ASSESSMENT IN ALZHEIMER’S DISEASE

Assessment of patients as individuals is integral to the planning of care and treatment.

Accurate diagnosis is therefore essential, especially for early intervention in confirmed or
suspected Alzheimer’s disease.

There is no single diagnostic test that can determine if a person has Alzheimer’s disease.
Physicians (often with the help of specialists such as neurologists, neuropsychologists,
geriatricians and geriatric psychiatrists) use a variety of approaches and tools to help make a
diagnosis. Although physicians can almost always determine if a person has dementia, it may be
difficult to identify the exact cause. 

Medical history

During the medical workup, your health care provider will review your medical history,
including psychiatric history and history of cognitive and behavioral changes. He or she will
want to know about any current and past illnesses, as well as any medications you are taking.
The doctor will also ask about key medical conditions affecting other family members, including
whether they may have had Alzheimer's disease or other dementias.

Physical exam and diagnostic tests

During a medical workup, you can expect the physician to:

 Ask about diet, nutrition and use of alcohol.

 Review all medications. (Bring a list or the containers of all medicines currently being
taken, including over-the-counter drugs and supplements.)

 Check blood pressure, temperature and pulse.

 Listen to the heart and lungs.

 Perform other procedures to assess overall health.

 Collect blood or urine samples for laboratory testing.

Neurological exam

During a neurological exam, the physician will closely evaluate the person for problems
that may signal brain disorders other than Alzheimer's. The doctor will look for signs of small or
large strokes, Parkinson's disease, brain tumors, fluid accumulation on the brain, and other
illnesses that may impair memory or thinking.

The physician will test:

  Reflexes.

 Coordination, muscle tone and strength.

 Eye movement.

 Speech.

 Sensation.

The neurological exam may also include a brain imaging study.

Mental status tests

Mental status testing evaluates memory, ability to solve simple problems and other thinking
skills. Such tests give an overall sense of whether a person:

 Is aware of symptoms.

 Knows the date, time, and where he or she is.

 Can remember a short list of words, follow instructions and do simple calculations.

Mini-Mental State Exam (MMSE) and the Mini-Cog test 

The MMSE and Mini-Cog test are two commonly used assessments.

During the MMSE, a health professional asks a patient a series of questions designed to test a
range of everyday mental skills. The maximum MMSE score is 30 points. A score of 20 to 24
suggests mild dementia, 13 to 20 suggests moderate dementia, and less than 12 indicates
severe dementia. On average, the MMSE score of a person with Alzheimer's declines about two
to four points each year.

During the Mini-Cog, a person is asked to complete two tasks:

1. Remember and a few minutes later repeat the names of three common objects.

2. Draw a face of a clock showing all 12 numbers in the right places and a time specified by
the examiner.
The results of this brief test can help a physician determine if further evaluation is needed.

Computerized tests cleared by the FDA

A growing area of research is the development of devices to administer computer-based tests
of thinking, learning and memory, called cognitive tests.
The U.S. Food and Drug Administration (FDA) has cleared several computerized cognitive
testing devices for marketing. These are the Cantab Mobile, Cognigram, Cognivue, Cognision
and Automated Neuropsychological Assessment Metrics (ANAM) devices.

Some physicians use computer-based tests such as these in addition to the MMSE and Mini-
Cog. Computerized tests have several advantages, including giving tests exactly the same way
each time. Using both clinical tests and computer-based tests can give physicians a clearer
understanding of cognitive difficulties experienced by patients.

Mood assessment
In addition to assessing mental status, the doctor will evaluate a person's sense of well-being to
detect depression or other mood disorders that can cause memory problems, loss of interest in
life, and other symptoms that can overlap with dementia.

Genetic testing

Researchers have identified certain genes that increase the risk of developing Alzheimer's and
other rare "deterministic" genes that directly cause Alzheimer's. Although genetic tests are
available for some of these genes, health professionals do not currently recommend routine
genetic testing for Alzheimer's disease.

Brain imaging

A standard medical workup for Alzheimer's disease often includes structural imaging with

magnetic resonance imaging (MRI) or computed tomography (CT). These tests are primarily
used to rule out other conditions that may cause symptoms similar to Alzheimer's but require
different treatment. Structural imaging can reveal tumors, evidence of small or large strokes,
damage from severe head trauma, or a build-up of fluid in the brain.
In some circumstances, a doctor may use brain imaging tools to find out if the individual has
high levels of beta-amyloid, a hallmark of Alzheimer’s; normal levels would suggest Alzheimer’s
is not the cause of dementia.
Imaging technologies have revolutionized our understanding of the structure and function of
the living brain. Researchers are studying other brain imaging techniques so they can better
diagnose and track the progress of Alzheimer’s.
These cognitive assessment tools are used to identify individuals who may need additional
evaluation. No one tool is recognized as the best brief assessment to determine if a full
dementia evaluation is needed. However, the expert workgroup identified several instruments
suited for use in primary care based on the following: administration time ≤5 minutes,
validation in a primary care or community setting, psychometric equivalence or superiority to
the Mini-Mental State Exam (MMSE), easy administration by non-physician staff and relatively
free of educational, language and/or cultural bias. For a definitive diagnosis of mild cognitive
impairment or dementia, individuals who fail any of these tests should be evaluated further or
referred to a specialist.

