A patient receiving a cholinesterase inhibitor may be treated in the hospital, nursing home, or in an outpatient setting. The patient's cognitive ability and functional ability are assessed before and during therapy. The baseline or initial assessment depends on the stage of AD. The nurse assesses the patient for confusion, agitation, and impulsive behavior. Speech, ability to perform activities of daily living, and self-care ability also are assessed. These assessments will be used by the nurse in the ongoing assessment in monitoring the patient's improvement (if any) after taking the cholinesterase inhibitors. These drugs may slow the progression of the disease but are not a cure for AD.
Before starting therapy for the hospitalized patient, the nurse obtains a complete psychiatric and medical history. With AD, patients often are unable to give a reliable history of their illness. A family member or primary caregiver will be able to verify or give information needed for an accurate assessment. During the time the history is taken, the nurse observes the patient for any behavior patterns that appear to be deviations from normal. Examples of deviations include poor eye contact, failure to answer questions completely, inappropriate answers to questions, a monotone speech pattern, and inappropriate laughter, sadness, or crying. These patients are in varying stages of decline. Display 33-1 identifies the stages of AD and the associated clinical manifestations. The nurse documents the patient's cognitive ability using Display 33-1 as a guide.
Late dementia or the final phase of AD may last from a few months to several years while the patient becomes increasingly immobile and dysfunctional.
Physical assessments include obtaining blood pressure measurements on both arms with the patients in a sitting position, pulse, respiratory rate, and weight. The functional ability of the patient is also important.
DISPLAY 33-1 • Clinical Manifestations of Alzheimer's Disease
EARLY PHASE-MILD COGNITIVE DECLINE
• Increased forgetfulness
• Decreased performance in social settings
• Evidence of memory deficit when interviewed
• Mild to moderate anxiety
EARLY DEMENTIA PHASE-MODERATELY SEVERE COGNITIVE DECLINE
• Needs assistance for activities of daily living
• Unable to recall important aspects of current life
• Difficulty making choices (ie, what clothes to wear, what to eat)
• Able to recall major facts (ie, their name and family member's names)
• Need assistance for survival
LATE DEMENTIA PHASE-SEVERE COGNITIVE DECLINE
• Incontinent of urine
• No verbal ability
• No basic psychomotor skills
• Needs assistance when bathing, toileting, and feeding
The initial assessments of the outpatient are basically the same as those for the hospitalized patient. The nurse obtains a complete medical history and a history of the symptoms of AD from the patient (if possible), a family member, or the patient's hospital records. During the initial interview, the nurse observes the patient for what appear to be deviations from a normal behavior pattern. The nurse also should assess the patient's vital signs and body weight.
Ongoing assessment of patients taking the cholinester-ase inhibitors includes both mental and physical assessments. Cognitive and functional abilities are assessed using Display 33-1 as a guide. Initial assessments will be compared with the ongoing assessments to monitor the patient's improvement (if any) after taking the cholinesterase inhibitors.
Drug-specific nursing diagnoses are highlighted in the Nursing Diagnoses Checklist. Other nursing diagnoses applicable to these drugs are discussed in depth in Chapter 4.
The expected outcomes for the patient may include an optimal response to drug therapy, management of common adverse drug reactions, an absence of injury, and compliance with the prescribed therapeutic regimen.
The nurse develops a nursing care plan to meet the patient's individual needs. It is important to monitor vital signs at least daily. The nurse should report any significant change in the patient's vital signs to the primary health care provider.
Behavioral records should be written at periodic intervals (frequency depends on hospital or unit guidelines). An accurate description of the patient's behavior and cognitive ability aids the primary health care provider in planning therapy and thus becomes an
lursing Diagnoses Checklist
1 Imbalanced Nutrition: Less than Body Requirements related to adverse reactions (eg, anorexia, nausea) 1 Risk for Injury related to an adverse drug reaction (eg, dizziness, syncope, clumsiness) or disease process Impaired Physical Mobility related to adverse drug reactions (eg, dizziness, syncope) or disease process
important part of nursing management. Patients with poor response to drug therapy may require dosage changes, discontinuation of the drug therapy, or the addition of other therapies to the treatment regimen. However, it is important for the nurse to know that response to these drugs may take several weeks. The symptoms that the patient is experiencing may get better or remain the same, or the patient may experience only a small response to therapy. It is important to remember that a treatment that slows the progression of symptoms in AD is a successful treatment.
Donepezil is administered orally once daily at bedtime. It can be taken with or without food. Galantamine is administered orally twice daily, preferably with morning and evening meals.
Rivastigmine is administered as a tablet or oral solution twice daily. When rivastigmine is administered as an oral solution, the nurse removes the oral dosing syringe provided in the protective container. The syringe provided is used to withdraw the prescribed amount. The dosage may be swallowed directly from the syringe or first mixed with a small glass of water, cold fruit juice, or soda.
Tacrine is administered orally 3 or 4 times a day, preferably on an empty stomach 1 hour before or 2 hours after meals. For best results the drug should be administered around the clock.
When taking the cholinesterase inhibitors, patients may experience nausea and vomiting. Although this can occur with all of the cholinesterase inhibitors, patients taking rivastigmine appear to have more problems with nausea and severe vomiting. Nausea and vomiting should be reported to the primary health care provider because the primary care provider may discontinue use of the drug and then restart the drug therapy at the lowest dose possible. Restarting therapy at the lower dose helps to reduce the nausea and vomiting.
Weight loss and eating problems related to the inability to swallow are two major problems in the late stage of AD. These problems coupled with the anorexia and nausea associated with administration of the cholinesterase inhibitors present a challenge for the nurse or the caregiver. Mealtime should be simple and calm. The patient should be offered a well-balanced diet with foods that are easy to chew and digest. Frequent, small meals may be tolerated better than three regular meals. Offering foods of different consistency and flavor is important in case the patient can handle one form better than another. Fluid intake of 6 to 8 glasses of water daily is encouraged to prevent dehydration. In later stages, the patient may be fed through a feeding syringe, or the caregiver can encourage chewing action by pressing gently on the bottom of the patient's chin and on the lips.
Physical decline and the adverse reactions of dizziness and syncope place the patient at risk for injury. The patient may require assistance by the nurse when ambulating. Assistive devices such as walkers or canes may reduce falls. To minimize the risk of injury, the patient's environment should be controlled and safe. Encouraging the use of bedrails, keeping the bed in low position, using night lights, and frequenting monitoring by the nurse or caregiver will reduce the risk of injury. The patient should wear an identification tag, such as a medical alert bracelet.
When administering tacrine, the nurse must monitor the patient for liver damage. This is best accomplished by monitoring alanine aminotransferase (ALT) levels. ALT is an enzyme found predominately in the liver. Disease or injury to the liver causes a release of this enzyme into the bloodstream, resulting in elevated ALT levels. In patients taking tacrine, ALT levels should be obtained weekly from at least week 4 to week 16 after the initiation of therapy. After week 16, transaminase levels are monitored every 3 months.
Within 6 weeks of the discontinuation of cholinesterase inhibitor therapy, individuals lose any benefit they have received from the drugs.
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