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Diagram 1 shows comparison between a healthy brain and brain with mild and severe Alzheimers disease. (1) http://alzheimersinfo.info/living-with-alzheimers-50-tips-for-caregivers/
Alzheimer's disease (AD) is the most common form of dementia, a brain disorder that affect seriously people's ability to carry out daily activities among older people. Alzheimer's patients easily forget the things that happen recently and feel hard to remember the names the people they ever know. They even can forget how to carry out daily activities. Alzheimer's could happen as a result of impairment of memory, thus disabling reasoning, language, planning and perception. Usually, Alzheimer disease occurs after 60 years old. The probability increases as one gets older. This is a hereditary disease. The risk one will get Alzheimer increases after 70 years old.
Diagram 2 shows numbers of people in the US with Alzheimer's disease for different age groups in 2000 and in the future, 2030 and 2050. (2) http://www.alzalliance.org/aboutalz.htm
So far, there is no treatment for Alzheimer disease. However, I think that by using drugs, we can prevent the symptoms from getting worse for a range of time. In this report, I would like to discuss about this solution.
A Possible Solution
I feel that it is important that a patient should take cholinesterase inhibitors as it is the most effective treatment from stopping the disease from progressing.
Diagram 3 shows the way cholinesterase inhibitors work. (3)
In my opinion, by the using of cholinesterase inhibitors, the actions of the enzyme cholinesterase to break down acetylcholine are impeded and become normal. Hence, the nerve cells in the brain have more acetylcholine. (4)As a result of this, new memories may become easier to form.
Cholinesterase inhibitors are used to treat mild to moderate Alzheimer. One evidences of this is four types of cholinesterase inhibitors are available starting mid-2000. The drugs that are used are donepezil (Aricept®), rivastigmine (Exelon®), galantamine (Reminy®), and tacrine (Cognex®).
However, only tacrine (Razadyne - previously called Reminyl) are used by most physicians as tacrine (Cognex) has more undesirable side effects than the donepezil hydrochloride rivastigmine and galantamine.So far, only rivastigmine and galantamine are only approved by the FDA for mild to moderate Alzheimer's disease, while donepezil is approved for mild, moderate, and severe Alzheimer's disease..(5)
Besides, I think that another type of drugs that could be used to treat Alzheimer's patients is memantine. Memantine is believed to be able to regulate glutamate, an important brain chemical. This drug's main effect is to delay progression of some of the symptoms of moderate to severe Alzheimer Disease (AD).
Memantine, an NMDA receptor antagonist ,
Works on the glutamatergic system. It does this by blocking NMDA glutamate receptors and thus inhibit overstimulation by glutamate.
It decreases the effect of excess glutamate activate nerve cells.
It can block effect of excess glutamate and restore back physiological signal transmission. As a result, signal detection is stabilized and signal detection is enabled.
Excess glutamate has bad effects on brain as it,
Masks signal transmission
Prevented detection of signal in NMDA receptor
Deteriorate nerve cells.
Memantine decreases.the symptoms of Alzheimer which studies show that patients with Alzheimer who take memantine can care for themselves better than patients on sugar pills (placebos). With the treatment of memantine, patients can carry out normal activities a little longer than the patients without the treatment of memantine. For instance, with the medication, memantine may help a patient with severe Alzheimer comb the hair themselves, brash their teeth and bath themselves for several months. This decreases the burden for both the caregiver and patients.
In my opinion, as NMDA antagonist and cholinesterase inhibitors work very differently, they can be combined to be used together.
Social and economic Implications
One of the economic implications that I have encounter is that Alzheimer disease is the most costly disease as its cost is very high-rising. In my perspective, with the increase of ageing of society, the cost also increases, as more of the ageing people are in the countries, more of the Alzheimer cases; hence more of the money is needed to handle it. I can divide the cost related to this disease into few stages that are direct costs in medical form, like nursing home care, or direct non-medical costs, day care and nonmedical costs like lost of productivity of both patients and caregiver. I truly believe that the living cost becomes extremely high when long term of daily care is needed. This is shown when the disease becomes worse, where the patients need longer time to be cared and higher cost for nursing-care is needed.
Cognition and Behavioral change
As people with Alzheimer often develop memory problem at the early stage, I think that they have difficulty in remembering recently learned facts, activities and unable to interpret new information. Regarding the personality, they become apathy, less spontaneous and tend to isolate themselves.
So, I believe that with the progression of the disease, difficulties in learning and memory increase. They are unable to perceive or have difficulties with language, haveproblems in abstract thinking and in other intellectual functions. At this stage their older memory is not very much affected but has difficulties in with new memory. The person begins to have problem when working bills, with understanding the passage and
planning their daily activities. Regarding their behavior, they may become aggressive, anxious and suspicious. They tend to misinterpret what they see or what they hear. In my opinion, this can lead to misunderstanding of both the patients and care-giver.
Table 1 shows the cognition and behavioral change of an Alzheimer's patient from normal, early, moderate to severe Alzheimer. (16)
Retrieved from 'The Alzheimer's Answer Books: Professional Answer to more than 250 questions about Alzheimer's and dementia'
I believe pharmaceutical used as a method of treatment do have benefits. The drugs can prevent the symptoms from progressing within a limited time and provide patients with comfort and dignity. Besides, as the symptoms are prevented from getting worse within a range of time, the patient can be independent for a longer period of time. Their cognition impairments can be improved. This can decrease the care-giving burden as well as the caring cost.
