The Pharmacist’s Role in the Management of Alzheimer’s Disease

Yvette C. Terrie , BSPharm, RPh

Pathophysiology

Although the exact etiology of AD still is unknown, research suggests that it can be attributed to both inherited and environmental factors. The 3 standard neuropathologic features of AD include amyloid plaques; neurofibrillary tangles; and a third factor, which has been described only in the last 3 decades—synaptic and neuronal cell death that involves a progressive or gradual loss of connections between neurons.^6,8,9 As the death of the neurons progresses and spreads through the brain, brain atrophy occurs in the affected areas.⁹ Whereas researchers have known about these features of AD for several years, they are still learning more about them and their roles in the development and progression of AD. The progression of AD often is unpredictable, and the severity varies from patient to patient.

There are 2 distinct forms of AD: (1) familial and (2) sporadic.¹⁰ Familial AD is considered very rare and typically occurs before the age of 60. It also is referred to as early-onset AD. Less than 5% of the cases are early-onset, and this form is believed to be caused by gene mutations on chromosomes 1, 14, and 21.^10,11

As for sporadic AD, genes may not be the direct cause of the disease but may influence the risk of developing it. Sporadic AD also is referred to as lateonset AD, because many cases occur in individuals after the age of 60, with the vast majority in their 70s and 80s.^10,11 There are, however, exceptions to thegeneral observations regarding age at onset.

The apolipoprotein E (apo E) gene, which is found on chromosome 19, is the best studied susceptibility gene in sporadic AD.¹⁰ The apo E gene is responsible for the manufacturing of a protein that moves cholesterol and other fats throughout the body.¹⁰ It is postulated that this protein may be involved in the structure and function of the fatty membrane that surrounds a brain cell.¹⁰ The apo E gene occurs in many forms or alleles. The 3 forms that occur most frequently are apo E-II, apo E-III, and apo EIV.^10-12 Furthermore, the apo E-IV gene may increase an individual’s chance of developing late-onset AD. It is estimated that between 35% and 50% of individuals with AD carry some form of the apo E-IV gene.¹⁰

Risk Factors

Current research indicates that AD may be triggered by several factors, including age, genetics, serious head injuries, and inflammation of the brain, as well as environmental factors. Age is the most well-documented risk factor. Other possible risk factors include the following^13-15:

• Down’s syndrome
• Head injury
• Diabetes mellitus
• Hypertension
• Hypercholesterolemia
• Hyperglycemia
• Family history
• Sedentary lifestyle
• Diets high in saturated fat

Signs and Symptoms

Recognizing the warning signs associated with the development of AD is crucial in order to initiate early intervention, as well as to differentiate AD from other forms of dementia. In many cases, an individual’s symptoms may progress gradually over time and may not be obvious initially. Patients may exhibit cognitive or intellectual symptoms, such as acalculia (inability to perform simple mathematical calculations), aphasia (inability to communicate effectively), apraxia (inability to perform daily activities such as brushing teeth or combing hair), amnesia, and agnosia (loss of the ability to interpret sensory stimuli) as the disease progresses. Behavioral signs and symptoms—such as depression, apathy, and anxiety—typically are present in the early stages, and delusions, hallucinations, and psychosis are prevalent during the latter stages.^16,17 In the advanced stages, individuals also may present with extrapyramidal symptoms, such as gait disturbance, myoclonus, tremor, and urinary incontinence.¹⁶

Potential Warning Signs

Some warning signs of AD are as follows¹⁶:

• Memory loss that may affect job performance
• Difficulty in performing routine, familiar tasks
• Difficulty or problems with speech
• Decrease in judgment skills
• Difficulty with abstract thinking
• Disorientation as to time and place
• Difficulty in finding objects or misplacing items
• Changes in mood, personality, or behavior, such as agitation, aggression, and hallucinations
• Loss of initiative or motivation
• Impaired memory or thinking
• Impaired visual or spatial skills

Stages

Because AD progresses in severity over time, the disease generally is characterized by the following stages: mild, moderate, and severe. During the mild stage, the individual may start to experience some memory loss, which may be insignificant enough that others may not notice a problem. Short-term memory usually is affected first.

