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Alzheimer’s Disease and Reality Orientation Therapy

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Contact Hours: 2

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Course Purpose   

The purpose of this course is to provide an overview of Alzheimer’s disease, the importance of early diagnosis, and possible treatment modalities to delay cognitive decline.

Overview 

Alzheimer’s disease is an irreversible neurological disorder that likely develops from multiple factors such as genetics, lifestyle, and environment. The success of Alzheimer’s disease treatment is dependent on early diagnosis, monitoring for disease progression, treatment modalities, and the presence of other medical conditions. This course provides an overview of Alzheimer’s disease, diagnosis, treatment options, and an introduction to reality orientation to help slow cognitive decline.

Objectives

Upon completion of this course, the learner will be able to: 

  • Define Alzheimer’s disease
  • Describe medical tests commonly used to aide in the diagnosis of Alzheimer’s disease
  • Review medications commonly used to treat Alzheimer’s disease
  • Describe the stages of mild cognitive impairment as they relate to Alzheimer’s disease
  • Understand the common forms of Reality Therapy 

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Disclosures

Fast CE For Less, Inc. and its authors have no disclosures. There is no commercial support. 

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Definitions
Alzheimer’s DiseaseA brain disorder that slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks.
Cholinesterase InhibitorsA group of medicines that block the normal breakdown of acetylcholine. Acetylcholine is the main neurotransmitter found in the body and has functions in both the peripheral nervous system and the central nervous system.
DementiaThe loss of cognitive functioning; thinking, remembering, and reasoning, to such an extent that it interferes with a person’s daily life and activities.
MemantineAn NMDA Receptor Antagonists that is used to treat moderate to severe confusion (dementia) related to Alzheimer’s disease.
Mild Cognitive ImpairmentThe stage between the expected cognitive decline of normal aging and the more serious decline of dementia.
NeuronsThe fundamental units of the brain and nervous system, the cells responsible for receiving sensory input from the external world, for sending motor commands to our muscles, and for transforming and relaying the electrical signals at every step in between.
NMDA Receptor AntagonistsA class of drugs that work to antagonize, or inhibit the action of, the N -Methyl- D -aspartate receptor (NMDAR), which can treat memory loss and brain damage associated with Alzheimer’s disease.
N-Methyl-D-Aspartate Receptor (NMDAR)A glutamate receptor and ion channel found in neurons.
Reality Orientation TherapyA program that is utilized to improve the cognitive function in people who are disoriented or confused.
Reminiscence TherapyAlso known as life review therapy, It is often used to treat severe memory loss or dementia and works by encouraging people to revisit moments from their past.
Introduction

Alzheimer’s disease (AD) is an irreversible neurologic disorder that causes the brain to shrink and brain cells to die. The brain will shrink to some degree with aging, but it usually does not lose neurons in large numbers. In Alzheimer’s disease, many neurons stop functioning because of losing connections with other neurons, causing neuron death. This results in shrinkage of brain regions and brain atrophy, which causes a significant loss in brain volume. Despite technological advancement and extensive research, no treatment option is available to cure AD. It mainly occurs in older people, and it is the most common cause of dementia, accounting for up to 80% of cases. Alzheimer’s disease progression can start years before symptoms appear. Often, therapies may slow disease progression, but they will not be effective in eliminating Alzheimer’s disease altogether.2 The time that it may take to develop symptoms is determined by factors such as age, genetics, and sex.2 This course will focus on the overview of Alzheimer’s disease and the use of reality orientation therapy in its treatment.

Neuron Function

The healthy brain consists of billions of neurons that connect with each other to send messages between different parts of the brain, and from the brain to the muscles and organs of the body. The healthy brain will usually shrink with age progression, but it does not typically lose neurons in large numbers as with Alzheimer’s disease. In AD, the connection between the network of neurons is disrupted, resulting in the breakdown of neurons, loss of neuron function, and neuron death. The death of neurons results in shrinkage of regions of the brain, causing atrophy. Alzheimer’s disease disrupts processes vital to neurons and their networks, including communication, metabolism, and repair.

