What is Alzheimer’s? Essay Example
Alzheimer’s disease is one of the six main causes of death in the USA. It is a degenerative disease that occurs due to the genetic predisposition and is, in fact, the gradual destruction of neurons in the brain. This disease is responsible for almost 60-70 percent of cases of dementia. It is characterized by cognitive, psychological and behavioral symptoms. The aim of this paper is to analyze the disease with a particular emphasis on the psychological aspect. In this regard, attention is paid to the overall description of the disease, causes of it and diverse approaches to treatment. The psychological implications of the caregivers and patients are also outlined.
Key words: Alzheimer’s disease, dementia, psychological and behavioral symptoms.
In the history of human civilization, one of the crucial tasks of human life was to prolong it and live it with a good health and happiness. The problem of illnesses and diseases remains an inevitable part of human life. However, unlike before, contemporary medicine knows more about the origins of certain illnesses and their treatment or hereditary conditionality. Since illnesses are part of human lives, they require to be studied systematically and in the relationship with the surrounding environment and people in it. The aim of this paper is to explore Alzheimer’s disease, paying primary attention to the psychological aspect of it. In this regard, the essence of the disease, psychological symptoms their origin and explanation, psychological implications of the caregivers and consequent reflection upon the patient will be outlined.
Alzheimer’s disease is one of the forms of dementia. Dementia is a persistent or chronic misbalance of mental activity conditioned by a certain disease or injury of the brain. It is characterized by memory and personality disorders, dysfunction in reasoning and logical thinking (Brill, 2005). The loss of memory and deterioration of intellectual abilities results in patient’s inability to carry on with daily life on their own, without caregivers. Alzheimer’s disease corresponds to 60-80 percent of dementia cases.
Although the earliest symptom is the inability of an individual to remember newly acquired information, this disease is not a part of the normal human aging process. Although the disease often progresses on the late onset of people over 65, around 5 percent of patients have early symptoms in the age of 40-50s (Lillrank, et al., 2007). The main distinction is that while with age memory function deteriorates, it does not disappear entirely like in the case of Alzheimer. In other words, elder people can remember a new information after a certain time or they need more time to remember something, while the brain of people with Alzheimer’s simply cannot process the information correctly and store it as a healthy brain would (Brill, 2005). This is conditioned by the dysfunction of nerve cells ability to transfer information across the brain:
“Scientists believe Alzheimer’s disease prevents parts of a cell’s factory from running well. They are not sure where the trouble starts. But just like a real factory, backups and breakdowns in one system cause problems in other areas. As damage spreads, cells lose their ability to do their jobs and, eventually die, causing irreversible changes in the brain” (Alzheimer’s Association, 2015).
Alzheimer’s is one of the diseases that progress over time. Gradually, patient’s situation deteriorates. During the first few years, the loss of memory is partial and is within the short-term memory segment. The person becomes irritated, has mood swings and irrational reactions to the surrounding environment (Brill, 2005). On the late stages, patients lose the ability to recognize people, they have hallucinations, are incapable of talking interacting with the surrounding environment. This condition often ends in death within 8 years after the diagnosis. However, depending on a range of factors and health condition of the patient, some patient can live up to 20 years, yet with the late stage symptoms. For the USA, this is the sixth leading cause of death (Lillrank, et al., 2007).
At the present stage of research, there is no cure from this disease since the cause of its occurrence is considered to be genetic predisposition and the presence of a certain gene causing its development (Brill, 2005). However, there are various medicines to treat the symptoms. In this regard, the primary purpose of the existing medicine it to make the symptoms more bearable but this medicine cannot stop them from progressing. Thus, medicine is aimed at improving the quality of life of patients rather than being able to treat their condition. At the current stage of the research conducted by the Alzheimer’s Research Organization, the primary purpose is to delay the onset and disease’s development (Lillrank, et al., 2007).
The historical origin and the name of the disease are associated with the work of German physician Alois Alzheimer who discovered “a peculiar disease” in 1906. He was the first one to relate the symptoms to “microscopic brain changes, describes the haunting case of Aguste D., a patient who had profound memory loss, unfounded suspicions about her family, and other worsening psychological changes. In her brain at autopsy, he saw dramatic shrinkage and abnormal deposits in and around nerve cells” (Alzheimer’s Association, 2015). In 1910, this disease was named after Alzheimer by one of the physicians he worked with.
