2nd GROUP DISCUSSION RESULT

NERVOUS SYSTEM

“ALZHEIMER’S DISEASE“

Arpidho Prasetya 105070200131012

Lalatul Purwasih 105070200131013

Awaliya Ramadhan 105070207131005

Hadiyan Raditya 105070201131013

Dannial Bagus S. 105070203131006

Fatimatuzzahroh 105070204131001

Vina Nur Puspitasari 105070201131004

Nurul Kamajaya C A 105070201131014

Muhammad Hafidl H 105070201131016

Titik Tri Ardiani 105070207131001

Resti Lovita 105070200131011

NURSING DEPARTMENT (K3LN)

MEDICAL FACULTY

UNIVERSITY OF BRAWIJAYA

2011

Trigger 3:

Eyang kung dan eyang uti sudah menikah selama 47 tahun. Keduanya

berusia 66 tahun. Kedua anaknya sudah menikah dan tinggal terpisah.

Selama Sembilan bulan terakhir, Eyang Uti tidak dapat mengingat nama

anak-ananknya dan juga nomor telepon mereka. Kesehariannya, semua

aktifitas di rumah di bantu oleh Eyang Kung, bahkan untuk memilih

bajunya pun tidak bisa. Suatu sore, Eyang Kung meminta Eyang Uti untuk

membelikan roti di warung. Namun setelah ditunggu satu jam, Eyang Uti

tidak kunjung pulang. Tetangga menemukan Eyang Uti terlihat gemetar,

bingung, dan berjalan tanpa tujuan yang jelas. Saat diperiksa oleh

perawat, kesadaran baik, afebril, skor MMSE 20/30, mempunyai riwayat

DM tipe 2, TD 160/100 mmHg, N=80x/menit, RR=18x/menit, S=37o C.

Eyang Kung mengatakan kesulitan merawat Eyang Uti dengan kondisi

seperti ini. Dokter menginstruksikan pemberian anti-kholinesterase dan

anti-hipertensi.

1st Group Discussion:

A. Keyword

- Can’t remember her sons’/ daughters’ name

- Eyang Kung and Eyang Uti are 66 y.o

- Afebril

- Given anti-cholinesterase and anti-hypertensi as treatment

- Eyang Uti was helped by Eyang Kung to do her daily activity

- Eyang Uti is female

- They live separately from their sons/ daughters

- MMSE score: 20/30

- Tremble, confuse, walk without destination

- Has DM type 2

- TTV ( BP = 160/100 mmHg, Pulse = 80/ mnt, RR = 18/ mnt, T =

37,5o C)

- Eyang Kung get difficulty for giving care to Eyang Uti

- Consciousness = compos mentis, GCS 15

B. Questions

- Is there a relation between DM type 2 with this disease?

- Is there a relation between high blood pressure with this disease?

- Do age and gender influence this disease?

- What is causes this disease?

- What is the mean of MMSE score 20/30?

- Is there a relation between keyword no. 2 and 9?

- What is the indication of giving anti-cholinosterase?

- Is this disease acquired or genetic?

- What is the nurses’ role?

- What is the disease?

- Is there a time to be forgetting something?

- Does marriage status influence this disease?

C. Hypothesis

- Definition : Alzheimer’s disease

- Etiology : Age, gender, past history, genetic, etc.

- Pathway :DM Type 2/ other factor nerve impairment

Alzheimer’s wandering/ trembling.

D. SLO

- Definition

- Etiology

- Pathophysiology

- Epidemiology

- Clinical manifestation

- Diagnostic test

- Implementation

- Nursing care

E. Diagnosa (Nursing Care)

- Chronic confusion f.r Alzheimer’s

- Wandering f.r cognitive impairment

- Self care deficit f.r cognitive impairement

- Caregiver role strain f.r receiver cognitive impairment

2nd Group Discussion:

1. Definition

Alzheimer’s disease is a disease of the brain cause problems with

memory, thinking, and behavior. It is not a normal part of aging.

Alzheimer's disease (AD) is the most common form of dementia among

older people. Dementia is a brain disorder that seriously affects a

person's ability to carry out daily activities.

