1. Neurodegenerative Disorders
Chapter 23
Neurodegenerative Disorders
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2. Neurodegenerative Disorders
Neurodegenerative disorders are seen in older adults more than any other age group May be barely noticeable in the beginning, slight exacerbations and remissions, but the ultimate trajectory is a downward slope Parkinson’s, Alzheimer’s, and dementia with Lewy bodies (LB) are three terminal disorders that will be discussed; other nonterminal neurocognitive disorders (NCDs) are listed in Box 23-1 The word “dementia” has been replaced with the phrase “neurocognitive disorder” (NCD)
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3. Neurodegenerative Disorders (Cont.)
Diagnosis
Evaluation is initiated by the person, significant other, or health care provider when changes are noted in comparison to a prior state of cognition, especially memory or physical stability, such as balance or tremors
The diagnostic process begins with the assessment of potentially all reversible causes for changes, such as delirium, infection, vitamin deficiencies, or endocrine disturbances (Box 23-4)
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4. Signs and Symptoms of NCDs
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5. Parkinson’s Disease (PD)
The 14th cause of death, affecting 6.3 million people worldwide More common in men than women Second most common neurodegenerative disease after Alzheimer’s disease (AD) In late stages many develop NCDs, referred to as PD dementia Persons of all races and ethnicities are affected
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6. Parkinson’s Disease (PD) (Cont.)
Diagnosis
As a movement disorder, diagnosis can be made with reasonable certainty considering the absence or presence of classic signs and symptoms
Confirmed by a “challenge test” when symptoms improve dramatically after the administration of levodopa
Early falls, poor response to levodopa, symmetry of motor symptoms, lack of tremor, and early autonomic dysfunction are characteristic of other movement disorders (Box 23-5)
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7. Parkinson’s Disease (PD) (Cont.)
Etiology
Deficiency of the neurotransmitter dopamine, a reduction in dopamine receptors, and the accumulation of LB, especially in the basal ganglia
Severity associated with the degree of neuron loss
By the time a person becomes symptomatic, 70-90% of dopamine-producing cells are lost
Epigenetic factors influence development
15-25% of those with PD have a relative with PD
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8. Parkinson’s Disease (PD) (Cont.)
Signs and Symptoms
The four core signs of PD are resting tremor, muscular rigidity, bradykinesia, and asymmetric onset
Resting tremor is the first sign in 70% of those with PD
Rigidity can be assessed with passive ROM
Muscle rigidity and bradykinesia worsen, affecting the striated muscles in the extremities, trunk, and ocular areas, including muscles of chewing, swallowing, and speaking
Other symptoms experienced (Box 23-8)
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9. Parkinson’s Disease (PD) (Cont.)
Treatment
No cure for PD, but when symptoms interfere with function, pharmacological interventions are initiated
First-line medication is levodopa
Other drugs: carbidopa and dopamine agonists
When medications don’t provide relief from disabling symptoms, patients may elect to have surgical intervention, such as deep brain simulation or ablation
Nonpharmacological approaches: gait training and muscle strengthening
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10. Alzheimer’s Disease
Incidence increases dramatically with age By 2050 the number of persons with AD is expected to grow to 16 million Researchers may have found a gene placing African Americans at twice the risk for AD Hispanics are one and a half times more likely to develop AD; no known genetic risk identified 6th leading cause of death in whites, 10th for blacks, and 9th for Asian American and Native Hawaiian/Pacific Islander
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11. Alzheimer’s Disease (Cont.)
Etiology
Familial AD, diagnosed between 30 and 60 years of age, is caused by a single gene mutation on one of three chromosomes: 21, 14, or 1
Most AD diagnosed in persons over 60 years is likely due to a number of factors, including genetic risk
APOE gene type ε4 is found in 40% of late onset AD
Persons with NCD due to AD also have an increased number of -amyloid proteins outside the neuron and accumulation of tau proteins inside the neuron
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12. Alzheimer’s Disease (Cont.)
Symptoms
The initial symptom is memory loss, specifically the ability to remember new information
Additional signs and symptoms develop over time
Functional decline correlates to cognitive decline
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13. Alzheimer’s Disease (Cont.)
Diagnosis
Diagnosis of NCD due to AD requires:
a decline from previous level of functioning.
the onset was insidious.
there has been a gradual progression in cognitive abilities.
NCD disorders are now characterized as possible or probable, and major or minor
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14. Alzheimer’s Disease (Cont.)
Pharmacological Treatment
Pharmacological therapy is aimed at slowing cognitive decline
Medications used:
Cholinesterase inhibitors:
donepezil (Aricept)
galantamine (Razadyne)
rivastigmine (Exelon)
Regulation of the activity of glutamate:
Memantine HCL (Namenda)
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15. Neurocognitive Dementia with LB
NCD due to LB affects 1.3 million people in the United States It is second in prevalence to AD Often confused with PD, but distinctly different in chronology of symptomology In LB, cognitive changes always precede movement disorders Men affected slightly more than women
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16. Neurocognitive Dementia with LB (Cont.)
Signs and Symptoms
Severe loss of thinking, especially problem solving, use of language, and numerical concepts
Fluctuating attention and alertness
About 80% have hallucinations, which may lead to delusions and paranoia
Disordered sleep
Mood problems: depression, apathy, anxiety, and agitation
Autonomic signs and symptoms (Box 23-9)
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17. Neurocognitive Dementia with LB (Cont.)
Etiology
Normal healthy brains have alpha-synuclein proteins that help neurons communicate with each other at their synapse, but in LB abnormal spherical protein aggregates are found within neurons
Alpha-synuclein is highly expressed with these bodies, which displace other cellular structures and may contribute to cell death
Progression of the disease leads to significant deficits in neurotransmitter production along the cholinergic and dopaminergic pathways
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18. Neurocognitive Dementia with LB (Cont.)
Diagnosis
According to the new DSM-5 diagnostic criteria, the person identified as one with NCD due to LB must first meet all of the initial mild or moderate criteria for other NCDs and then be classified as “possible” or “probable”
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19. Neurocognitive Dementia with LB (Cont.)
Pharmacological Treatment
Persons have a wide range of symptoms over time, and changes in these symptoms result in change in priority of treatment
Medications:
Cholinesterase inhibitors
Benzodiazepines
Clonazepam
SAFETY ALERT: Typical antipsychotics can never be used in persons with NCD due to LB due to a very high rate of irreversible side effects and possible death
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20. Neurocognitive Dementia with LB (Cont.)
Complications
Decreasing risk for NCDs (Box 23-11)
Complications:
Pressure ulcers
Pneumonia
Dysphagia
Aspiration
Under nutrition and weight loss
Behavioral disturbances
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21. Promoting Healthy Aging: Implications for Gerontological Nursing
A skilled and caring multidisciplinary team is essential
Treatment focuses on:
relieving symptoms with medication.
increasing functional ability.
preventing excess disability.
decreasing risk for injury.
Key factors in care are:
appropriate use of nonpharmacological and pharmacological interventions.
prompt treatment of reversible conditions.
coordination between all care providers.
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22. Question 1
Signs and symptoms related to the diagnosis of PD includes all of the following except:
dramatic improvement with administration of levodopa.
resting tremor.
symmetry of motor symptoms.
muscular rigidity.
ANS:  C
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23. Question 2 Which group is at greatest risk for developing AD?
African American
Hispanic
White (Caucasian)
Asian American/Native Hawaiian
ANS: A
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