Patient assessment tools:

 The GPCOG is a screening tool for cognitive impairment designed for use in primary care
and is available in multiple languages.
 Mini-Cog - The Mini-Cog is a 3-minute test consisting of a recall test for memory and a
scored clock-drawing test. It can be used effectively after brief training and results are
evaluated by a health provider to determine if a full-diagnostic assessment is needed.

Informant tools (family members and close friends):

 Eight-item Informant Interview to Differentiate Aging and Dementia (AD8) – is an

eight-question interview used to distinguish between normal signs of aging and mild
dementia. This tool assesses individual change and can be administered in the primary
care setting.

 General Practitioner Assessment of Cognition (GPCOG) – is a screening tool for

cognitive impairment designed for use in primary care and is available in multiple
languages.

 Short Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) – the

IQCODE screening tool is an informant questionnaire designed to assess cognitive
decline and dementia. 

DIAGNOSIS IN ALZHEIMER’S DISEASE

Doctors use several methods and tools to help determine whether a person who is having
memory problems has “possible Alzheimer’s dementia” (dementia may be due to another
cause), “probable Alzheimer’s dementia” (no other cause for dementia can be found), or some
other problem.

To diagnose Alzheimer’s, doctors may:

 Ask the person and a family member or friend questions about overall health, use of
prescription and over-the-counter medicines, diet, past medical problems, ability to
carry out daily activities, and changes in behavior and personality
 Conduct tests of memory, problem solving, attention, counting, and language
 Carry out standard medical tests, such as blood and urine tests, to identify other
possible causes of the problem
 Perform brain scans, such as computed tomography (CT), magnetic resonance imaging
(MRI), or positron emission tomography (PET), to rule out other possible causes for
symptoms
These tests may be repeated to give doctors information about how the person’s memory and
other cognitive functions are changing over time. They can also help diagnose other causes of
memory problems, such as stroke, tumor, Parkinson’s disease, sleep disturbances, side effects
of medication, an infection, mild cognitive impairment, or a non-Alzheimer’s dementia,
including vascular dementia. Some of these conditions may be treatable and possibly
reversible. People with memory problems should return to the doctor every 6 to 12 months. It’s
important to note that Alzheimer’s disease can be definitively diagnosed only after death, by
linking clinical measures with an examination of brain tissue in an autopsy. Occasionally,
biomarkers—measures of what is happening inside the living body—are used to diagnose
Alzheimer's.

PLANNING AND GOALS

The goals include promoting the patient’s safety, independence in self-care activities,

reducing anxiety and agitation, improving communication, providing for socialization and
intimacy, adequate nutrition and supporting and educating the family caregivers.

NURSING INTERVENTIONS

Promoting physical safety

 Remove all environmental hazards. Turn on nightlights.
 Monitor food, intake and medication intake of patient.
 Diversional activities and encouragement hasten wandering behavior caused by
forgetfulness and short attention span.
 Avoid restraints as it may increase agitation.
 Provide identification band.

Supporting cognitive functions

 Provide calm and predictable environment with routine activities that helps the patient
interpret his or her surroundings and activities.
 Limit environmental stimuli. Follow a regular routine of activities. A quiet, pleasant
manner of speaking with clear and simple explanation, use of memory aids and cues
help to minimize confusion and disorientation and give the patient a sense of security.
 Provide clocks and calendars to promote orientation to time.
 Color coding the doors may help in identifying his or her room.

Reducing anxiety and agitation

  Reinforce a positive self-image through constant emotional support.
 The environment should be kept uncluttered, familiar and noise free. Excitement and
confusion can be upsetting and may precipitate a combative, agitated state known as a
catastrophic reaction. During such reaction, the patient responds by screaming, crying
or becoming abusive (physically or verbally). This may be the patient’s only way of
expressing an inability to cope with the environment. When this occur, it is important to
remain calm and unhurried.
 Diversional activities such as listening to music, stroking, rocking, or distraction may
calm down the patient. Frequently, the patient forgets what triggered the reaction.
 Structured routine activities are helpful to aid with patient’s forgetfulness.
 Be familiarized and predict the patient’s responses to certain stimuli will help the nurse
and caregivers to avoid untoward situations.
 Dementia education for caregivers will get the family’s support, participation and
cooperation with the care.

Improving communication
 Use clear, easy-to-understand and concise sentences in conveying messages because
the patient frequently forgets the meaning of words of has difficulty organizing and
expressing thoughts.
 The nurse must remain unhurried, reduce noise and avoid distractions to promote the
patient’s interpretation of messages.
 Provide list of reminders and written instructions.
 Be aware to non-verbal cues and language since patient often used it to communicate.
 Tactile stimuli, such as a hug or a hand pat, are usually interpreted as signs of affection,
concern and security.

