Abnormal psychological Alzheimer's disease

2021-07-19 12:28 AM

To be diagnosed with AD, the deficits must cause significant impairments in occupational or social functioning and make a marked difference from the past.

Alzheimer's disease is the most common form of dementia, accounting for 5-10% of people over 65 years old and at least 20% of people over 80 years old (Roca et al. 1998). However, the disease is not only found in the elderly. The person Alois Alzheimer first described in the early 20th century was a middle-aged woman. The DSM-IV-TR defines AD as a progressive disease that has the following features (usually summarized by the four A's):

Amnesia (amnesia).

Aphasia (aphasia).

Apraxia: Loss of the ability to perform movements even though the motor function is preserved.

Agnosia: Loss of the ability to perceive objects even though the sensory function is preserved.

Executive dysfunction (eg, planning, organizing, reasoning, generalizing).

To be diagnosed with AD, the deficits must cause significant impairments in occupational or social functioning and make a marked difference from the past. Progressive amnesia, typically with current memory disordered first, followed by distant memory—a memory that is considered stable because of practice reinforcement over time. However, as the disease progresses, the patient also forgets the emotional distant figures. At first, it is forgetting events that still happen, then forgetting about daily tasks, and then even forgetting family members. Another very common phenomenon is the difficulty of finding the right words. In the final stage, AD destroys the communication function.

In the early stages of AD, patients can recognize their disabilities. However, as the disease progresses, the patient also gradually loses this ability. They also lose all sense of self and their lives are completely dependent on the care of others.

Other common phenomena are suspicion, paranoia, and paranoia. Individuals may experience erratic emotional changes including anger, frustration as well as agitation. Confusion is also a common phenomenon, especially at night when the fulcrums that help individuals orientate time and position are less and the oxygen supply to the brain is also reduced. While all health care services are aimed at maximizing an individual's independence and keeping them in their home, at some point these people still need to be hospitalized. . By then, they were very confused about the time, had no self-control, and responded very poorly to the environment.

From the time of being diagnosed with AD until the patient's death can take up to 20 years or more. However, the usual time period is 4-8 years. During this time, the individual goes through the following stages:

Suspected dementia: the individual begins to exhibit “strange” behaviors and the problems that follow.

Mild Dementia: Dementia is obvious, however, the individual can still take care of himself.

Moderate dementia: help is needed for the patient to perform daily tasks, "problematic" behaviors, such as being lost, aggressive, are evident.

Severe dementia: the individual has become more frail, even with only a bed and chair all day.

Alzheimer's disease does not affect the individual immediately. Among those infected, women account for a high proportion (Parker and Lawton, 1990). It is possible to care for someone with dementia in their own home even until the disease is severe. These people often experience severe stress.

Causes of Alzheimer's

Genetic factors

If 1 person has Alzheimer's disease, nearly 50% of the patient's first-degree relatives will also develop the disease (Korten et al. 1993). Genes located on chromosomes 14, 21 and, the apoE4 gene on chromosome 19 are associated with AD. ApoE4 is one of several forms, or alleles, of the apoE gene. Others are apoE2, apoE3. People with two apoE4 genes are eight times more likely to develop AD than people with two E3 alleles. The apoE4 gene can cause disease onset up to 17 years earlier (Warwick Daw et al. 2000). However, only about 40% of people with the disease have this gene, and there are also many people who have the gene but do not get the disease. Therefore, this can only be a risk factor, not a causative factor. It is also important to note that the risk of AD for a known gene is very low: Familial Alzheimer's accounts for less than 1% of all cases,

Currently, some of my colleagues have organized several focus groups to explore factors related to the quality of life of people with mild and moderate dementia. The results were quite interesting in that it wasn't just what the people in the group said, but also what they didn't say. Here are some quotes from the focus group. Team members told us what increased or decreased their quality of life. These quotes don't seem to be anything special. It can happen to anyone and at any age. Crucially, what the group members didn't say was that the memory impairment had worsened their quality of life. Some say that is possible in the future. However, it has become a topic related to the current issue. Although people's cognitive abilities can be bad, they don't always affect the current quality of life. But that doesn't mean memory loss isn't a problem for people with dementia - and some people can become severely depressed due to reduced abilities. However, there are also many things that affect the quality of life of patients but do not belong to cognitive abilities.

Neural processes

Alzheimer's disease is caused by premature degeneration of brain systems. Progressive degeneration and AD can be marked on brain maps. Usually, the problems start in the inner cortex then spread to the hippocampus and gradually spread to other areas, namely the cerebral cortex. Degeneration of hippocampal neurons, it leads to a decline in short-term memory and the ability to perform everyday tasks. As the disease spreads to the cerebral cortex, it begins to affect language.