Psychological and behavioral effects of Alzheimer’s disease and treatment
From outlined above description of the disease, it can be concluded that its development is largely conditioned by individual specifics of health and one’s brain physiology. For this reason, certain symptoms might be found in some patients and absent in the case of the others. In this regard, symptoms are divided into two large categories: cognitive symptoms (related to the memory loss, understanding and rational thinking) and behavioral and psychological symptoms (aggression, depression, agitation, disorientation in space, inability to recognize their relatives) (Lillrank, et al., 2007). In this regard, the cognitive symptoms are explained by dysfunction of neuron activity while the conditionality of the second category of behavioral and psychological symptoms (BPSD) remains unknown.
Just as cognitive symptoms BPSD progress with time. On the first stage of the disease, they include deterioration of one’s mood, slight irritation when not being able to find certain objects, personality changes, disinterest in previously liked things and activities, apathy. On the second stage or during the moderate progress of the disease, the symptoms might include: substantial behavioral changes related to hygiene, sleeping pattern, concerns over one’s appearance; confusing people’s identities. Other symptoms at this stage include the inability to sit still, fidgeting, and acting improperly without a reason (swearing, biting, kicking, screaming and grabbing other people or objects). Furthermore, hallucinations, aggressive behavior, depression and agitation are viewed (Brill, 2005).
At the final stage, patients often lose any ability to recognize themselves and their family members, have difficulty speaking and understanding speech. They often become incapable of taking food on their own, choke and forget how to swallow food. They also can lose control over bowel and bladder (Lillrank, et al., 2007). Consequently, with the progression of the disease, BPSD deteriorate with a complete change of one’s behavior and psychological condition. In other words, the outcome is the destruction of one’s personality and behavioral pattern.
The primary problem researchers have with the treatment of BPSD is not only the fact that each patient has a different combination of the outlined above symptoms and their consequent timeframe of development. The problem with BPSD is that these symptoms can develop only in half of the patients and the other half might have only the cognitive symptoms of the disease. Since the cause of BPSD in some patients and the absence of it in the others are not yet explored, there is a tendency to explore BPSD as a separate phenomenon and its consequent occurrence (Brill, 2005). This approach is largely conditioned by the lack of efficiency in treating BPSD as a totality of psychological symptoms and not as a complex phenomenon with a distinctive origin. It is argued:
“There are no adequate treatments available for these symptoms at present. Antidepressants and tranquillizers are commonly prescribed for the control of psychological symptoms of dementia. However, their effectiveness in the treatment of symptoms as agitation and aggression is open to debate and their side-effects (such as drowsiness and increased social withdrawal) coupled with the over prescription of these drugs become a problem in itself ” (Passmore, 2007).
In order to trace the genetic conditionality of BPSD, a research by Professor Peter Passmore was conducted at Queen’s University, Belfast. The primary aim of the research was to explore different genes related to the creation of behavior and thought related to BPSD in Alzheimer patients susceptible to those symptoms. All patients were on their third year of the disease progressing, some having BPSD and some not (Lillrank, et al., 2007). The findings demonstrated that BPSD develop around 45-50 months after the diagnosis. This timeframe is explained by the necessity of a certain level of neurodegeneration to be reached for BPSD to emerge. The study also demonstrated the following findings:
“Furthermore, of the 12 symptoms studied (apathy, aberrant motor behavior, appetite disturbance, irritability, agitation/aggression, sleep disturbances, depression, anxiety, delusions, disinhibition, hallucinations and elations), most were present in over 50 per cent of the study population at any time, with apathy being the most common symptom, present in 75 per cent of patients at any stage. Hallucinations, disinhibition and elation were lest common, being present at any time in less than 30 per cent of the study population. Delusions, hallucinations and irritability were the only symptoms to vary significantly with degree of cognitive decline”(Passmore, 2007).
Moreover, it was found that delusions were more characteristic of the moderate stage of the disease progressing, while hallucinations were more typical for the latest stages. On the other hand, irritability was not characteristic of the late stage as it was common for the early and moderate conditions (Brill, 2005). In terms of causing inconvenience, different symptoms have a different effect on patients and their caregivers. It was outlined that apathy, sleep and appetite disorders and motor behaviors are particularly problematic for the patients, while sleeping disorders, depression and aggression are difficult to deal with for the caregivers (Passmore, 2007).