2. Epidemiology

Alzheimer's disease can occur at any age, 96% of cases found after

40 years of age or older. Schoenburg and Coleangus (1987) reported

incidence by age: 4.4 / 1000.000 at the age of 30-50 years, 95.8 /

100,000 at age> 80 years. The revalence of this disease per 100,000

population about 300 in the age group 60-69 years, 3200 in the age

group 70-79 years, and 10 800 at age 80. It is estimated that in 2000

there were 2 million people with Alzheimer's disease. While in Indonesia

estimated the number of old age range, 18.5 million people with the

incidence and prevalence of Alzheimer's disease is not known with

certainty.

Based on gender, the prevalence of three times more women than

men. This may be a reflection of women's life expectancy longer than

men. From some studies no differences for gender.

The World Health Organization estimated that in 2005, 0.379% of

people worldwide had dementia, and that the prevalence would

increase to 0.441% in 2015 and to 0.556% in 2030. Other studies have

reached similar conclusions. Another study estimated that in 2006,

0.40% of the world population (range 0.17–0.89%; absolute number

26.6 million, range 11.4–59.4 million) were afflicted by AD, and that the

prevalence rate would triple and the absolute number would quadruple

by 2050.

3. Etiology

The exact cause of AD is inknown. Several causes which have

been (dihipotesa) is metal intoxication, impaired immune function,

infection viruses, air pollution/industrial, trauma, heriditer predispotition,

etc.

There’s some risk factor:

- Age

The greatest known risk factor for Alzheimer’s is increasing age.

Most individuals with the illness are 65 and older. The likelihood

of developing Alzheimer’s approximately doubles every five

years after age 65. After age 85, the risk reaches nearly 50

percent.

- Family history

Risk of Alzheimer's that appears slightly higher if first-degree

relatives - parents and siblings - have Alzheimer's.

- In additional to aging and genetic factors, all the following have

been documented as risk factors for Alzheimer’s disease:

- DM type 2

- Head injury

- Stroke and mini-stroke

- High cholesterol level

- High blood pressure

- Down syndrome

- Chronic inflammatory condition

- History of depression

- Stress

- Lack of physical exercise

- Inadequate brain exercise

- Unhealthy consumption

- Obesity

- Gender

Women are more susceptible than men, this is because women

generally live longer than men.

- Mild cognitive impairment (MIC)

People who have mild cognitive impairment have memory

problems that get worse than what might be expected at his age

and has not been bad enough to classify as dementia. Many of

those who are in this condition continues to have Alzheimer's

disease.

- Lifestyle

Same factors that made you are at the same risk of heart

disease also increases the likelihood you will get Alzheimer's

disease.

- Level of education

Some scientists theorize, the more often you use your brain

synapses will be more that you create will be available where a

lot of reserves in the old days. It would be difficult to find the

Alzheimer's brain in people who train regularly, or those who

have higher education levels.

4. Pathophysiology

5. Clinical Manifestation

There are 10 warning signs of Alzheimer’s disease:

a. Memory loss that disrupts daily life

One of the most common signs of Alzheimer’s disease, especially in

the early stages, is forgetting recently learned information. Others

include forgetting important dates or events; asking for the same

information over and over; and relying on memory aides (e.g.,

reminder notes or electronic devices) or family members for things

they used to handle on their own.

b. Challenges in planning or solving problems

Some people may experience changes in their ability to develop and

follow a plan or work with numbers. They may have trouble following

a familiar recipe or keeping track of monthly bills. They may have

difficulty concentrating and take much longer to do things than they

did before.

c. Difficulty of completing familiar tasks at home

People with Alzheimer’s disease often find it hard to complete daily

tasks. Sometimes, people have trouble driving to a familiar location,

managing a budget at work or remembering the rules of a favorite

game.

d. Disorientation time and place

People with Alzheimer’s can lose track of dates, seasons and the

passage of time. They may have trouble understanding something if

it is not happening immediately. Sometimes they may forget where

they are or how they got there.

e. Trouble understanding visual images and spatial relationships

For some people, having vision problems is a sign of Alzheimer’s.

They may have difficulty reading, judging distance and determining

color or contrast. In terms of perception, they may pass a mirror and

think someone else is in the room. They may not realize they are the

person in the mirror.

f. Have problem with words in speaking or writing

People with Alzheimer’s may have trouble following or joining a

conversation. They may stop in the middle of a conversation and

have no idea how to continue or they may repeat themselves. They

may struggle with vocabulary, have problems finding the right word

or call things by the wrong name (e.g: calling a watch a “hand

clock”).

g. Misplacing things and losing the ability to retrace steps

A person with Alzheimer’s disease may put things in unusual places.

