A HOLISTIC APPROACH TO ALZHEIMER’S DISEASE CARE
Ginny Fuller
1 March 2008
PAS 646
Dr. Hadley
ABSTRACT
With at least 4.5 million Americans diagnosed with Alzheimer’s disease, as providers we must become familiar with this disease, the treatment options that are available, and how to provide a holistic care plan to our patients. Alzheimer’s disease is thought to be mainly due to a decreased number of cholinergic neurons in the brain, leading to a decrease in memory function and eventually a decrease in the patient’s ability to care out everyday tasks. Currently there are a limited number of standard treatment options, including selective cholinesterase inhibitors and NMDA receptor antagonists. In today’s society, in addition to these standard options, more and more people are opting for complementary and alternative approaches as adjunctive treatments, such as music therapy, aromatherapy, ginkgo biloba, and antioxidants (Alzheimer’s Association 2007).
The psychological, social, and spiritual aspects of treating Alzheimer’s disease are now being taken into consideration more than ever. With 82% of the population over 65 years of age stating that they are actively involved in a faith community, the role of faith and spirituality in patients with dementia must be incorporated into their treatment and care plan (US Bureau of the Census 2000). It has been proposed that faith in general may lead to improved health, and in AD patients, spirituality may even lead to slower progression of the disease and improved cognitive function (Hill 2006). Both caregivers and patients have stated that prayer and religious involvement are used as major coping mechanisms throughout this devastating disease (Post 2004). It is up to providers to ask the difficult questions regarding religion and faith in order to determine individual’s needs and desires in every aspect of their life, so that a personalized and unique care plan can be developed in order to provide them with the most inclusive and holistic care possible.
Introduction:
It is often said that people become forgetful or lose their memory as they begin to age; however, major memory loss, changes in the ways that our minds tend to work, as well as, confusion, are not normal signs of aging (Alzheimer’s Association 2007). As providers, family members, and friends, dementia in the elderly and occasionally in younger individuals is something that we are going to be faced with nearly every day. With the continuing increase in the number of patients dealing with Alzheimer’s disease (AD), treatment options are widening greatly. In addition to standard, traditional therapy, many patients are beginning to use complementary and alternative treatment options. Faith based medicine continues to grow in the AD population, and studies on the effects of religion and spirituality both in the patient and in the caregiver are growing in number. As providers, we must take these new and individualized treatment plans and options into consideration with all our patients. As one editorial author wrote, dementia treatment must be “broader than drugs alone.” AD patient care, treatment, and support needs to include primary, secondary, and social care. Providers should give treatment that covers the social, psychological, and medical aspects of AD, and this treatment must be given from the earliest detection of the disease until death (Dillon 2007). While there is much needed ongoing research regarding various forms of dementia, such as Alzheimer’s disease, there is still so much that is left to be discovered.
Overview of Alzheimer’s Disease:
It is known that Alzheimer’s disease is the most common form of dementia in the world today, affecting approximately 4.5 million Americans (National Institutes on Aging 2007). While this number is already outrageous, it is estimated to triple by the year 2050, with the growing elderly population (Mayo Clinic 2007). Normally, AD is found in individuals who are over 60 years of age, with a prevalence of 5 % in people 65-74 years of age. It is also estimated that close to 50% of patients older than 85 have AD (National Institutes on Aging 2007).
Alzheimer’s disease was first described by Dr. Alois Alzheimer over 100 years ago. It is now known that Alzheimer’s disease is a progressive, non-curable brain disorder in which the disease kills important brain cells which are necessary for memory recall, thinking, and behavior. Patients with Alzheimer’s typically develop symptoms over a long period of time, but progression of the disease is very detrimental, leaving the patient unable to carry out normal daily activities and putting the patient at risk for injury or other diseases (Alzheimer’s Association 2007). Mild cognitive impairment (MCI) is now thought to be a prodrome to the development of AD. This is leading to new research aimed at developing new biochemical markers, other diagnostic tools, and possible early prevention of AD (Winblad et al. 2004).