In terms of this research, it was suggested to treat the studied 12 symptoms as four sub-syndromes that would further require individual treatment and caregivers’ attention. It was suggested that “affect factor” includes anxiety, depression, agitation and irritability; “apathy and physical behavior factor” combines apathy, motor behavior dysfunction, sleep and appetite disorder. The factor of psychosis covered illusions and hallucinations, while “hypomania factor” covered the symptoms of disinhibition and elation (Lillrank, et al., 2007). The significance if this grouping is aimed at the demonstration of the interconnectivity of the symptoms and their temporal progression. From the research perspective, it is suggested that psychiatric exploration of these sub-syndromes could further deepen the research.
One of the most crucial findings of this research was related to the demonstration of the genetic conditionality of the development of BPSD. In this regard, it was outlined that genetic predisposition was conditioned by the inability of transferring serotonin and dopamine that are the primary neurotransmitters in the process of behaviors and emotions formation (Passmore, 2007). In other words, if gene encoding for a certain enzyme involved in serotonin or dopamine synthesis is dysfunctional, the amount of serotonin or dopamine will be lesser than normal resulting in aggressive behavior.
In this regard, psychological symptoms in Alzheimer are similar to the patients that do not suffer from dementia but severe mental conditions like schizophrenia. Thus, it is concluded that due to the similarities of symptoms both Alzheimer and schizophrenia have the same neurobiological conditionality: “the possibility thus exists that genetic variations in this enzyme could be responsible for the prevalence of aggressive behavior in people with Alzheimer disease” (Passmore, 2007).
Irrespective of the outlined above research, there is no definite answer to the exact origin of BPSD and their definite treatment, various studies argue for different approaches to treating these symptoms, yet there is no definite conclusion which medication is the most effective and for which reasons. Another crucial aspect to take into account in treating BPSD is that the current medicine and non-traditional treatments are not capable of delaying further onset or eliminating symptoms entirely. They aim at improving activities of daily living (ADL) and quality of life (QOL). In this regard, irrespective of the outlined above clustering of various symptoms and the suggestion of their separate study, in the treatment of the entire disease and orientation of the treatment on the improvement of ADL and QOL, it has to be systematic taking into consideration both drug and non-pharmacological therapies (Brill, 2005).
Some studies of BPSD treatment
In this section, attention is paid to the examples of two approaches to BPSD treatment and their overall potential. The first approach is a pharmacological treatment of BPSD. In this regard, the Korean study on the use of one of the antipsychotics can be shown as an example. The primary purpose of this type of treatment is to decrease or slow down patient’s morbidity, distress of caregivers and consequent institutionalization of patients related to the deterioration of their BPSD (Brill, 2005). In this regard, antipsychotic drugs are used in order to control such symptoms as aggression, fidgeting, paranoia, delusions and hallucinations. As it was mentioned above, the main problem with the use of antidepressants and antipsychotics is that they tend to suppress the symptoms instead of actually treating them. Consequently, the one of the main tasks of the drug research in this field is related to the safety and efficiency considerations (Lillrank, et al., 2007).
The research of Korean doctors of the use of Risperidone in the treatment of the Korean patients aimed at the exploration of how the new antipsychotics affect BPSD and ADL. In this regard, the research of the effect of antidepressants and antipsychotics on the cognitive function and ADL symptoms of Alzheimer patients is essential since the disease and the age of patients result in systematic changes of their health and the drugs can have numerous side-effects unpredicted under the regular circumstances (Brill, 2005). Another aspect that became evident in the research on antidepressants and the antipsychotic prescription is that their efficiency varies across different ethnic groups. In the case of risperidone, the tests demonstrated that the efficacy of BPSD treatment differed across ethnic Groups. For instance, Caucasians were more respondent to the 1mg/day, while Asian group 0.5-0.85 mg/day, and Korean case study showed the optimal effect from the approximate 0.7 mg/day (Jin-Sang Yoon, et al., 2003). Consequently, another challenge of treating Alzheimer and finding a universal treatment is further individualization of treatment effect according to ethnic specifics of one’s organism and likelihood of perceiving a certain drug or not (Jin-Sang Yoon, et al., 2003).
