ASSESSING ALZHEIMER’S DISEASE AND DEMENTIA:BEST PRACTICES IN NURSING CARE

Christine A. Ganzer, MA, MSN, NPP

Alzheimer’s disease (AD) is a chronic pro-gressive neurodegenerative disorder thatleads to irreversible dementia. As the num-ber of older adults increases, so will the in-cidence of AD. The purpose of this article isto offer information to nurse clinicians re-garding the differential diagnosis of demen-tia of the Alzheimer’s type, describe avail-able assessment instruments, and reviewpractice recommendations for treatment.(Geriatr Nurs 2007;28:358-365)

Alzheimer’s disease (AD) is the most prev-alent form of dementia in the UnitedStates.1 It is believed that 4.5 million

older adults suffer with this chronic illness thattypically begins after age 65 years and directlyaffects the quality of life experienced by the indi-vidual and their caregiver.1-4 Current projectionspredict that the incidence of AD will increase by27% in 2020, and to an astonishing 70% by 2030.5

There are several forms of what is known asdementia, with AD and vascular dementias beingthe most common. The clinical syndrome of de-mentia involves both memory impairment and adisturbance in at least 1 other area of cognition,such as executive function or attention. The onsetof AD is slow and insidious and may take severalyears to manifest. Changes in function and behav-ior are considered a part of the disease processand are reviewed in this article.

Nurse clinicians practicing in primary caresettings often have little experience and op-portunity to evaluate cognitive dysfunctionadequately because of time constraints and lackof knowledge.4 Consequently, many patients goundiagnosed because their initial symptoms ofimpairment are mild and may not have the hall-mark symptoms of functional decline. Nursesmust be primed to understand patient cues thatcan be elicited during history taking, physical ex-amination, and laboratory testing. Assessment

measures that have been designed, validated, and

Geriatric Nursing, Volu358

found to be reliable with the older adult can assistthe novice practitioner in screening for mild cog-nitive impairment.6 The purpose of this article isto offer information to nurse clinicians regardingthe differential diagnosis of dementia of the Alz-heimer’s type, describe available assessment in-struments, and review practice recommendationsfor treatment.

Pathophysiology

Progressive mental deterioration in old agehas been recognized and described throughouthistory. Alzheimer’s disease was first reportedin 1906 by Alois Alzheimer, a German physician.The cause of the disease is considered complex,but several factors may contribute to its devel-opment. Research has shown that one indicatoris the collapse of the cholinergic system, whichregulates acetylcholine in the brain, an impor-tant chemical for memory.7

Alzheimer’s disease is a clinical diagnosis withobservation of the plaques and tangles duringbrain autopsy confirming diagnosis of the diseaseonly after dealth.8 Many advances have been madeconcerning the nature of the protein plaques andtangles and the brain regions that become affectedas the disease progresses. Specialized testing candiagnosis Alzheimer’s with up to 90% accuracy,and the use neuropsychological measures andbrain scans can aid in diagnosis.

Researchers are gaining greater insight intothe genetic factors contributing to AD in certainfamilies. AD that occurs before age 65 occurs inless than 5% of all AD patients.9 For example,familial AD (FAD), or early-onset dementia, oc-curs before age 65 and affects less than 10% ofpatients. Symptoms of early-onset AD are simi-lar to those of late-onset Alzheimer’s disease buttypically occur at a time when the person is stillworking and engaged in family and social activ-ities that often complicate his or her life.

The majority of AD cases are late onset, usu-

ally developing after age 65 years. Late-onset AD

me 28, Number 6

has no known cause and shows no obviousinheritance pattern.8,10 However, in some fami-lies, clusters of cases are seen. Although a spe-cific gene has not been identified as the cause oflate-onset AD, genetic factors do appear to playa role in the risk of developing this form of thedisease.11 Genetic risk factors, such as the Apo-lipoprotein 4 allele, alone are not enough tocause late-onset AD, and researchers are ac-tively exploring education, diet, and environ-ment to learn what role they might play in thedevelopment of the disease.10

Presentation of Symptoms

The early symptoms of AD are insidious, andthe onset is slow. Symptoms of mild forgettingmay be present but may be perceived by theindividual and family as simply age related. Thedisease typically manifests itself as difficulty inremembering recent events, activities, or namesof familiar people or things. Some individualsmay experience difficulty with calculations, butthese problems are often mild and do not raiseconcerns.12 AD is a progressive disorder, and assymptoms continue to worsen, forgetfulness in-terferes with general activities of daily living.1

Individuals who are manifesting midstage dis-ease begin to forget simple tasks such as takingmedications and begin to lose their ability torecognize familiar people and places.