Alzheimer’s disease patients tend to have severe and debilitating memory loss, especially with regards to short term memory. AD also involves “difficulty performing familiar tasks,” language deficits, disorientation to place and time, decreased judgment ability, and problems with difficult mental tasks and abstract thinking. As AD progresses, patients tend to have changes in personality, behavior, and a loss of initiative. The diagnosis for AD requires the presence of decreased cognition and memory impairment plus at least one of the following: apraxia, agnosia, aphasia, or decreased executive functioning (Alzheimer’s Association 2007).
AD may have some genetic component, but it is likely to be polygenic and influenced by the environment. Deficits that are present result from the loss of cholinergic neurons, increased levels of glutamate, atrophy of various areas of the brain, and accumulation of toxic B-amyloid plaques and tau protein tangles. Another common finding in AD patients is brain tissue inflammation. One theory presented by scientists is that inflammation is used to combat dangerous beta amyloid plaque buildup, and this process may actually be beneficial to brain tissue. In contrast, another theory is that inflammation, developed by the presence of the tangled tau proteins and beta-amyloid plaques, causes more neural death leading to the progression of AD. Lifestyle factors, similar to the risk factors for developing heart disease are also associated with AD. The level of education that patients have may also influence their risk for developing Alzheimer’s disease. Scientists and researchers hypothesize that people who have a higher of level of education use their brain more, and therefore they develop more active neural synapses to act as storage as they age. Another important risk factor for AD that can be avoided in many situations is head injuries. Traumatic injuries, such as those received by boxers or a concussion that causes loss of consciousness, may significantly increase a person’s risks for developing AD (Mayo Clinic 2007).
Standard Treatment for Alzheimer’s Disease:
Standard, or traditional, therapy options that are used to treat AD patients are broken up into two categories: treatments that work on cognitive symptoms, such as memory, judgment, attentiveness, and language, and treatments that work on psychiatric and behavioral symptoms, including depression, anxiety, delusions, aggression, and agitation. Acetylcholinesterase inhibitors have been approved for use in treating mild to severe forms of AD since 1996. Since cholinergic neurons are depleted in Alzheimer’s patients, acetylcholinesterase inhibitors act to increase the amount of acetylcholine in the brain by decreasing its breakdown. Added acetylcholine is thought to improve communication between nerve cells in the brain, which may lead to improved learning and memory function (Aricept® Prescribing Information 2007). There are currently three acetylcholinesterase inhibitors which are commonly prescribed: Aricept® (donepezil), Exelon® (rivastigmine), and Razadyne® (galantamine). Exelon® is now available in a patch form to possibly decrease the side effects associated with these drugs (Alzheimer’s Association 2007). Using scaled scores regarding cognitive function and activities of daily living, studies have shown that acetylcholinesterase inhibitors improve both memory and behavior when compared to placebos in 24-48 week, double-blind, placebo controlled, randomized trials (Aricept® Prescribing Information 2007). Many people may choose to discontinue drug use due to side effects with the most notable being nausea, diarrhea, and vomiting (Mayo Clinic 2007).
The second type of AD treatment is a N-methyl D-aspartate (NMDA) receptor antagonist called Namenda® (memantine). This drug is the only one in its class approved for the treatment of moderate to severe AD, and it has been used since 2003. Namenda® works by regulating the activity of glutamate in the brain, and it may protect the brain and nerve cells from the damaging effects of excess glutamate found in AD patients. Multiple studies have shown that Namenda® delays cognitive worsening and increases patients’ ability to perform activities of daily living when compared to a placebo (Namenda® Prescribing Information 2007). This drug’s effects may be synergistically combined with an acetylcholinesterase inhibitor. The most common side effect noted is dizziness; however Namenda® may also increase delusions and agitation in some AD patients (Mayo Clinic 2007).