The findings of the Korean research demonstrated that the use of this drug in a small dosage of around 0.5 mg/day was the most effective in influencing behavioral and psychological symptoms without damaging cognitive function and ADL activities. In this regard, it was noted that “risperidone treatment was generally well tolerated, although extrapyramidal symptoms were noted in a dose-dependent pattern” (Jin-Sang Yoon, et al., 2003, p. 631). The significance of these findings is that it confirmed that antipsychotics were effective in the treatment of BPSD without influencing cognitive function and ADL activity if the dosage was chosen correctly and on an individual basis.
The research demonstrated that risperidone was effective in treating such symptoms as hallucinations, delusions, violent and aggressive behavior, fidgeting, sleeping and eating disorders. However, it was not effective in treating anxiety and various phobias. For these symptoms, different drugs were suggested to be effective. Another crucial outcome of this drug use was the improvement of cooperation of patients with caregivers due to the decrease of violent and aggressive behavior:
“Caregivers also reported that patients became less troublesome and dangerous while on risperidone treatment as estimated by Part2: Global rating of the BEHAVE-AD-K. These are encouraging findings for dementia care since no curative or prophylactic drugs are available for cognitive and ADL symptoms of AD” (Jin-Sang Yoon et al.,2003, p. 631).
This research of antipsychotics use for the treatment of BPSD demonstrates the overall issues of the drug approach to BPSD treatment. First of all, the primary problem with drug treatment is the concern of the dosage and safety. In this regard, for the drug to be suitable it should undermine the cognitive function of the body and should not interfere with the activities of daily living. For instance, as it was mentioned above, the antidepressants tend to have significant negative effect on patient’s ability to interact with the surrounding world, making them even more introverted than the disease itself (Lillrank, et al., 2007). Secondly, the issue of efficiency is highly controversial for various drugs due to the individual perception of the drug and also ethnic predisposition for certain types of drugs over the others.
Thirdly, as it was shown in the Korean case study, a single drug is incapable of eliminating all of the BPSD symptoms. Consequently, the issue of drugs compatibility and the prevention of mutually excluding effects becomes another concern in drug treatment. On various occasions, individual sensitivity to drug combinations was resulting in the aggravation of BPSD (Brill, 2005). Fourthly, drugs cannot cure the symptoms but only suppress them and make more tolerable for the patient and his caregivers. Finally, the long-term implications of drug treatment were not studied systematically, but only on the stage of immediate effects on BPSD demonstration.
For the outlined above reasons, an alternative approach to BPSD treatment was developed. Its primary purpose is to reduce the symptoms through non-invasive, non-pharmacological therapies. One of the examples of this type of treatment is art therapy researched by Japanese doctors. In the study that compared the effects of art therapy in contrast to calculation training, the findings showed that it had more positive effect on mental (BPSD) symptoms of dementia (Hattori, 2010). The studied patients were at the earliest stage of the development of disease with the demonstration of the primary psychological and behavioral symptoms.
The finding showed the improvement of patients’ behavior in the art therapy group particularly in terms of the Apathy Scale (P=0.014) and the Mini-Mental State Examination score (P=0.015). In terms of the quality of life, the art therapy group showed a greater improvement than calculation training group (P=0.038) (Hattori, 2010). This study suggests that the use of art therapy which requires concentration and stimulation of unusual brain activity than everyday requirements, the preliminary symptoms of Alzheimer can be slightly improved or at least controlled with the use of this therapy. In this regard, patients demonstrated to be more satisfied with their daily lives, showed signs of interest (reduction of apathy). Their caregivers and family argued to observe positive behavioral changes, more balanced personal integrity decrease in mood swings and irritation (Lillrank, et al., 2007).
The importance of this approach is that the disease’s psychological and behavior symptoms can be affected by non-pharmacological means suggesting that psychological aspect of the treatment has a great potential for development and success at least on the early stage of the progressing of the disease (Brill, 2005). In this regard, the medics are not being delusional about the potential of this approach and argue that it has to be combined with drug treatment of both cognitive and BPSD aspects of the disease.