Promoting independence in self-care activities

 Routine, predictable and simplified daily activities organized into short, free and easy
achievable steps so that the patient experiences a sense of accomplishment. Follow the
SMART rule.
 Provide a room for patient’s independence rather than dependence, direct supervision
is a must but preserve the person’s autonomy and dignity during nursing care.
 The patient is encouraged to make choices and decisions when appropriate and
encouragement is needed to participate self-care activities.

Providing patient’s need for socialization, self-esteem and intimacy:

 Letters, phone calls and visits from old friends and socialization can be comforting.
 Plan for a brief and non-stressful visits and socialization, limiting visitors to one or two at
a time helps to reduce over-stimulation.
  Program recreational activities not contraindicated to patient and encourage enjoying
simple activities.
 Simple expressions of love, such as touching and holding, are often meaningful.
Encourage love ones and relatives bonding and affectionate time together.

Maintaining adequate nutrition:

 Mealtime should be simple and calm without confrontations, AD patients may perceive
this as a pleasant time, social occasion or an upsetting activity.
 Prepare a meal served with patient’s food of choice that look so appetizing and taste
good.
 Serve one dish at a time to avoid patient’s playing with food.
 Cut food into small pieces to avoid choking.
 Serve gelatins instead of liquid.
 Check food temperature to prevent accidents and burns. Foods should be served warm.
 Adaptive equipment can be use if lock of coordination interferes with self-feeding.
 Apron and smock gown but never a bib can be used to protect clothing, especially when
eating with fingers.
 As deficits progress, it is necessary to feel the patient.

Managing sleep pattern disturbances:

 Assess patient’s physical and psychological conditions, sleep pattern disturbances,
usually arise due to unmet needs.
 It is imperative that caregivers seek to learn the needs of the patient who is exhibiting
sleeping problems, because further health decline can ensue if the source of the
problem is not corrected.
 Adequate sleep and physical exercise are essential. If sleep is interrupted or the patient
is unable to fall asleep, music, warm milk, or a back rub may help the person relax.
 During daytime, the patient should be given sufficient opportunity to participate in
passive exercise activities, because regular a regular pattern of activity and rest well
enhance nighttime.

Supporting and educating family care givers:

 The family can be referred to a group that provides the opportunity to congregate with
others who are experiencing the same condition.
 The nurses should be aware and sensitive to the highly emotional issues that the family
experience and emphasize with the family’s ordeal.
 Support and education of the caregivers are essential components of care.
EVALUATION OF ALZHEIMER’S DISEASE

This involves a careful medical evaluation, including a thorough medical history, mental status
testing, a physical and neurological exam, blood tests and brain imaging exams, including:

 CT imaging of the head: Computed tomography (CT) scanning combines special x-ray
equipment with sophisticated computers to produce multiple images or pictures of the
inside of the body. Physicians use a CT of the brain to look for and rule out other causes
of dementia, such as a brain tumor, subdural hematoma or stroke.
 MRI of the head: Magnetic resonance imaging (MRI) uses a powerful magnetic field,
radio frequency pulses and a computer to produce detailed pictures of organs, soft
tissues, bone and virtually all other internal body structures. MRI can detect brain
abnormalities associated with mild cognitive impairment (MCI) and can be used to
predict which patients with MCI may eventually develop Alzheimer's disease. In the
early stages of Alzheimer's disease, an MRI scan of the brain may be normal. In later
stages, MRI may show a decrease in the size of different areas of the brain (mainly
affecting the temporal and parietal lobes).
 PET and PET/CT of the head: A positron emission tomography (PET) scan is a diagnostic
examination that uses small amounts of radioactive material (called a radiotracer) to
diagnose and determine the severity of a variety of diseases.

A combined PET/CT exam fuses images from a PET and CT scan together to provide
detail on both the anatomy (from the CT scan) and function (from the PET scan) of
organs and tissues. A PET/CT scan can help differentiate Alzheimer's disease from other
types of dementia. Another nuclear medicine test called a single-photon emission
computed tomography (SPECT) scan is also used for this purpose.

Using PET scanning and a new radiotracer called C-11 PIB, scientists have recently
imaged the build-up of beta-amyloid plaques in the living brain. Radiotracers similar to
C-11 PIB are currently being developed for use in the clinical setting.

Active participation may help the patient to maintain cognitive, functional and social
interaction abilities for a longer period. Physical activity and communication have also been
demonstrated to slow some of the cognitive decline of Alzheimer’s disease. Forgetfulness,
disinterest, dental problems, incoordination, overstimulation and choking can all serve as
barriers to good nutrition. Many patients with Alzheimer’s disease exhibit sleep
disturbances, wandering and behaviors that may be deemed inappropriate. These
behaviors are most likely to occur when there are underlying physical or psychological
needs that are unmet. Side rails are always secured for patient’s safety. Always observe
therapeutic environment. Provide adequate time for sleep, rest and activities through well-
planned nursing interventions. Significant others always observe therapeutic
communication with full of encouragements. It is imperative that family members are
always supportive and participative in the activities and nursing intervention.