances (eg, hypernatremia)

    • Glucose abnormalities (eg, hypoglycemia)

    • Infectious processes (eg, tertiary syphilis)

    • Vision, hearing, or other sensory impairments

    • Other common types of dementia in late life (see Table 71-1)

  • Stages of Alzheimer disease (see Table 71-2)

  • Appropriateness of current living situation (eg, independent living, assisted living, nursing home)

  • Appropriateness and effectiveness of current medication regimen

Plan*

  • Tailored ...

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