Neurocognitive disorders (previously called dementia) are a large group of diseases that cause progressive decline in memory, intellectual ability, social skills, and normal emotional reactions in one or more domains (Sousa et al., 2020).
Alzheimer’s disease is the most common cause of dementia, killing more individuals than breast and prostate cancers combined. An estimated 1 in 9 Americans aged 65 and older live with Alzheimer’s, and two-thirds of them are women.
This year alone, Alzheimer’s will cost the nation $345 billion. Experts project this number to skyrocket to $1 trillion by 2050 (Alz.org, 2023). In addition, caregivers provided more than 18 billion hours in care, valued at $340 billion. These numbers demonstrate a crisis for individuals, families, healthcare, and the nation (Alz.org, 2023).
Providing quality care
Access to care affects many facets of physical and mental health for both patients and providers. As Alzheimer’s numbers increase, so does the need for a competent healthcare workforce to care for an aging population. Most primary care providers (nearly 40%) admit hesitancy regarding Alzheimer’s diagnoses and feel inadequate when caring for these individuals and families (Alz.org, 2023).
Unfortunately, the healthcare system must triple the number of qualified providers by 2050 to deliver gerontological care to the 1 in 3 elderly who ultimately die from Alzheimer’s.
Risk factors and social determinants of health (SDOH)
Factors including health, birthplace, living conditions, work, and recreation have a significant impact on Alzheimer’s development (CDC, 2023). Researchers have noted a positive association between higher levels of education and brain health. Cognitive reserve in the early years may protect and also compensate for health in later years.
The monumental weight placed on families and health systems requires doing more for this vulnerable population, starting with a healthy risk analysis. Age and family history are non-modifiable risk factors for Alzheimer’s disease. Protective risk factors include physical activity, avoiding smoking/vaping, and mental acuity.
Dietary modifications are an important part of decreasing overall health risk. A heart-healthy diet emphasizes fruits, vegetables, whole grains, fish, chicken, nuts, and legumes while limiting saturated fats, red meat, and sugar (Alzheimer’s dementia, 2023). Individuals who demonstrate these and other changes could decrease the risk of Alzheimer’s.
Brain changes in Alzheimer’s disease
Billions of neurons in the brain communicate through synapses. Information flows through bursts of chemicals, which are released by one neuron and taken up by another. The synapses allow signals to travel through the brain, which creates the cellular groundwork for memories, thoughts, sensations, emotions, movement, and skills (Alzheimer’s dementia, 2023).
Alzheimer’s changes the framework of neurons. Beta-amyloid protein fragments accumulate in clumps outside the neuron, while the protein tau forms tangles inside the neuron, causing neurodegeneration, the critical feature of Alzheimer’s dementia (Alzheimer’s dementia, 2023).
Beta-amyloid damages neuron-to-neuron communication, while tau tangles impede the transportation process and other essential nutrients for the survival of neurons. This can lead to brain atrophy and inflammation.
The presence of altered neurons is thought to activate immune cells, which attempt to clear the toxic proteins, but as the chronicity of the disease sets in, the immune cells cannot keep up with the number of dying or dead cells. These proteins can be identified in the cerebrospinal fluid of individuals evaluated for Alzheimer’s disease.
Recommended course: Alzheimer’s Disease and Related Dementias for Home Health, 2nd Edition
Evaluation of Alzheimer’s disease
Alzheimer’s disease occurs on a continuum, touching each of these phases:
- Mild cognitive impairment
Slight, undetectable changes progress to memory problems leading to physical disability (Cordell et al., 2013). The earlier a provider provides a diagnosis, the more time individuals and families have to plan for the future.
Medicare pays for Annual Wellness Visits as part of the Affordable Care Act. The Health Risk Assessment provides a structured evaluation of the geriatric client through medical and family history reviews, current providers, and assessments of vital signs, cognitive impairment, mood disorders, and functional ability.
The components vary based on individual presentation. Therefore, elements of a complete dementia evaluation should include the following (Cordell et al., 2013):
- Assessment of multiple cognitive domains
- Episodic memory
- Executive function
- Visuospatial skills
- Neurological exam
- Standard laboratory tests
- Thyroid stimulating hormone
- Complete blood count
- Serum B12 and folate
- Complete metabolic panel
- Human immunodeficiency virus
- Structural brain imaging
- Magnetic resonance imaging
- Computed tomography
The Alzheimer’s Association® recognizes that no single cognitive tool is optimal. However, identifying changes in the client is paramount, since up to 81% of patients who meet the criteria for dementia never receive a diagnosis.
Pharmacology in Alzheimer’s dementia
Most pharmacologic agents in Alzheimer’s disease target some portion of the amyloid cascade, working hand-in-hand with early diagnosis while demonstrating slowed disease progression (Stahl, 2020). Many newer treatments boost cholinergic functioning by blocking acetylcholinesterase enhancing memory in patients and slowing early cognitive decline.
Donepezil is a reversible, long-acting selective inhibitor of acetylcholinesterase. It increases acetylcholine availability thereby regulating memory (in early decline).
Memantine is a type of NMDA antagonist which reduces abnormal activation of glutamate neurotransmission, thus improving cognitive function and slowing decline over time. Donepezil and memantine are the two most commonly used medications. However, rivastigmine and galantamine are also used in the clinical setting.
Along the Alzheimer’s continuum, many individuals experience various behavioral and emotional symptoms. Treatment of aggression is controversial and leads to the potential misuse of antipsychotics in this population.
These medications carry an increased risk for adverse reactions and have not been approved by the Federal Drug Administration for Alzheimer’s symptoms (Stahl, 2020). Therefore, behavioral modification and caregiver education is a first line defense in changing unwanted behaviors.
- Alzheimer’s Disease Facts and Figures (2023). https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf
- Centers for Disease Control and Prevention, CDC (2023). Social Determinants of Health-Related and Alzheimer’s Disease and Related Dementias https://www.cdc.gov/aging/disparities/social-determinants-alzheimers.html
- Cordell, C., Borson, S., Boustani, M., Chodosh J., Reuben, D., Verghese, J., Thies, W., Fried, L., (2013). Alzheimer’s Association recommendations for operationalizing the detection of cognitive impairment during the Medicare Annual Wellness Visit in a primary care setting. Alzheimer’s & Dementia 9, 141-150. https://www.alz.org/media/Documents/jalz-1528.pdf
- McDonald, W. M. (2017). Overview of Neurocognitive Disorders. Focus: Journal of Lifelong Learning in Psychiatry, 15(1), 4-12. https://doi.org/10.1176/appi.focus.20160030
- Sousa, S., Teixeira, L., & Paúl, C. (2020). Assessment of Major Neurocognitive Disorders in Primary Health Care: Predictors of Individual Risk Factors. Frontiers in Psychology, 11, 515314. https://doi.org/10.3389/fpsyg.2020.01413
- Stahl, S. (2020). Stahl’s Essential Psychopharmacology: Neuroscientific basis and practical application (4th Ed). Dementia and its treatment.