Nursing Assessment

Many health care providers, along with pa-tients and family members, often inaccuratelyview the early symptoms of dementia as a con-sequence of aging. Nurses interact with clientsat various points of care and can be trained torecognize the subtle signs of impaired cognition,and then assess for dementia. Advanced clinicalunderstanding of the possible differential causesof dementia, such as depression or polypharmacy,can afford patients and their families the possibil-ity of treatment.

Several conditions mimic dementia. Depres-sion, alcohol abuse, and medication toxicity inolder adults can manifest itself as cognitive de-cline.13 Nurses are in an ideal position to iden-tify older adults with a depressed mood.14 Olderadults experience high rates of depression and

may be reluctant to disclose their problems be-

Geriatric Nursing, Volu

cause of embarrassment.14 The treatment ofpseudodementia in depression has proved tobe effective, and cognitive symptoms may bereversed.15 Nurses can use the Geriatric De-pression Scale (GDS)16 to screen for depres-sion quickly in the older adult. This instru-ment can be found at the the John A. HartfordFoundation Institute for Geriatric Nursing Website (www.hartfordign.org/publications/trythis/

issue04.pdf).Older adults who have long-term histories of

abusing alcohol may begin to experience a Kor-sakoff syndrome that manifests as memory loss.Korsakoff syndrome is a degenerative brain dis-order caused by a lack of thiamine (B1) in thebrain. The amnestic manifestation of alcoholicdementia may be minimized if abstinence isachieved and the underlying thiamine deficiencyis treated.17

Older adults frequently have complex medi-cation regimens related to chronic health con-ditions. The use of multiple medications, orpolypharmacy, can cause drug interactions thatresult in cognitive changes.18,19 Nurses are in anideal position to evaluate complex medicationregimens that may be the underlying cause ofthis potentially reversible dementia.

Persons who experience cognitive changesand memory loss that are greater than expectedfor their age but do not meet the currently ac-cepted criteria for clinically probable AD as es-tablished by the Diagnostic and Statistical

Manual of Mental Disorders (4th edition, re-vised), are experiencing mild cognitive impair-ment ( MCI).6 Approximately 50% of individualswith MCI eventually progress to probable AD.6

The prevalence of MCI varies among studies, butthis may be a result of different diagnostic criteria,sampling, and assessment procedures.20

AD results in a chronic irreversible dementiathat is caused by progressive neurodegenera-tion. The consequences of nonreversible demen-tias include symptoms such as incontinence, wan-dering, behavioral disturbances, and depression,which can be treated effectively.21,22 Despite thefact that the disease process is considered ter-minal, the correct diagnosis of the illness in itsearly stages can be beneficial to patients andfamily, preventing costly and inappropriatetreatment. Early diagnosis can give patients and

families time to prepare for the challenging fi-

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nancial, legal, and medical decisions that lieahead.

Pharmacological Treatment

There is no cure for AD; however, medica-tions are available that help manage or delay theinevitable cognitive changes. In 1993, the U.S.Food and Drug Administration (FDA) approvedthe first drug to treat AD, Cognex (tacrine),which increases the amount of the neurotrans-mitter acetylcholine in the brain and can slowcognitive decline. A second drug, Aricept (done-pezil), became available in 1996, and in 2000, thedrug Exelon (rivastigmine) was approved byFDA. Razydyne (galantamine) is another medi-cation that can be used to treat mild to moder-ate AD. These medications also work by in-creasing the amount of acetylcholine availablein the brain. Cognex, although effective, hasmore adverse side effects than the other medi-cations.

In 2003, the FDA approved the first drug totreat moderate to severe Alzheimer’s disease,Memantine (namenda). Namenda is an NMDA(N-methyl-D-aspartate) receptor antagonist andappears to protect the brain’s nerve cells againstexcess amounts of glutamate, a messenger chem-ical released in large amounts by cells damagedby this devastating neurological disease. Na-menda is used to treat moderate to severe mem-ory loss and has shown some promising resultsin select patients; however, more research isnecessary to determine its long-term effects.23

Best Practice Recommendations

Evidence-based guidelines for the assessmentof AD have been established to assist cliniciansin identifying the disease. Best practice recom-mendations put forth by the American GeriatricSociety include first taking a careful, accuratehistory of the onset and course of the cognitiveproblems from an informant who knows theclient and is considered to be a good historian.24