As the disease progresses from mild to moderate, the signs may become more noticeable to family and friends, because the patient may exhibit difficulty in self-care and in accomplishing everyday tasks. At this stage, some behavioral changes often are noted, such as frustration, anger, and anxiety. Usually at this stage, the need for caregiver assistance may become essential for the safety of the individual.

In the severe stage of AD, individuals typically are characterized as being solely dependent on the caregiver. Some patients in this stage may experience loss of bladder and bowel control and episodes of aggression. Table 1 lists, for each stage of AD, behavioral and cognitive changes as well as how the disease may affect the individual’s daily routine.

The Role of the Pharmacist

In almost every area of pharmacy practice, pharmacists are very likely to encounter a patient with AD and/or a caregiver. Therefore, it is imperative for pharmacists to keep abreast of new developments in research and pharmacologic therapies regarding the disease.

Pharmacists can be a vital resource for both patients and their caregivers, thereby improving quality of life. A comprehensive understanding of the etiology, pathophysiology, and stages of AD, as well as pharmacologic therapy, is imperative to provide effective care to the patient.

Pharmacists can assist patients with AD through monitoring drug regimens for potential drug interactions as well as possible contraindications. More importantly, pharmacists always should try to demonstrate empathy toward patients with AD and their caregivers, keeping them informed about new developments in the fight against this condition and suggesting resources of information for them.

Caring for a patient with AD involves more than drug treatment. Caregivers should be encouraged to join a local support group and to take care of themselves and seek assistance when warranted.

During counseling, pharmacists can provide patients and their caregivers with various suggestions for techniques that may aid in the management of AD, such as the use of memory aids or schedules. Examples of memory aids include a list of daily routines, important telephone numbers in case of an emergency, and instructions on how to perform various tasks. In addition, pharmacists can make recommendations for creating a safe environment and establishing an exercise routine, if appropriate.⁴⁴

PRESENT CONTINUOUS/ELECTRICITY

 

El “Present Continuous” (Presente Continuo) lo utilizamos cuando queremos hablar de acciones que están ocurriendo “ahora” o, en un tiempo cercano a “ahora” o, que no han terminado.
Por ejemplo: Estoy comiendo (I’m eating) o, estoy leyendo un libro (I’m reading a book). En este último caso, te refieres a una acción inacabada, no a que estás leyendo el libro en el momento en que hablas.

Estructura: Sujeto + “to be” en presente + el verbo principal acabado en “ing”.

Ejemplo 1: I am (I’m) working . Yo estoy trabajando.

Ejemplo 2: She is (She’s)studying . Ella está estudiando.

Ejemplo 3. It is (It’s) working . Está funcionando.

Ejemplo 4: They are (They’re) looking . Ellos/Ellas están mirando.

Problemas que presenta el Present Continuous: En teoría es un tiempo muy sencillo de dominar. No obstante, dado que a veces en español utilizamos el “Presente” para hablar de algo que ocurre en el momento en que hablamos, en inglés cometemos el error de utilizar el “Presente” cuando deberíamos utilizar el “Present Continuous”.

Por ejemplo, decimos: “She comes” , cuando deberíamos decir: “She’s coming” . (Ella viene). Es verdad que en inglés hay algunos verbos que no se conjugan en “Present Continuous”, por ejemplo, “want”  (querer), pero son pocos.

Recuerda: Para hablar de algo que está ocurriendo en el mismo momento en el que hablas, debes utilizar en inglés el “Present Continuous”, no el tiempo “Simple Present Tense” Por ejemplo: “It’s raining now.”  (Ahora llueve). No:”It rains now.”

¿Cómo se pregunta con el “Present Continuous”?

Estructura preguntas: Verbo + sujeto + verbo principal terminado en “ing”+?

Ejemplo: Is she working?  ¿Está ella trabajando

¿Cómo se niega con el “Present Continuous?

Estructura negación: Sujeto + verbo “to be” en presente + not + verbo principal terminado en “ing”.

