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Alzheimer's disease (AD) poses a major clinical challenge because of its high prevalence in the aging population, its prolonged course, and the absence of curative treatment. Important advances have recently been made, however, in the diagnosis of the disease and the elucidation of its neuroscientific basis. Genetic research has identified an allele of apolipoprotein E that may confer a higher risk of developing AD. In addition, new possibilities for treatment are being investigated. One drug therapy--tacrine--has been approved, although uncertainty lingers about its efficacy and safety. In the absence of effective medical treatment, AD is a difficult problem for patients and their families. However, the physician can help by providing emotional support, symptom management, and informed counseling.
Dr. Filley CM. Alzheimer's disease: It's irreversible but not untreatable. Geriatrics 1995; 50(July):18-23. An unfortunate tendency to consider Alzheimer s disease (AD) one of the "untreatable" dementias persists in the medical literature. However, if we required all of our patients to have entirely curable illnesses, few indeed would qualify for treatment. There is no untreatable disease, although AD is among the many that are irreversible. Effective pharmacotherapy may someday be available, but there is much you can do now for AD patients and their families.
Treatment approaches: Counseling, drug therapies
Counseling. After you have excluded reversible causes of dementia by appropriate tests, clarify and explain the diagnosis, even though this initially may be difficult for patients and families to accept. Informed and sympathetic counseling allows for some appreciation of the problems that may arise, the approximate time course of the disease, and what kind of adjustments may be necessary.
As the disease advances, it is important to bring up the issue of advance directives while the patient still has decision-making capacity. The two most common advance directives are the durable power of attorney for health care, which allows a family member or other person to make healthcare decisions in the event of the patient's incapacity, and the living will, which instructs medical personnel to with-old or withdraw death-delaying procedures when the patient is in a terminal state and unable to communicate his or her wishes.
Referral to appropriate community resources, such as the Alzheimer's Association, can provide significant support and further information for patients and families as they grapple with progressive neurobehavioral decline. Educational materials such as The 36-Hour Day and Understanding Alzheimer's Disease are of great help. For legal and financial protection, many families obtain advice from an attorney who is knowledgeable in elder law.
Continuing follow-up of AD patients will usually involve your participation in the resolution of issues such as driving ability, legal competency, nursing home placement, and termination of care; problems such as these highlight the vital role in AD of caregivers--usually the family--who also need your attention as the "second victims" of the disease.
Reflection Exercise #6
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