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+ +++++++++++++++++++++++++++++++++++++++++ + +++ +++ +++++++++++++++++++++++++++++++++++++++++ SPECIAL SECTION: NEUROSCIENCE Memory Loss: Distinguishing Pathology from Normal Aging By Debbie Borowske, DNP, RN, GCNS-BC rently affl icting over fi ve million people in the U.S. according to recent statistics issued by the Alzheimer's Association. Mainly, it affects older individuals, with a cost of over 10 billion dollars annually in the U.S. The prevalence of dementia is greater than 40% for individuals over the age of 85. Characterized most notably by memory loss and progressive loss of executive function with the lack of ability to perform activities of daily living, the burden on caregivers and the health care system is enormous. The pathophysiology and neuropathol- A ogy of AD are amalyoid plaques and neurofi brillary tangles in the cerebral cortex, which disrupt cerebral neuronal circuits and result in the symptoms com- monly seen with AD. There is currently no laboratory test which identifi es AD. The clinical, pathologic and radiologic criteria for diagnosis are those of the Diagnostic Manual of Mental Disorders, Fourth Edition (DSMIV) and those developed in 1984 by a joint task force on the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimer's Disease and Related Disorders Association. They consist of: neuropsychological examina- tion with an in-depth exploration of an individual's performance in a wide range of functional domains along with heavy reliance on interviews exploring symptom and behavior history. Magnetic Resonance Imaging (MRI), imaging with Positron Emission Tomography (PET), and cerebrospinal fl uid (CSF) analyses, which identify structural and molecular LZHEIMER'S DEMENTIA (AD), the most prevalent form of dementia, is rapidly emerging as a public health issue, cur- biomarkers, are used to confi rm the pres- ence of at least one abnormal biomarker. Often, confi rmation of AD is delayed. Reluctant to confirm the presence of pathology, patients and family members often attribute early signs of cognitive impairment to "normal aging." Memory loss, particularly short term, is the most common presenting symptom. A precur- sor to AD, Mild Cognitive Impairment (MCI), which slightly affects the ability to perform ADLs, has been shown to progress to full AD at 12% annually. Ignoring the early signs, families often wait until advanced symptoms (agita- tion, paranoia, psychosis, delusions and insomnia) are problematic before seeking health care advice. Sleep disturbances, which include nighttime awakening and early morning awakening, often serve as a primary catalyst for caregivers to seek treatment for their spouse or parent. Over 100 years since its discovery, AD remains progressive and ultimately fatal. Currently, no therapy has been proven to slow the biologic progression of the disease. While the cure for AD remains elusive, earlier diagnosis could benefi t in the establishment of safeguards and planning for the future. Similar to any other progressive, chronic disease, optimal advanced care planning involves patient and family understanding of disease trajectory, treatment options, and goal setting. Although a number of medications have been approved for treat- ment, such as donepezil, galantamine, rivastigmine, and Memantine, they are not curative. Death typically occurs four to six years after initial diagnosis. Patient education to reduce risk factors is warranted with a burgeoning aging population. Multiple studies have shown 30 | Cleveland-Akron-Canton MD NEWS MDNEWS.COM SEPTEMBER-OCTOBER 2011 a strong association between metabolic syndrome and vascular risk factors, specifi cally diabetes mellitus, insulin resistance, high cholesterol, hyperten- sion, reduced exercise, and obesity as risk factors for AD. Plus, identifi cation of early signs of AD or MCI could position the physician to initiate discussions on advanced care planning. Studies have shown end-of-life (EOL) care for AD patients often results in aggressive, medically futile treatments, such as insertion of feeding tubes and artifi cial hydration due to the family's lack of knowledge and preparation with the AD disease trajectory and failure to identify the patient's wishes when cogni- tive competency was present. Patients and their caregivers look to the medical experts to educate them on health care prevention and disease process. While the outcome of AD is fatal, patients and their caregivers can still be helped by honest discussions which allow them to be empowered to live the life they have left to their fullest, and when independence is no longer possible, to leave their loved ones with a roadmap that details their wishes. The burden of caregiving is clear. Yet, to "know" one is executing care according to what one's loved one wanted, eases the burden and allows the caregiver to be at peace with the diffi cult decisions that present as independent functionality ceases for the AD patient. Dr. Debbie Borowske is director of Community Health, Geriatric Services and Home Health, and Hospice Services at Southwest General Health Center. Additionally, she is a member of the Adjunct Faculty at Kent State University, College of Nursing. n