Assessment

HISTORY. DAT is a slowly progressing disease, and secondary sources are used for diagnosis because the patient is often unaware of a thought-processing problem. Past medical history should be evaluated for previous head injury, surgery, recent falls, headache, and family history of DAT.

PHYSICAL EXAMINATION. The history will help determine which stage the disease process has reached at the time of patient assessment. The following four-stage scale reflects the progressive symptoms of DAT:

Stage 1 is characterized by recent memory loss, increased irritability, impaired judgment, loss of interest in life, decline of problem-solving ability, and reduction in abstract thinking. Remote memory and neurological exam remain unchanged from baseline.

60 Alzheimers Disease

Stage 2 lasts 2 to 4 years and reveals a decline in the patient's ability to manage personal and business affairs, an inability to remember shapes of objects, continued repetition of a meaningless word or phrase (perseveration), wandering or circular speech patterns (circumlocution dysphasia), wandering at night, restlessness, depression, anxiety, and intensification of cognitive and emotional changes of stage 1. Stage 3 is characterized by impaired ability to speak (aphasia), inability to recognize familiar objects (agnosia), inability to use objects properly (apraxia), inattention, distractibility, involuntary emotional outbursts, urinary or fecal incontinence, lint-picking motion, and chewing movements. Progression through stages 2 and 3 varies from 2 to 12 years. Stage 4, which lasts approximately 1 year, reveals a patient with a masklike facial expression, no communication, apathy, withdrawal, eventual immobility, assumed fetal position, no appetite, and emaciation.

The neurological examination remains almost normal except for increased deep tendon reflexes and the presence of snout, root, and grasp reflexes that appear in stage 3. In stage 4, there may be generalized seizures and immobility, which precipitate flexion contractures.

Appearance may range from manifesting normal patient hygiene in the early stage to a total lack of interest in hygiene in the later stages. Some patients also demonstrate abusive language, inappropriate sexual behaviors, and paranoia. The Folstein-mini-mental exam is a quick evaluation tool that can assist in diagnosis and monitoring of the disease's progression.

PSYCHOSOCIAL. The nurse needs to assess the family for its ability to cope with this progressive disease, to provide physical and emotional care for the patient, and to meet financial responsibilities. A multidisciplinary team assessment approach is recommended for the patient and family.

Diagnostic Highlights

Diagnostic tests need to rule out a treatable condition that could be causing dementia; these conditions include thyroid disease, stroke, vitamin deficiency, brain tumor, drug and medication effects, infection, anemia, and depression.

Test

Normal Result

Abnormality with Condition

Explanation

Brain biopsy upon autopsy

Negative

Positive for cellular changes that are associated with the disease

No diagnostic test is definitive for AD. Clinical criteria for diagnosis of DAT: (1) presence of at least two cognitive deficits; (2) onset occurring between ages 40 and 90; (3) progressive deterioration; (4) all other causes ruled out.

Other Tests: Supporting tests include computed tomography (CT) scan; magnetic resonance imaging (MRI); positron emission tomography (PET). During the early stages of dementia, CT and MRI may be normal, but in later stages, an MRI may show a decrease in the size of the cerebral cortex or of the area of the brain responsible for memory, particularly the hippocampus. Genetic testing for the ApoE gene is available and the presence of the gene is a risk factor for AD. Genetic tests may be helpful in diagnosis, but further studies are needed to confirm their reliability.

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