As mentioned previously, behavioral and psychiatric effects of Alzheimer’s disease can be very challenging and distressing for both the AD patient and the caregiver. Most of these effects are medicated symptom by symptom. The use of psychoactive drug treatment in the AD population is very controversial, and AD patients have a slightly increased risk of developing serious side effects and even death from the use of anti-psychotic medicines, so their use must be closely monitored. As Dr. Goldberg stated, the treatment of AD is no where close to where it will be one day, but there are increasingly more options. Since Alzheimer’s is a disease with many dimensions, doctors argue that a combination of treatments is necessary and better than one treatment alone. These possible treatment options for consideration include cholinesterase inhibitors, NMDA blocking agents, antioxidants, MAO-B inhibitors, NSAIDS, and neurotrophic agents (2005).
Complementary and Alternative Treatments for Alzheimer’s Disease:
As mentioned previously, the use of complementary and alternative medicine to combat AD only continues to increase among patients. Studies have shown that at least 55% of Alzheimer’s patients have tried some sort of “unconventional” therapy, and out of these patients, 20% had tried three or more alternative therapies. Most of the remedies tried included “vitamins, health foods, herbal medicines, smart pills, and home remedies” (NCAHF 1996). While these options are growing in popularity, there are some things that must be taken into consideration before beginning any new treatment option. Since the Food and Drug Administration does not monitor the use of dietary supplements and other alternative therapies, there are some safety concerns. The effectiveness of these methods and the safety are not fully known or regulated, and many times adverse reactions are not monitored or reported. The purity of these substances is also unknown, and it is up to manufacturers to develop and monitor safety and purity guidelines. Most importantly, these substances many have serious interactions with prescribed drugs, so it is necessary to always consult with a provider before beginning a new treatment regimen (Alzheimer’s Association 2007).
Ginkgo biloba is one of the alternative drugs which has shown the most promise in the treatment of AD. Ginkgo is extracted from plants and has been found to have both anti-inflammatory and antioxidant properties. These properties may be useful in AD patients by protecting neuronal cell membranes and also by increasing neurotransmitter function. This extract has been used in Eastern and Chinese medicine for many years to treat a variety of neurological conditions and cognitive problems; however ginkgo’s exact mechanism of action is still unknown (Kanowski et al. 2003). In a 24 week, randomized, placebo controlled study of 60 patients with mild to moderate dementia in Rome, there was no difference found between the efficacies of ginkgo biloba compared to Aricept®. Ginkgo biloba may be a significant, cost efficient AD treatment option (Mazza et al. 2006). Phosphatidylserine is another supplement option that may be used by some patients to treat AD. Phosphatidylserine is one type of lipid which acts by protecting and surrounding nerve cells. Researchers believe that supplements of this type of lipid may slow down or prevent the degeneration of nerve cells, such as cholinergic neurons in AD patients. In a 12 week, placebo controlled, double-blind trial, phosphatidylserine was shown to increase mood, behavioral functioning, and cognitive functioning significantly compared to placebo treatment (Cenacchi et al. 1993).
Another supplement which shows promise for AD patients is Huperzine A. Huperzine A is another plant alkaloid, which is extracted from a Chinese moss plant. It has similar anticholinesterase activity compared to conventional drugs, such as Aricept® and Exelon®. This dietary supplement is currently used in Chinese medicine to treat schizophrenia, inflammation, fever, and to enhance memory. Also, in Chinese studies, Huperzine A has been shown to increase memory function in mild to moderate AD patients compared to a placebo. In addition to its cholinesterase inhibiting properties, huperzine has also been shown to protect against increased glutamate activity, similar to the NMDA blocker Namenda® (Sierpina et al. 2005).