On the other hand, the problem with combination of treatments and the lack of the clinical research of their diverse combination is the same as in the case of the use of different antidepressants for the different symptoms – they can simply undermine the effects of one another and contribute to the negative outcome of the further development of disease. Another essential factor that needs to be further explored in terms of the non-pharmacological therapies is its effect on various categories of people depending on their occupation, ethnic belonging, age group and plenty of other factors that can affect the efficiency of the therapy (Brill, 2005). For instance, the aforementioned study was conducted for the Japanese population, that is ethnically has a predisposition to creative arts due to the drawing of their hieroglyphs. On the other hand, what would be the effect on the people that are artists by their profession? Thus, the question would be whether the art therapy itself, or the change of activity from the usual to the new one that have a better impact on the BPSD and the quality of life. In any case, both approaches and their systematic application require further profound exploration since no definite answer is available at this stage of scientific development.
Psychological aspect of caregivers and patients
Another essential factor to consider is the relationship between patients and their caregivers. In this regard, since patients gradually become more and more dependent on their caregivers either within the family or the professional nurses, the state of interpersonal relationship and the progressing of disease have tremendous impact on both sides and consequent efficiency and regularity of treatment and care (Zarit and Talley, 2012). Thus, the psychical and psychological condition of caregivers has an impact on the state of the patients.
In terms of the physical symptoms, caregivers often develop negative health conditions as a result of a chronically stressful process, meaning caring after an individual with dementia. According to one study in one of the universities in Indiana (USA) a group of caregivers were tested for the physical effects of caring after Alzheimer patients. The findings demonstrated that 32 % suffered from headaches, 29 % – nervousness, 29 % – insomnia, 26% – gained or lost weight and 22% had various degrees of drowsiness (Mannion 2008). Consequently, since the physical condition of caregivers deteriorates so does their ability to provide the care at the constant level across the entire time of its development.
The situation gets even worse when the psychological aspect of caregivers is addressed. In this regard, caregivers are at risk to develop psychological disorders like depression anxiety: 76 percent are likely to develop anxiety and 42 percent depression (Lillrank, et al., 2007). The severity of psychological disorders largely depends on the stage of the progressing of the disease and consequent complexity of treatment and deterioration of patients’ behavior. In terms of gender differentiation, it is found that female caregivers are more likely to develop a psychological disorder than the male ones. This can be explained from two perspectives. First of all, women are more empathic to the sufferings of other people and are more likely to take their care more emotionally than men. On the other hand, one study demonstrated that women are more likely to spend more time with patients rather than men and thus are more influenced by the patient’s conditions than men caregivers (Mannion 2008).
Another factor to consider is the age factor. Caregivers coping ability demonstrated to be higher with age, while caregivers who experienced psychological disorder before their 30s, often had to face long-term psychological disorders even after the caregiving was over (Zarit and Talley, 2012). The potential dysfunctional relationship between caregiver and the patient often occurs when no preliminary relationship was present, or it was a negative one. In other words, if caregivers and patients were not acquainted before (professional caregivers) or they were in a bad relationship (caregivers within the family), the further treatment and relationship is expected to be a poor one. Some other features to be considered are the following:
“Yamashita and Amagai (2004) found in a qualitative study in Japan that good prior relationships were necessary for successful caregivers…a poor prior relationship with the care recipient predicted depression in the caregiver” (Mannion 2008, p. 31).
Moreover, another explanation of the differentiation of mental conditions among caregivers is the use of different coping strategies. In the study of the most effective coping strategies, it was outlined that an essential element of coping was emotion-focused coping approach. Only when caregivers could abstract their emotional attachment or frustration with the patient’s behavior, they could achieve a more rational perception of the situation and their role in caregiving (Brill, 2005). Another quite common strategy was aimed at avoiding confrontations and accepting personal blame. On the other hand, contemporary psychologists argue that under such circumstances active coping strategies would be the most advantageous for all parties involved. They include such activities as seeking counseling support, expression of emotions and applying stress-relieving practices (Zarit and Talley, 2012).