They may lose things and be unable to go back over their steps to

find them again. Sometimes, they may accuse others of stealing.

This may occur more frequently over time.

h. Decreased or poor judgement

People with Alzheimer’s may experience changes in judgment or

decision making. For example, they may use poor judgment when

dealing with money, giving large amounts to telemarketers. They

may pay less attention to grooming or keeping themselves clean.

i. Withdrawal from work or social activities

A person with Alzheimer’s may start to remove themselves from

hobbies, social activities, work projects or sports. They may have

trouble keeping up with a favorite sports team or remembering how

to complete a favorite hobby. They may also avoid being social

because of the changes they have experienced.

j. Changes in mood and personality

The mood and personality of people with Alzheimer’s can change.

They can become confused, suspicious, depressed, fearful or

anxious. They may be easily upset at home, at work, with friends or

in places where they are out of their comfort zone.

Stage of Alzheimer’s disease

According to National Alzheimer’s Association (2011), there are 7

stages of AD:

Stage 1: No impairment (normal function)

The person does not experience any memory problems. An interview

with a medical professional does not show any evidence of symptoms

of dementia.

Stage 2: Very mild cognitive decline (may be normal age-related

changes or earliest signs of Alzheimer's disease)

The person may feel as if he or she is having memory lapses —

forgetting familiar words or the location of everyday objects. But no

symptoms of dementia can be detected during a medical examination

or by friends, family or co-workers.

Stage 3: Mild cognitive decline (early-stage Alzheimer's can be

diagnosed in some, but not all, individuals with these symptoms)

Friends, family or co-workers begin to notice difficulties. During a

detailed medical interview, doctors may be able to detect problems in

memory or concentration. Common stage 3 difficulties include:

- Noticeable problems coming up with the right word or name

- Trouble remembering names when introduced to new people

- Having noticeably greater difficulty performing tasks in social or

work settings Forgetting material that one has just read

- Losing or misplacing a valuable object

- Increasing trouble with planning or organizing

Stage 4: Moderate cognitive decline (Mild or early-stage

Alzheimer's disease) 

At this point, a careful medical interview should be able to detect clear-

cut symptoms in several areas:

- Forgetfulness of recent events

- Impaired ability to perform challenging mental arithmetic — for

example, counting backward from 100 by 7s

- Greater difficulty performing complex tasks, such as planning

dinner for guests, paying bills or managing finances

- Forgetfulness about one's own personal history

- Becoming moody or withdrawn, especially in socially or mentally

challenging situations

-

Stage 5: Moderately severe cognitive decline (Moderate or mid-

stage Alzheimer's disease)

Gaps in memory and thinking are noticeable, and individuals begin to

need help with day-to-day activities. At this stage, those with

Alzheimer's may:

- Be unable to recall their own address or telephone number or

the high school or college from which they graduated

- Become confused about where they are or what day it is

- Have trouble with less challenging mental arithmetic; such as

counting backward from 40 by subtracting 4s or from 20 by 2s

- Need help choosing proper clothing for the season or the

occasion

- Still remember significant details about themselves and their

family

- Still require no assistance with eating or using the toilet

Stage 6: Severe cognitive decline (Moderately severe or mid-stage

Alzheimer's disease)

Memory continues to worsen, personality changes may take place and

individuals need extensive help with daily activities. At this stage,

individuals may:

- Lose awareness of recent experiences as well as of their

surroundings

- Remember their own name but have difficulty with their personal

history

- Distinguish familiar and unfamiliar faces but have trouble

remembering the name of a spouse or caregiver

- Need help dressing properly and may, without supervision,

make mistakes such as putting pajamas over daytime clothes or

shoes on the wrong feet

- Experience major changes in sleep patterns — sleeping during

the day and becoming restless at night

- Need help handling details of toileting (for example, flushing the

toilet, wiping or disposing of tissue properly)

- Have increasingly frequent trouble controlling their bladder or

bowels

- Experience major personality and behavioral changes, including

suspiciousness and delusions (such as believing that their

caregiver is an impostor)or compulsive, repetitive behavior like

hand-wringing or tissue shredding

- Tend to wander or become lost

Stage 7: Very severe cognitive decline (Severe or late-stage

Alzheimer's disease)

In the final stage of this disease, individuals lose the ability to respond

to their environment, to carry on a conversation and, eventually, to

control movement. They may still say words or phrases.