This interview should explore those changes inthe patient’s cognitive performance and behav-ior that have negatively affected his or her dailylife. The informant is essential to establish thepremorbid baseline performance and the tem-poral course of symptoms (ie, chronic, step-

wise, or progressive), information that the pa-

Geriatric Nursing, Volu360

tient may not be able to provide reliably.25 Theinformant also may provide information thatcan be used to assess the patient’s recent andlong-term memory. This includes details of re-cent events happening in the individual’s life orpersonal historical facts. Typically, cognitivechanges due to aging relate to limited atten-tional resources (“I forgot what I came in hereto get”) or to diminished speed of informationprocessing (“I couldn’t remember his name untillater”). Such changes usually do not progress,nor do they seriously interfere with everydayactivities.26

Significant functional changes in memory andother cognitive domains that interfere with ev-eryday activities (ie, deficits in driving, function-ing at work, or interactions with family andpeers) should alert the practitioner about issuesthat are not attributable to the aging process.Vision and hearing loss also should be elimi-nated as factors in functional decline.25

A clinical assessment for depression and aninquiry of recent behavioral and psychotic dis-turbances should be made during the exam. Pa-tients with AD typically experience memory andother cognitive disturbances but do not have theprominent delusions and gross perceptual dis-tortions that are characteristic of psychotic dis-orders.27

Cognitive impairment is a symptom of manyreversible disorders (Table 1). Patients sus-pected of having dementia should be examinedfor coexisting medical conditions.28 In some in-stances, physical and neurologic examinationscan yield clues about the cause of dementia. Forexample, dry skin, periorbital edema, thin hair,and depressed reflexes may indicate hypothy-roidism; extrapyramidal signs may indicate Par-kinson’s disease or dementia with Lewy bodies;focal motor or sensory deficits may indicatevascular dementia; gait disturbances may indi-cate communicating hydrocephalus.29 Coexist-ing conditions that may exacerbate dementia in-clude profound hearing or visual loss that isolatesthe patient. Patients who are suspected to be ex-periencing Alzheimer’s dementia should be re-ferred to a neurologist for additional testing thatmay include neuroimaging such as an magneticresonance imaging or positron emission testing.

Nurses can access additional information per-

taining to the assessment of Alzheimer’s demen-

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Table 1.Causes of Dementia

Cause Nursing Assessment

Reversible Dementia

Medications: polypharmacy ofprescription medications

Evaluation of medication side effects andcross-toxicity

Illegal drugs (eg, heroin) History of drug abusePsychological: severe depression Depression screening: begin with evaluation of mood

and affect, sleep, appetite, level of energy, anddegree of social isolation

Traumatic falls Gait evaluation, bruising, subdural hematomaChronic medical condition Ask if there concurrent medical illnessesHydrocephalus;

communicating/noncommunicating“normal pressure” hydrocephalus

Triad of gait disturbance, urinary incontinence, anddementia with spasticity in the legs; imagingreveals dilated ventricles

Nutritional deficiency, alcoholism,toxic exposure

● Thiamine deficiency, vitamin B12deficiency, Carbon monoxidepoisoning

● Heavy metal poisoning,Endocrinopathies, Electrolyteimbalance

Assessment of chronic alcoholism, nutritional intake,and recent weight loss; thyroid testing andcomplete blood count, chemistry for electrolyteimbalance and evaluation of renal disease

Irreversible Dementia

Degenerative diseases● Alzheimer’s disease● Huntington’s disease● Parkinson’s disease● Wilson’s disease● Pick’s disease● Cortical Lewy body disease● Progressive supranuclear palsy

Typically slow and insidious onset with forgetting,difficulty planning and completing tasks, word-finding difficulties, disorientation to time and place,poor judgment, problems with abstraction, andchanges in personality and initiative

Subcortical vascular dementia● Microvascular disease, Multiple

infarcts● Cerebral vasculitis● Binswanger’s disease

Assess for hypertension, history of transient ischemicattacks and stroke, heart disease, diabetes; signsinclude spasticity in the limbs, hyperreflexia,plantar extensor reflexes and abnormal gait;personality is well preserved; neuroimaging revealscerebrovascular disease

Late onset schizophrenia (�45 yearsof age)

Characterized by bizarre delusions that have apredominantly persecutory flavor; auditoryhallucinations are the second most prominentpsychotic symptom

Neoplastic● Secondary cancer deposits● Primary cerebral tumor

Determine whether the patient has a history ofcancer

Post–head injury● Chronic subdural hematoma● Chronic traumatic encephalopathy

(boxing)

History of multiple concussions over a period ofyears; signs include lack of coordination, speechproblems, declining mental abilities, unsteady gait

Geriatric Nursing, Volume 28, Number 6 361

tia at the Department of Health and HumanServices Web site (www.ahrq.gov/clinic/alzover.

htm) and at the National Institute of Aging Website (www.nia.nih.gov/Alzheimers/Publications/

adfact.htm).