Curcumin, which is the yellow pigment found in curry, is another alternative therapy that may be considered with Alzheimer’s patients. In animal traumatic brain injury models, curcumin has shown brain protection 100% of the time. It acts by directly binding to beta-amyloid plaques and essentially making them disappear. In one study focusing on mice with “Alzheimer’s like disease plaques,” curcumin caused a 30% reduction in size of the plaques in one week. There are currently human trials being conducted to determine how well humans can tolerate the 2-4 gram/day dose of curcumin. Tests are also being performed to check curcumin’s effects on various cognitive ability tests used to track AD progression (Schardt 2007). Curcumin has been used by Indians for many years as an anti-inflammatory drug, and now it may be used to treat oxidative damage and inflammation found with AD. Curcumin was also found to be more effective in preventing the buildup of beta-amyloid plaques than other currently researched traditional drugs (Allen 2005).
Studies are also focusing on the role of antioxidants used to fight the progression of AD. Many years ago, a study focusing on the use of vitamin E showed that it slowed the progression of AD symptoms by approximately 7 months. Other studies are focusing on vitamin C, alpha-lipoic acid, selenium, and coenzyme Q’s effects in AD patients (National Institute on Aging 2007). For example, blueberries, which are full of antioxidants and proanthocyanidins, have been show to promote healthy brain activity and to possibly delay the progression of dementia (Joseph et al. 2003).
In addition to dietary supplements, herbs, and spices, lifestyle changes and complementary approaches may also slow the progression of AD and alleviate certain symptoms. As mentioned earlier, patients with AD often have increased levels of stress, agitation, and also an increased amount of cortisol released into the bloodstream, all of which may decrease the patient’s ability to carry out activities of daily living. Relaxation therapy, such as massage therapy, “expressive physical touch,” and vocalization were all found to induce calming behavior and to decrease anxiety levels. Lifestyle changes, such as environmental cues with playing music, aromatherapy, and sound therapy are also shown to decrease the AD associated symptoms of agitation and wandering. Storytelling by the AD patient has shown an increase in creativity, conversations, and positive interactions with others. Music therapy has also been found to improve attentiveness and social interaction between the AD patient, caregiver, and others. These findings were summarized nicely by the doctors’ statement: “only by embracing a variety of approaches from the psychosocial, nutritional, biologic, and even the spiritual dimensions of human life can we help our AD patients and their families move from despair to hope and meaning” (Sierpina et al. 2005).
Spirituality and the Alzheimer’s Patient:
Religion and spirituality are topics of a patient’s wellbeing which must be taken into consideration when dealing with individuals who suffer from Alzheimer’s disease. The area of faith-based medicine is also a field that has grown by leaps and bounds over the last ten years. While most of the research has focused on religion and the caregiver, the spiritual needs of the AD patient cannot be ignored. As mentioned inAlzheimer’s Care Quarterly, current research is honing in on the clinical and practical application of spiritual care in AD patients, religion as a coping mechanism, personal accounts of spirituality and dementia, and the theological and philosophical realm of AD (Stuckey et al. 2002). As with many hard to grasp concepts, religion and its use in medicine can be difficult to study objectively from a scientific standpoint.
Current research has suggested that involvement with religious activities and practices may actually improve health and longevity in all patients, and cognitive functioning may benefit later in life. It has also been shown that religious involvement, not necessarily identity, is correlated with a slowing of cognitive impairment. One study showed that patients who attended a religious service at least once a week had a 36% reduction in cognitive impairment over three years, as compared to those who did not attend a religious service once a week (Hill 2006). Another study showcased at an annual meeting of the American Academy of Neurology stated that spirituality may decrease the rate of AD progression (“Faith may slow…” 2005). Using the Mini-Mental State Examination, higher degrees of religiosity were correlated with decreased rates of mental function in AD patients. These findings are likely due to the amount of cognitive activities that are found in religious functions. From sermons to singing, scripture study, prayer, and socializing, individual’s minds are constantly being stimulated at religious events. If patients’ minds are being stimulated on a regular basis, cognitive deterioration may be delayed as the patient ages due to the maintenance of neural synapses in the brain (Hill 2006).