At this stage, individuals need help with much of their daily personal

care, including eating or using the toilet. They may also lose the ability

to smile, to sit without support and to hold their heads up. Reflexes

become abnormal. Muscles grow rigid. Swallowing impaired.

6. Diagnostic Test

a. Neuropathology

It’s generally obtained a bilateral atrophy, symmetrical, often heary

brain revolves about 1000 gr.

b. Neuropsychology

To assess the presence of dysfunction of general cognitive and to

know the detail of pattern of deficit. Also aims to assess the function

of some parts of the brain such as memory, loss of expression,

calculation, attention, and understanding language.

c. CT Scan, MRI, EEG, PET, SPECT

d. CBC, urinalysis, electrolyte serum, Ca2+, liver function.

e. Lumbal punction

f. Genetic screening

7. Implementation

FDA-approved treatments:

Two types of drugs are currently approved by the U.S Food and

Drug Administration (FDA) to treat cognitive symptoms of

Alzheimer’s disease.

1) Cholinesterase inhibitors, are designed to prevent the

breakdown of acetylcholine, a chemical messenger important for

memory and learning. By keeping levels of acetylcholine high,

these drugs support communication among nerve cells. They

delay worsening of symptoms for six to 12 months for about half

of those who take them.

Three cholinesterase inhibitors are commonly prescribed:

- Donepezil (Aricept®), approved in 1996 to treat mild-to-

moderate Alzheimer’s, and in 2006 for the severe stage

- Rivastigmine (Exelon®), approved in 2000 for mild-to-

moderate Alzheimer’s

- Galantamine (Razadyne®), approved in 2001 for mild-to-

moderate stages

2) Regulating the activity of glutamate, a different messenger

chemical involved in information processing:

- Memantine (Namenda®), approved in 2003

Memantine is the only currently available drug in this class.

Approved for treatment of moderate-to-severe Alzheimer’s

disease, memantine may also temporarily delay the

worsening of symptoms for some people.

3) Vitamin E

Doctors sometimes prescribe vitamin E for cognitive symptoms

of Alzheimer’s disease. One large federally funded study

showed that vitamin E slightly delayed loss of ability to carry out

daily activities and placement in residential care.

Scientists think that vitamin E may work because it is an

antioxidant (an-tee-OX-uh-dent), a substance that may protect

cells from certain kinds of chemical wear and tear.

No one should use vitamin E to treat Alzheimer’s disease except

under the supervision of a physician. The doses used in the federal

study were relatively high, and vitamin E can negatively interact

with other medications, including those prescribed to prevent blood

from clotting.

8. Nursing Care

A. Assessment

- Name : Eyang Uti

- Age : 66 y.o

- Sex : Female

- Race : -

- Religion : -

- Marriage status : Married

- Address : -

- Main problem : wandering, trembling, confuse, can’t

remember sons’/daughters’ name and phone number.

- Current problem : Eyang Uti can’t remember her

sons’/daughters’ name and phone number for 9 months. She

was helped by Eyang Kung to do her daily activities even to

choose her clothes. Eyang uti wandered and found in trembling

condition, confused, and walk without destination.

- History : DM type 2

Physical assessment:

- General condition:

consciousness = compos mentis, GCS = 15, tremble, confuse.

- Sense:

Eye (N)

Mouth (N)

Ear (N)

Tongue (N)

Nose (N)

- Respiration : RR = 18/mnt

- Cardiovascular : BP = 160/100 mmHg, pulse = 18/mnt

- Digestion : (N)

- Urogenital : (N)

- Integument : (N)

- Musculoscetal : (N)

- Endokrin : (N)

B. Analytical dates

Data Etiology Problem

DO: -

DS: Helped by

eyang Kung to do

her activities,

even choose her

clothes

Predispotition factor

decreasing of metabolism

and bloodstream

degeneration of

neuronkoligenik difuse

neurofiblar damaged / loss

of koligenic nerve cells

plac sentis / decreasing of

koligenic nerve cells

neurotransmitter impairment

antikolin decrease

alzheimer’s decreasing of

self care ability self care

deficit

Alzheimer’s weird

behaviour, like to wander

Wandered

Alzheimer’s forgetful

convulsive chronic

confusion

Alzheimer’s Self care

deficit/ lost abilities to solve

problem/ wandering/ etc.