Ejemplo: She is not (isn´t)working . Ella no está trabajando.
Repaso de las estructuras:

Positivo	Sujeto+ Verbo”to be” en presente+VP terminado en “ing”. You are (You’re)working.
Negativo	Sujeto + Verbo “to be”en presente +not+VP terminado en“ing”. You are not (aren’t) working.
Pregunta	Verbo “to be” en presente+ Sujeto+ VP terminado en “ing”+?Are you working?

FORM[am/is/are + present participle]

Examples:

• You are watching TV.
• Are you watching TV?
• You are not watching TV.  

USE 1 Now

 Use the Present Continuous with Normal Verbs to express the idea that something is happening now, at this very moment. It can also be used to show that something is not happening now.

Examples:

• You are learning English now.
• You are not swimming now.
• Are you sleeping?
• I am sitting.
• I am not standing.
• Is he sitting or standing?
• They are reading their books.
• They are not watching television.
• What are you doing?
• Why aren’t you doing your homework?

USE 2 Longer Actions in Progress Now

 

In English, “now” can mean: this second, today, this month, this year, this century, and so on. Sometimes, we use the Present Continuous to say that we are in the process of doing a longer action which is in progress; however, we might not be doing it at this exact second.

Examples: (All of these sentences can be said while eating dinner in a restaurant.)

• I am studying to become a doctor.
• I am not studying to become a dentist.
• I am reading the book Tom Sawyer.
• I am not reading any books right now.
• Are you working on any special projects at work?
• Aren’t you teaching at the university now?

USE 3 Near Future

 

Sometimes, speakers use the Present Continuous to indicate that something will or will not happen in the near future.

Examples:

• I am meeting some friends after work.
• I am not going to the party tonight.
• Is he visiting his parents next weekend?
• Isn’t he coming with us tonight?

USE 4 Repetition and Irritation with “Always”

The Present Continuous with words such as “always” or “constantly” expresses the idea that something irritating or shocking often happens. Notice that the meaning is like Simple Present, but with negative emotion. Remember to put the words “always” or “constantly” between “be” and “verb+ing.”

Examples:

• She is always coming to class late.
• He is constantly talking. I wish he would shut up.
• I don’t like them because they are always complaining.

REMEMBER Non-Continuous Verbs/ Mixed Verbs

It is important to remember that Non-Continuous Verbs cannot be used in any continuous tenses. Also, certain non-continuous meanings for Mixed Verbs cannot be used in continuous tenses. Instead of using Present Continuous with these verbs, you must use Simple Present.

Examples:

• She is loving this chocolate ice cream. Not Correct
• She loves this chocolate ice cream. Correct

ADVERB PLACEMENT

The examples below show the placement for grammar adverbs such as: always, only, never, ever, still, just, etc.

Examples:

• You are still watching TV.
• Are you still watching TV?

ACTIVE / PASSIVE

Examples:

• Right now, Tom is writing the letter. Active
• Right now, the letter is being written by Tom. PassiveACTIVITY

ACTIVITY

Simple Present / Present Continuous

Using the words in parentheses, complete the text below with the appropriate tenses,

1. Every Monday, Sally (drive)_________ her kids to football practice.

2. Usually, I (work) ______as a secretary at ABT, but this summer I (study)______ French at a language school in Paris. That is why I am in Paris.

3. Shhhhh! Be quiet! John (sleep)________ .

4. Don’t forget to take your umbrella. It (rain)________ .

5. I hate living in Seattle because it (rain, always)_________ .

6. I’m sorry I can’t hear what you (say)______ because everybody (talk)______ so loudly.

7. Justin (write, currently)_____________ a book about his adventures in Tibet. I hope he can find a good publisher when he is finished.

8. Jim: Do you want to come over for dinner tonight?
Denise: Oh, I’m sorry, I can’t. I (go)_______ to a movie tonight with some friends.

9. The business cards (be, normally )________ printed by a company in New York. Their prices (be) ______inexpensive, yet the quality of their work is quite good.

10. This delicious chocolate (be)_________ made by a small chocolatier in Zurich, Switzerland.