Alzheimer's Disease

Alzheimer's disease is a neurodegenerative disorder characterized by typical progressive cognitive deterioration with declining daily activities and neuropsychiatric symptoms. It is the most common type of dementia in USA. Alzheimer's disease currently affects over 4 million older adults in America, and these numbers are expected to double by the year 2030.The most important symptom is loss of short-term memory called amnesia in the early stages. In the later stages of the disease, aphasia, apraxia, agnosis are very common. The disease is more associated with the frontal and temporal lobes of the brain. Pathologically, there is a neuronal loss in the temporoparietal cortex and frontal cortex region (Landreth G, 2006).                  
     
Challenges in Acute Care:

The cause of the disease is still unknown. The clinical diagnosis is done based on the history, clinical observation, memory function tests and neuroimaging. Alzheimer's disease is the most frequent type of dementia in the elderly and affects almost half of all patients with dementia all over the world.Thus, age is an important factor in occurrence of the disease. Statistical data provide that in the USA, Alzheimer's disease was the 7th leading cause of death in 2004, with 65,829 numbers of deaths. At over $100 billion per year, it is the third most costly disease in the U.S., after heart disease and cancer. An estimated 4.5 million Americans have Alzheimer’s disease and it is projected that 14.3 million Americans will have the disease by mid-century: a 350 percent increase from 2000.Alzheimer's disease risk has been found to be greatly reduced by regular physical exercise, intellectual stimulation, social interaction, a diet with low saturated fat supplemented with Vitamin B, Omega 3 fatty acids, E and C Vitamin. Inadequate cardiovascular care due to diabetes, smoking, hypertension and cholesterol increase the risk of the disease. Head injury and exposure to toxic metallic neurotoxic fumes seem to contribute to the disease. There is no cure for Alzheimer's disease but asymptomatic relief is available through medications. This includes the use of acetylcholineesterase inhibitors to reduce the choinergic neuronal activity, donepezil, galantamine and rivatigmine. Although tacrine is no longer in clinical use, NMDA receptor antagonists like memantine has been found effective clinically.

Further, cognitive and behavioral interventions and rehabilitation strategies as an adjunct to pharmacologic treatment in the early to moderately advanced stages of disease has been found effective. This includes psychological counseling, psychotherapy, reminiscent therapy and reality orientation therapy. Changes and modifications in the life style and living environment of the patient have a remarkable effect on the functional performance. 
                                 
Challenges in Long Term Care:

The long-term care insurance, direct and indirect costs of caring for an Alzheimer's patient average $77,500 per year in USA. The federal government estimates spending approximately $647 million for Alzheimer’s disease research in fiscal year 2005. The average yearly cost of care for an individual with Alzheimer’s is $174,000 in USA. Thus, it is cheaper and effective for the federal government to encourage hospice care with care givers working for around 100 hours on an average pay of $35 per hour. This not only reduces the cost of hospital care of these patients. but also the associated costs towards occupational therapy, physical therapy and speech therapy in advanced cases. Finally, intimacy is the most important aspect of caregiver patient relationship with psychological, emotional and physical components. It is true that we cannot cure these human beings with Alzheimer's disease but we can care for them.

Cognitive impairments pose a serious barrier on the reliability of such geriatric assessments and care. Effects of cognitive impairment on the reliability of geriatric assessments have been studied recently (Phillips et. al, 1993) to explore the relationship between cognitive status and reliability of multidimensional assessment data.  The studies have proved that the reliability of the patient’s communication and sensory ability are affected by cognitive status. Hence, caution should be exercised in treating such cognitively impaired patients. The patients in the early stages of the disease should be treated marginally competent and not incompetent to give an informed consent. Advance directives and proxy directives should be well documented.

Conclusion
  
Prevention of the onset of the disease should be possible by studying the factors that contribute to the disease onset like damaged blood vessels in the brain or atrophy in temporal lobe, high blood pressure, high cholesterol or diabetes.Brookmeyer et.al. (1998) have projected that Alzheimer's disease will become an enormous public health problem in the USA any interventions that could delay disease onset even modestly would have a major public health impact. As discussed, the origin of the disease is unknown and there is no known cure for the disease. Although the new anticholinesterase agent donepezil was licensed in the United States in December 1996 produced excellent improvements in randomized trials lasting 30 weeks, there are reports of mismatch between perceived benefits and the study data (David Melzer, 1998).

References

• Areosa Sastre A, McShane R, Sherriff F. "Memantine for dementia.". Cochrane Database Syst Rev: CD003154. PMID 15495043.
  
  
• David Melzer.(1998). New drug treatment for Alzheimer's disease: lessons for healthcare policy. British Medical Journal, March..
  
• Landreth G .(2006) PPARgamma agonists as new therapeutic agents for treatment of Alzheimer's disease. Exp Neurol 199 (2): 245-8.
  
  
• Phillips et, al (1993). Effects of cognitive impairment on the reliability of geriatric assessments in nursing homes. J Am Geriatr Soc, 41(2); 136-42.
  
  
• R Brookmeyer, S Gray and C Kawas (1998).Projections of Alzheimer's disease in the United States and the public health impact of delaying disease onset. American Journal of Public Health, 88(9); 1337-1342.
  
  
• The MetLife Study of Alzheimer’s Disease (2006): The Caregiving Experience". MetLife Mature Market Institute ®
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• Wenk G. Neuropathologic changes in Alzheimer's disease. J Clin Psychiatry 64 (9): 7-10. PMID 12934968.

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