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

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 following13-15:

  • 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

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May 21, 2008 - Posted by | Uncategorized

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