The causes of these changes are twofold: structural - the appearance and development of beta-amyloid plaques and neurofibrillary tangles and some neurotransmitters. Beta-amyloid is produced by the breakdown of amyloid precursor protein (APP) located in neuronal cell membranes. It is also a representative of the large family of proteins that surround neurons, forming the barrier that controls entry. Degradation of APP produces beta-amyloid fragments, which can overlap to form amyloid plaques causing neuronal cell death. The main reason is that because these plaques have created small slits in the cell membrane, calcium flux through these channels has not been controlled (Sinha et al. 2000). Neural filaments with double helix fibers are made up of a protein called tau. in healthy bodies, This combination plays a role in stabilizing the microvessels that carry nutrients and molecules from the cell body to the axon terminal. In AD, tau is chemically altered, so it causes tau to twist with microfibrils to form neurofibrillary tangles. Accordingly, the breakdown of the transport system disrupts the connections between neurons and causes them to be destroyed.

One of the neurotransmitters that play an important role in AD is acetylcholine: in AD patients, acetylcholine is reduced by up to 90% (Whitehouse et al. 1982). Acetylcholine is involved in memory processes and affects the neuronal activity of the hippocampus and cerebral cortex, other neurotransmitters may also be involved in this process. In some people with AD, serotonin and noradrenaline levels are lower than normal, so they can also contribute to sensory disturbances and aggressive behavior. These hormones may also be involved in other psychological disorders in the early stages of AD such as depression and anxiety.

Environmental factors

The risk of AD is partly due to environmental factors, although their exact role in the cause has not been determined. One of the more obvious risk factors is a history of brain injury (Mc Powell, 2001). The previous hypothesis of increased aluminum exposure risk has fallen out of favor, although in the UK the use of aluminum-contaminated water can lead to cognitive impairment in a small number of people (Altmann et al. cs. 1999). Smoking is considered a protective factor, although some of these have a family history of dementia. Other protective factors include exercise, moderate intake of red wine, and a diet high in vitamins B6, B12, and folic acid. Many drugs are also protective, including non-steroid, antiemetics, and estrogen replacement therapy in postmenopausal women.

Treating Alzheimer's Disease

Pharmacological intervention

Increased acetylcholine levels:

If a decrease in acetylcholine causes AD, increasing acetylcholine to the appropriate concentration may reverse the symptoms of the disease. Drugs are designed to prevent acetylcholinesterase from breaking down acetylcholine at the synaptic cleft and to increase postsynaptic receptor reabsorption (see Chapter 3). Acetylcholinesterase inhibitors such as donepezil (Aracept) can generally improve cognition in the short term and appear to inhibit rather than prevent cognitive decline (Rogers et al. 1998). Unfortunately, many users of the drug experience side effects, among which are gastrointestinal disturbances, and up to 35% of the trial participants gave up (Rogers et al. 1998). In addition, not all people respond to treatment and this remains unexplained (Forette & Kockwood 1999).

The second method to increase acetylcholine levels is to take nicotine to increase acetylcholine secretion. Experiments have shown that in this way, memory is improved in old monkeys (Buccafusco and Jackson 1991). People with AD also experienced improvements in some cognitive and emotional aspects after injecting nicotine. However, there is not enough reliable data to prove the effectiveness of nicotine in the treatment of AD.

Inhibits amyloid growth:

A completely different pharmacological approach is to find a way to block the production of beta-amyloid in the brain using vaccines. Experimental studies in mice showed that the vaccine provided some degree of protection against plaque formation (Schenk et al., 1999) and initially showed that injection of a vaccine is still safe in humans. Furthermore, Weiner et al. (2000) found a small but significant response when administered to rats by intranasal administration: this treatment can be tolerated for a long time (even throughout life).

Psychological approach

The psychological intervention aims to maximize the quality of life and psychological functions in the course of the disease. Support groups of different people with similar problems can improve support for coping strategies in the early stages of AD (Yale, 1995). In the late stages, there are usually three therapeutic approaches used.

Realistic Orientation

Reality orientation (RO - As Holden & Woods, 1995) involves equipping the elderly with signs of confusion with appropriate information to help them better understand the world around them. There are two types of RO: 24-hour RO to create an environment with many instructions to help individuals navigate time, space, and themselves: large clocks and calendars; instructions reminding the name of the facility or treatment area name badges etc. Social interventions for individuals are also designed to provide relevant information “hello Mr. Jones. Tom is here… It's pretty cold outside now, just like January is usually…”. Simple, specific sentences that repeat the information of the day or are used to communicate. The RO class consists of small groups that meet for 30-60 minutes. Despite the name, lessons are conducted in comfortable rooms with soft chairs with a relaxing atmosphere. Selecting participants based on ability, the sessions include debate and information, promoting memory in a variety of ways with different channels: from newspapers, pictures to chat, etc.

In a review of 21 RO trials, Holden and Wood (1995) concluded that the results obtained were small but important in orientation, compared with those without treatment or with no prior design therapy. . It seems that results in other areas such as cognitive or behavioral skills have also been modest, although Reever & Ivison (1985) reported that some progress in self-control was achieved after the intervention. combination of classroom and 24-hour RO.