Evaluation of Cognitive andFunctional Decline

Executive function is a set of interconnectedcognitive processes that includes cognitive flex-ibility, abstract thinking, and the initiation andinhibition of appropriate actions or self-moni-toring.30 The assessment of cognitive controlcan help to determine an individual’s capacity tocarry out health care decisions and activities. Asolder adults begin to experience declines in ex-ecutive function, they may begin to lose theirabilities to participate in instrumental activitiesof daily living (eg, medication adherence, bal-ancing the checkbook, driving), although theirmemory impairment may be mild.31

The American Geriatric Society’s practice rec-ommends that patients with mild cognitive im-pairment should be recognized and monitoredfor cognitive and functional decline because oftheir increased risk for subsequent dementia.24

The timely identification of cognitive impair-ment can help screen out illnesses that mimicAD and prompt implementation of treatmentthat can sometimes reverse troublesome symp-

Table 1.Continued

Cause

Infectious disease● Syphilis● HIV

N

H

● Prion disease● Creutzfeldt-Jakob disease (rare 1:

1,000,000.)

R

toms.

Geriatric Nursing, Volu362

It is important that nurses practicing in thearea of geriatrics be able to recognize persons invarying stages of cognitive impairment. Historytaking is considered a vital component that con-tributes significantly to the diagnostic process.Functional assessment is an important consid-eration in the evaluation of the patient with AD.The assessment of sensory abilities such as vi-sual acuity, hearing, and gait, which are stronglyrelated to functional status, can significantlycontribute to the clinical course of the patient.The assessment of functional status can be ac-complished by using instruments such as theKatz Activities of Daily Living Scale,32 which candownloaded at the Hartford Institute for Geriat-ric Nursing Web site (http://www.hartfordign.org/

publications/trythis/issue02.pdf). The scale of-fers nurses a quick and simple measure that canprovide helpful clinical information.

Recent research developments have placedan emphasis on early screening tools that can beused in combination with other testing meth-ods.33 Several dementia screening tests areavailable,34,35 but no single test has been estab-lished as the standard.36 Screening tests differfrom diagnostic tests. A screening test (such asa questionnaire) potentially identifies patientswho may have the disease, but its purpose is notto establish a diagnosis.37 The goal of thescreening test is to offer clinicians a reliable,

Nursing Assessment

yphilis: progressive dementia characterized byory problems, disorientation, moodrbances and personality changes; unsteadyincontinence, palsy, seizures, ataxia, andysisental slowness, poor memory andentration; motor symptoms include a loss of

otor control, poor balance and tremors;vioral changes may include apathy, lethargy,iminished emotional responsesprogressing dementia with myoclonus

luntary muscle twitching)

eurosmemdistugait,paralIV: Mconcfine mbehaand dapidly(invo

simple, and inexpensive tool to identify the po-

me 28, Number 6

tential for dementia. The test should be easy toadminister and interpret and not too taxing forthe patient. Instruments that have been specifi-cally constructed for use with older adults arebest. Tests that have not demonstrated validitywith older adults will not provide the desiredbenefits of early detection of cognitive declinesought by the practitioner.

In conducting a search of measures used todetect cognitive decline or MCI, literature be-fore 1970 reflects a paucity of information per-taining directly to the screening of individualswith suspected memory loss. The importance oftesting for cognitive decline is more evident inthe literature since that time. Because earlytreatment is dependent on early identification, 4of the most frequently used instruments are nowreviewed for effectiveness and sensitivity ateliciting mild cognitive decline.

Mini-Mental State Examination

One of the first screening instruments to beintroduced was the Folstein Mini-Mental-StateExamination (MMSE).38 The MMSE is a 30-itemmeasure that assesses the domains of orienta-tion, registration, attention and calculation, re-call, language, and visual-spatial construction. Ascore �24 on the MMSE is often used as acutoff-point for cognitive impairment, with indi-viduals having at least 8 years of education.39