66 y.o caregiver

Self care deficit

DO: -

DS: trembled,

confused, walked

w/o destination

Wandering

DO: -

DS: confuse, walk

w/o destination,

can’t remember

her sons’/

daughters’ name

and their phone

number.

Chronic

confusion

DS: -

DO: Eyang Uti

must be helped

Caregiver role

strain

by Eyang Kung,

Eyang Kung is 66

y.o, Eyang Kung

said that have

difficulty to give

care to Eyang Uti

caregiver role strain

C. Diganosis

1) Chronic confusion r.f Alzheimer’s disease

2) Wandering r.f cognitive impairment

3) Self care deficit r.f cognitive disorder

4) Caregiver role strain r.f cognitive problem of receiver

D. Intervention

1) Chronic confusion r.f Alzheimer’s disease

Aims: Maintain or improve concentration, memory, and thought

control.

Expected Outcomes:

- Client will responds to the visual cue and hearing cue.

- Client can have interaction to other people

Intervention and rational:

a. Determine the underlying cause for chronic confusion, as

noted in Related Factors.

Helps to sort out possible causes and likelihood for

improvement, as well as helping to identify potentially

useful interventions and therapies.

b. Review and evaluate responses on diagnostic examinations

(e.g., cognitive, functional capacity, behavior, memory

impairments, reality orientation, attention span, quality of life).

A combinationof tests (e.g., Confusion Assessment

Method [CAM], Mini-Mental State Examination [MMSE],

Alzheimer’s Disease Assessment Scale [ADAS-cog], Brief

Dementia Severity RatingScale [BDSRS],

Neuropsychiatric Inventory [NPI], Functional Assessment

Questionnaire [FAQ], Clinical Global Impression of

Change [CGIC]) is often needed to complete an

evaluationof client’s overall condition relating to chronic or

irreversible condition.

c. Monitor for treatable condition

That may contribute to or execrable distress, discomfort,

and agitation

2) Wandering r.f cognitive impairment

a. Review responses of collaborative diagnostic examinations

A combination is often needed to complete an evaluation

of client’s overall.

b. Determine presence of depression

Research support the idea that wandering develops more

often in depression client with AD.

c. Identify client’s reason for wandering if possible

d. Determine bowel and bladder elimination pattern, timing of

incontinence

For possible colleration to wandering behaviour.

e. Monitor activity when hospitalized or admitted to facility

3) Self care deficit r.f cognitive disorder

a. Allow sufficient time for dressing and undressing

Because tasks may be tiring, painful, and difficult to

complete.

To allow for easier manipulation of clothing.

b. Teach to dress affected side first, then unaffected side

4) Caregiver role strain r.f cognitive problem of receiver

a. Inqure about and observe physical condition of care receiver

and surroundings as appropriate.

Important to determine factors that may indicate problems

that can interfere with ability to continue caregiving.

b. Assess caregivers current state of function

Provides basis for determining needs that indicate

caregiver is having difficulty dealing with role.

c. Note presence of high situations

Elderly client with total self care dependence due to

physical condition or developmental delays may

necessitate role reversal resulting in addedstress or

placing excessive demands on parenting skills

References:

Dongoes, Marylin E. 2000. Rencana Asuhan Keperawatan. Jakarta, EGC.

Muttaqin, Arif. Buku Ajar Asuhan Keperawatan dengan Gangguan System

Persyarafan. Jakarta, Salemba.

National Alzheimer’s Association. 2011. 7 Stages of Alzheimer’s.

http://www.alz.org accessed 6-12-2011.

http://zulliesiskawati.staff.ugm.ac.id accessed 6-12-2011.

Alzheimer’s Disease Education and Referral Center. 2010. Alzheimer’s

Disease Medications, US Department of Health and Human Service:

National Institute on Aging. http://www.nia.nih.gov accessed 5-12-

2011.

Corwin, Elizabeth J. 2008. Buku Saku Patofisiologi. Jakarta. EGC.

NANDA International 2009-2011