Table 2 shows the effects of using of rivastigmine as approved by the FDA for mild to moderate Alzheimer's disease which help in cognition impairments. (14) http://cme.medscape.com/viewarticle/467554
In addition, cholinesterase inhibitors are used for mild to moderate AD. It helps the symptoms from worsen and control some behavioral characteristics. (7)
Graph1 shows galantamine over 20 weeks which have an effect of preventing the emergence loss of doing ADL (activities of daily living) compared to patients received placebo which shows deterioration in abilities to do activities of daily life. (14) http://cme.medscape.com/viewarticle/467554
Study shows that when the ChEIs was given to th3 patients, the period of looking for NH admission delayed (HR: 0.37, 95% CI 0.27 to 0.49) compared with those who never used cognitive enhancers while with the use of Chels and memantine, the benefit is increases(HR: 0.29, 95% CI 0.11 to 0.72) compare to ChEI alone. (12)
Graph 2 shows that the using of memantine with ChEI to the treatment of AD extending time to nursing home admission. (12) http://jnnp.bmj.com/content/80/6/600.abstract
The most common side effects from taking cholinesterase inhibitors (ChEIs) are nausea, vomiting and increased frequency of bowel movements. These are due to cholinergic excess. Among the users, 10-20% of mild and severe patient will process those side-effects. (6)
For the secondary side-effects, they are muscle cramps, heart rate is decreased. Besides, it also decreases one's appetite and weight and increased gastric acid production in some patients. However, most of the patients (75%-90%) will tolerate therapeutic doses of ChEIs.(5)
Table 3 shows the risks of taking cholinesterase inhibitors. http://cme.medscape.com/viewarticle/467554
In my opinion, the risks of cholinesterase inhibitors are not life threatening. They may be lead the inconvenience to the patient .This is because of the increasing of acetylcholine in the brain. Hence, I think that patients should take cholinesterase inhibitors as the benefits compensate the risks. Besides, memantine causes hallucinations, confusion, dizziness, headache and fatigue. (6)
In addition, it can cause constipation, back pain, increase in blood pressure, vomiting, difficulty in breathing and coughing. The side effects are usually minor and do not need medical treatment. However, if you have hallucinations, allergic reaction, or difficulty in breathing, you should go for a doctor. For mild Alzheimer's patients, they often feel that the drugs are disgusting and unnecessary. This cause the symptoms become worse and they eventually labeled as moderate or severe patients.
In my opinion, the caregivers and patients have to realize the risks of memantine before and during taking it for the better treatment for Alzheimer's patients.
Psychosocial intervention is a room designed for sensory integration therapy, which is an emotion-oriented psychosocial intervention for dementia's patients.
Psychosocial interventions can be classified into (6)
Behavioural interventions which tend to identify and reduce the antecedents and effect of problem behaviours. Behavioural intervention is not helpful in reducing wandering but can help in incontinence.
Emotion-oriented interventions which include
reminiscence therapy(RT) that involved discussion of past experience individually or in a group, with the help of photographs, music or sound recordings and their past's familiar items. This therapy is found to be helpful in cognition and mood.
validation therapy that based on acceptance of reality and personal truth of past experience to help to improve in dementia while sensory integration is exercise that will help in stimulation.
supportive psychotherapy which is helpful in helping mildly impaired Alzheimer patients to adjust their illnesses.
sensory integration(snoezelen) and simulated presence therapy (SPT) which used the method recording and playing the sound and voice of closed relative to the Alzheimer patients.
cognition-oriented which included
Reality orientation which asks the patients to present the information about their place, surroundings, relatives or family.
Cognitive retraining(reduction of cognitive deficits)which improved the impaired ability by exercising their mind. From this treatment, cognitive abilities have been improved.
Stimulation-oriented approaches which consists of art, music and pet therapies, exercise, and any other kinds of recreational activities. This kind of treatment has most improvement in the aspect of behaviour, mood, and, to a lesser extent, function.
Surgery in gene therapy
Besides from drugs, Alzheimer can now be treated by surgery. This surgery is done by surgically implanted modified tissue into the brain of Alzheimer patients and is known as gene therapy protocol for Alzheimer's disease. The surgery is done on a 60-year-old Caucasian woman in the early stages of Alzheimer's disease and she recovered well.
This surgery use human gene therapy to treat Alzheimer. It prevents cell loss in Alzheimer by delivering a natural brain-survival molecule known as nerve growth factor (NGF) to the dying cells in the brain. (8)
It is done by collecting small sample of patients own skin cells and inserting an isolated NGF genes (naturally occurring proteins found in the brains of all vertebrate animals) from nervous system. The genetically engineered cells were cultured for three months. As they underwent mitosis, they produced large quantities of NGF. After confirming the genes has no harmful contaminants, it was implant into the patients' brain.
Although it cannot completely cures the disease, but it is hoped to protect and even restore certain brain cells and alleviate some symptoms, such as short-term memory loss, for a longer period or may be few years. This treatment targets a group of cells located deep in a brain's area known as cholinergic system which function as supporting memory and cognitive function as it is the degeneration of this system which leads to Alzheimer's. By preventing excessive loss of this type of cells, Alzheimer's disease can be improved.(8)
I found that http://www.alzalliance.org/aboutalz.htm is very reliable and factual as the extract below taken is agreed with other similar researchers like the one I found in http://www.alz.org/alzheimers_disease_what_is_alzheimers.asp which state that
This extract is taken from Better Nutrition.
I evaluated this source which proved cholinesterase inhibitors as the main treatment of Alzheimer. This source is reliable because the writer of this article, Ray Shahelian M.D.is the bestselling author of Mind Boosters, The Stevia Cookbook and may other books, which each of them have more than 1,000,000 copies sold. Besides that, Ray Shahelian M.D. is also a nutrition expert which he formulate many superb herbal products like Mind Power Rx and Passion Rx, Eyesight Rx.