Scores of 18–23 on the MMSE indicate mild tomoderate cognitive impairment, and scores be-low 18 indicate severe cognitive impairment.The MMSE is effective as a screening tool forcognitive impairment with older community-dwelling, hospitalized, and institutionalized adults.Since its creation in 1975, the MMSE has beenvalidated and extensively used in both clinicalpractice and research.40,41 When used repeatedly,the instrument is able to measure changes incognitive status in patients who may benefitfrom intervention. However, the instrument re-lies heavily on verbal response, reading, andwriting. Patients who are visually and hearingimpaired or who do not have proficient Englishmay perform poorly despite being cognitivelyintact. A limitation of the MMSE includes thefloor effect in which subjects score in the lowrange, for example, in advanced dementia, in

individuals with little formal education, and in

Geriatric Nursing, Volu

those with severe language problems related todementia (aphasia).42 The MMSE also has a ceil-ing effect; for example, ab individual who is welleducated may have a perfect score of 30, yet thehealth care practitioner may believe that thepatient meets the criteria for dementia.43

The MMSE is not able to indicate the reasonfor changes in cognitive function and should notreplace a complete clinical assessment of men-tal status. The MMSE can be found at www.

minimental.com.

Clock Drawing Test

There are several clock drawing tests that havebeen validated with older adults and that can beused to screen for cognitive changes. The tests allinvolve asking the patient to draw the face of aclock within a specified time. The Royall ClockDrawing Test is used extensively in the clinicalsetting as a cognitive screening instrument. Theexaminer draws a clock 2 inches in diameterwith the time set at 1:45 and asks the patient tocopy the drawing. If any of the elements aremissing from the drawing, there may be impair-ment. The test has good sensitivity (85%), spec-ificity (85%), predictive validity, and a high cor-relation with the MMSE.44,45 The test is able totap into a wide range of cognitive abilities, in-cluding executive function, and is quick to ad-minister and score. It also has a high interraterreliability and test-retest reliability.46 More in-formation about the clock drawing test can befound at www.clockdrawingtest.com.

The Mini-Cog

The Mini-Cog is a composite screening toolthat assesses recall and uses the Clock DrawingTest to detect Alzheimer’s disease.47 It is a sim-ple instrument that takes approximately 3 min-utes to complete. The Mini-Cog is reportedly notinfluenced by education, culture, or language,and assessment using this measure is perceivedas less stressful to the patient than longer men-tal status tests, which is an important consider-ation in evaluating older adults.47 The Mini-Cogscreening tool can be found at www.hartfordign.

org/publications/trythis/issue03.pdf.

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The Trail Making Test

The Trail Making Test (TMT) is a rough esti-mate of general mental ability. It requires thatthe individual count from 1 to 25 and then re-peat the letters of the alphabet. During the ac-tual test, letters and numbers are sequentiallypaired 1-A, 2-B, 3-C, and so on until 13-M isreached. The goal is to keep the number andletter sequence in working memory and not loseone’s place.48 Individuals who encounter 2 ormore errors in the 13 pairings are considered tobe experiencing some difficulty in executivefunction. This test reflects abstract mental op-erations that relate to problem solving, sequenc-ing, resisting distractions, intrusions, and perse-verations.31 The TMT is part of a larger set ofneuropsychological tests but can be purchasedseparately at www.reitanlabs.com.

Conclusion

Dementia has been associated with both revers-ible and nonreversible causes in older adults.Nurses are practically situated to identify earlychanges in cognitive function and can imple-ment therapeutic interventions that may poten-tially eliminate symptoms or slow the progres-sion of the disease process. The screening toolsreviewed in this article should be consideredonly 1 component of the assessment process.Clinicians who are working in the area of geri-atric nursing must become familiar with “bestpractice” assessment measures that include acareful history taking, physical examination,and diagnostic testing. Patients’ medical historyshould be thoroughly explored with the assis-tance of a well-informed informant such as aspouse or adult child who can provide the clini-cian with an accurate clinical picture. Thesesteps will lead to early identification of thoseindividuals suspected of MCI that may lead tochronic dementia.

Nurses should be able to identify the revers-ible causes of dementia (Table 1). Resourcesthat focus on the cognitive assessment of theolder adult can be found at www.Geronurse.org

and www.hartfordign.org. Nurses can effec-tively incorporate simple cognitive screening in-struments intended for the assessment of de-mentia into their routine examinations, offering

patients the benefit of identifying subtle symp-

Geriatric Nursing, Volu364

toms that may otherwise go unrecognized anduntreated.

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CHRISTINE A. GANZER, MA, MSN, NPP, is a doctoral

student at the University of Arizona, College of Nursing in

Tucson, and instructor of nursing at the New York Insti-

tute of Technology, School of the Health Professions, Old

Westbury, NY.

0197-4572/07/$ - see front matter

© 2007 Mosby, Inc. All rights reserved.

doi:10.1016/j.gerinurse.2007.10.008

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