Regardless of the end result, RO also has certain difficulties for those who intend to apply it, especially in cases where it is necessary to remind the patient of information to cause stress. . For example, many people with AD have forgotten their partner's death and, out of confusion, begin to search, wait, and ask to see the deceased. According to the RO, caregivers must tell the patient that their partner has died. And this can be bad news, causing stress for patients. Unfortunately, the patient then forgets and continues to ask and find a partner requiring the caregiver to deny the information that their partner has died: such a cycle continues to be stressful for both the patient and the caregiver. squirrel.

Effective therapy

To overcome the disadvantages of RO, Feil (1990) proposed another form of 'potent' therapy. This therapy involves listening to and paying attention to all of the patient's fears, taking the time to fully understand their problems, and making them "effective" by assessing their concerns. what they need to say. Such conversations should provide an opportunity to identify and change false beliefs, but this is not the core element of this approach. The focus is on hearing and responding to emotional reactions rather than the actual content of what they say.

In group therapy, small groups can be arranged to discuss expressed feelings such as anger, isolation, or loss (Bleathman & Morton, 1992). Feil (1990) suggested that by wording memory and thinking and being validated by the group, the individual gains a feeling of acceptance. This approach emphasizes the need to resolve unresolved conflicts. It also has psychodynamic components. When therapy emphasizes empathy and acceptance of the individual's view of the world around him, there are distinctly human aspects. However, there have not been any serious studies to evaluate the effectiveness of the method. What has been obtained is mainly based on historical analysis of uncontrolled cases. In a study Feil (1990) reported that crying episodes were reduced,

Reminiscence therapy

There are three types of flashback therapy (Mc Malion & Phuclick, 1964). Story-type flashbacks include re-enactment of pleasant events. Looking back on life involves recollecting and discussing both good and bad events, events that are primarily conscious. Finally, aura flashbacks include a repeated set of situations that cause distress or frustration. Looking back on life and reminiscing about auras are said to aid in resolving past conflicts.

Retrospective therapy is based on Erikson's (1980) developmental model in which life retrospectives often occur towards the end of life. Looking back on life in general can be either positive or negative. In individual therapy, the therapist helps the individual to clarify and more effectively analyze the self. In group therapy, small groups look at the members' lives using cues such as old photographs, radio or television broadcasts, etc. As with effective therapy, there is no There are many studies on the effectiveness of reminiscence therapy. The participants mainly enjoyed being in the retrospective group. There are also some reports of increased self-esteem as well as life satisfaction. After joining the group (eg, Kovach, 1990). However, there is not much evidence that it is more effective than other group activities.

Behavior change

Although observable approaches to changing behavior in the elderly with confusion have attracted some attention, little has been reported on its use or effectiveness. However, studies that have used this procedure have shown it to be generally effective. For example, Burgio et al. (1988) applied the program to increase rational use of toilets and reduce incontinence. This program consists of asking regularly, at regular intervals whether individuals want to go to the toilet and then reinforcing toilet use. The program has achieved remarkable results although individuals have not actively used the toilet themselves. In general, program participants have increased their use of the help system. Other programs together reduce wandering behaviors, shape and increase interaction, social advocacy (see Woods & Roth, 1997). According to Woods & Roth, the basic ingredient for ensuring observable processes in the elderly may not be a "reward" for right behavior. Chances are that the use of behavioral guidance systems plays a more important role.

Another essential element in caring for the elderly with dementia is to minimize cognitive demands on them (Woods &Brid, 1999). When having a dialogue, you must use short sentences, always repeating them. Additional compatible aids, such as pictures, can be used. However, help should also be avoided with incompatible information. Help needs to be simple and direct. For example, an arrow pointing to a picture of a toilet taped to a toilet door can be more effective than a typical female or male figure. Even people with moderate to mild dementia need such help. Any aid requires guidance and practice to reinforce its credentials. For example, every time you take a patient to the toilet, carers can talk to them while walking and give them directions and help. If at home, ensure safety to the maximum extent, for example, replace the gas heater with a heat storage heater, etc.

Help caregivers

Caring for people with AD at home also creates a lot of stress for caregivers, especially when they are often elderly and have limited health. Certain forms of support and help are also beneficial. These supports can be provided by volunteers, such as the Alzheimer's Society in the UK, and the brief periods of time for carers to rest when the patient is hospitalized. There may also be other forms of intervention.

In a meta-analysis of nine studies designed to help caregivers cope with stress, Knight et al. (1992) concluded that both group and group interventions reduce feelings of heaviness and depression.

Gallagher - Thomson and Steffen (1994) compared two types of interventions: cognitive behavioral and psychodynamic in the treatment of people with depression during the care of elderly relatives. By the end of the day, both types of interventions are effective. 71% of cases were no longer depressed. However, occupational therapy is more effective for people who do caregiving for short periods of time. This may be because for those new to the role of carer there is still a need to explore and find ways to fulfill the role. For those who have been in caregiving for a long time, it may be more beneficial to practice daily stress coping techniques.

A second way to help caregivers cope with stress is to equip them with strategies to help them manage their loved one's behavior more effectively. For example, Pinkston et al. (1998) showed how caregivers can manage many behaviors, including self-care, aggression, and wandering. Over 75% of patients experienced some behavioral improvement after caregivers received training to reduce stress.