The issue of the psychological condition of the caregiver is more problematic than just a short-term psychological disorder during the time of caregiving and its negative impact on the patient. When the caregivers get close to their patients or when caregiver is a family member or a spouse, then the psychological effect does not end with patient’s death, resulting in the long-term psychological implications and chronic disorders (Lillrank, et al., 2007). The study of 49 former caregivers of their spouses, 49 current caregivers and 52 individuals that had no caregiving experience demonstrated the following results:
“It was found that even several years after a spouse’s death, former caregivers did not improve in several measures of psychological well-being. Forty one percent of former caregivers had mild to severe depression two to three years after the spouse’s death, which was not significantly different from 43 percent depression rate among current caregivers. By contrast, the depression rate was 15 percent among controls”(Mannion 2008, p. 32).
From the outlined above psychological implications for the caregivers and the overall description of the disease progressing in the deterioration of the BPSD, Alzheimer creates a tremendous concern for the contemporary human society. It is not only one of the primary causes of death in the USA and a type of long-term incurable diseases. It is also a tremendous source of distress and development of psychological and physical disorders for the caregivers and the entire families of the patients (Zarit and Talley, 2012). From the perspective of mental health and psychological well-being, Alzheimer poses a threat to the generational well-being since its impact on families and communities has a domino effect. All the people that knew the patient at his/hers full mental and psychological capacities are traumatized by gradual dissolution of patient’s personality and the time of dying (Brill, 2005).
While the contemporary practitioners begin to pay attention to the physical and psychological conditions of caregivers, in a long run, the problem needs to be assessed on its global scale paying attention to all family members involved. Since when a parent no longer recognizes her/his children, the impact on their lives is far from a light shock or acceptance (Zarit and Talley, 2012). Although at the present stage, national system of welfare is far from being able to cope with psychological counseling for all people affected by the disease, the increasing number of Alzheimer-related psychological disorders among the involved people is a disturbing call for the national psychological well-being. In this regard, while the disease is still far from being cured, at least, the national system of healthcare can treat the psychological aspect of it and prevent people influenced by it from further deterioration of their psychological conditions (Brill, 2005). In other words, if attention to the systematic psychological implications of Alzheimer are addressed in advance, various psychological conditions can be treated on their early stage of development instead of chronic stages when even drug treatment of depression tend to be inefficient.
Overall, from all mentioned above it can be concluded that Alzheimer’s disease is a complex genetically induced disease that has no current cure. Its symptoms are divided between cognitive and behavioral and psychological one. Each category of symptoms requires a different treatment, yet the entire problem has to be treated systematically. From the psychological perspective, although some symptoms can be relatively controlled, the primary challenge is the long-term effect on the patients and their quality of life. The disease also causes tremendous physiological and psychological implications for the caregivers and thus is a threat to the overall national mental and psychological health.
Alzheimer’s Association (2015). What is Alzheimer’s? Retrieved from http://www.alz.org/alzheimers_disease_what_is_alzheimers.asp?type=carecenter_footer.
Brill, M. (2005). Alzheimer’s Disease. New York, NY: Marshall Cavendish Benchmark.
Hattori, H., Hattori, C., Hokao, C., Muzushima, K. and Mase, T. (2011). Controlled study on the cognitive and psychological effect of coloring and drawing in mild Alzheimer’s disease patients. Geriatrics Gerontology International, 11, 431-437.
Jin-Sang Yoon, Kim, J., Lee, H., Shin, I. and Choi, S. (2003). Risperidone use in Korean patients with Alzheimer’s disease: optimal dosage and effect on behavioural and psychological symptoms, cognitive function and activities of daily living. Human Psychopharmacology Clinical and Experimental Journal, 18, 627-633.
Mannion, E. (2008). Alzheimer’s disease: the psychological and physical effects of the caregiver’s role. Nursing Older People, 20(4), 27-32.
Lillrank, S., Collins, C. and Levitt, P. (2007). Psychological Disorders: Alzheimer’s Disease and Other Dementias. New York, NY: Infobase Publishing.
Passmore, P. (2007). Behavioural and psychological symptoms in Alzheimer’s disease. The Journal of Quality research in Dementia, 1. Retrieved from http://www.alzheimers.org.uk/site/scripts/documents_info.php?documentID=77&pageNumber=3.
Zarit, S. and Talley, R. (2012). Caregiving for Alzheimer’s Disease and Related Disorders. New York, NY: Springer.
Time is precious
don’t waste it!