At first, AD typically destroys neurons and their connections in parts of the brain involved in memory, including the entorhinal cortex and hippocampus. It later affects areas in the cerebral cortex responsible for language, reasoning, and social behavior. Eventually, many other areas of the brain are damaged. Over time, a person with Alzheimer’s gradually loses their ability to live and function independently. Ultimately, the disease is fatal.

Diagnosis

Early diagnosis of AD is always best so that treatment can be initiated, behavioral symptoms can be treated, and lifestyle changes can be modified to slow disease progression.6

In 2011, the clinical diagnostic criteria for Alzheimer’s disease dementia were revised, and research guidelines for earlier stages of the disease were characterized to reflect a deeper understanding of the disorder. The new guidelines were developed by the National Institutes of Health and the Alzheimer’s Association.7

Following are changes made to the 2011 guidelines from the 1984 diagnostic criteria:7

  • Expand the criteria for Alzheimer’s dementia beyond memory loss as the first or only major symptom. 
  • Recognize that Alzheimer’s disease progresses on a spectrum with three stages; an early, preclinical stage with no symptoms; a middle stage of mild cognitive impairment; and a final stage marked by symptoms of dementia. 
  • Recognize the potential use of biomarkers, and other indicators of underlying brain disease to diagnose Alzheimer’s disease. 
  • Reflect a better understanding of the distinctions and associations between Alzheimer’s and non-Alzheimer’s dementias, and between Alzheimer’s and disorders that may influence its development, such as vascular disease. 

Medical Tests to Diagnose Alzheimer’s Disease

There is no single diagnostic approach to follow to diagnose Alzheimer’s disease.9 The standard for the diagnosis of mild cognitive impairment (MCI), as well as for dementia, is a structured history focused on cognitive and functional changes and corroboration from a person familiar with the person experiencing symptoms.10 A detailed medical, psychiatric, and substance use history is conducted to assess for other etiologies such as medication side effects, depression, alcohol or substance dependence, and delirium. A physical examination, including a full neurological examination should also be performed, looking for acute and chronic illness.10

Listed in the table below are some common medical tests to diagnose Alzheimer’s disease.9,10

Medical testsCharacteristics
Neurological exam Reflexes, coordination, muscle tone and strength, eye movement, speech, and sensation are tested. May also include a brain imaging study.
Mini-Mental State Exam (MMSE)A series of questions designed to test various everyday mental skills.The maximum score is 30 points. A score of 20 to 24 suggests mild dementia, 13 to 20 suggests moderate dementia, and less than 12 indicates severe dementia.
Montreal Cognitive Assessment (MoCA)Designed to be more sensitive and specific for MCI and early AD than the MMSE, more useful for moderate and severe dementia. 
Brain imaging Includes structural imaging with magnetic resonance imaging (MRI) or computed tomography (CT).
Cerebrospinal fluid (CSF) testsUsed by dementia specialists to diagnose Alzheimer’s.One CSF Amyloid Ratio test, Lumipulse®, received FDA approval and is a new diagnostic tool that healthcare professionals can use to detect amyloid in CSF, which can be predictive of amyloid changes in the brain.
Blood tests Blood tests are simple, inexpensive, non-invasive, and easily available diagnostic tools.The currently available tests may predict the presence of amyloid changes in the brain or the presence of neurodegenerative disease or neuronal damage.

The gold standard for diagnosing mild cognitive impairment is clinical history with corroboration from a person familiar with the person experiencing symptoms. There are no definitive diagnostic tests for MCI, and neuropsychological tests and laboratory or brain imaging findings should be interpreted in conjunction with the healthcare professional’s history and assessment.10

Stages

The 2011 diagnostic guidelines describe three stages of Alzheimer’s disease that are reported by the National Institutes of Health and the Alzheimer’s Association:7

Preclinical (Presymptomatic)

In the preclinical stage, a person may have nerve cell changes that cause very mild symptoms; however, family and friends may be acutely aware of the symptoms. People in this stage will have diagnostic evidence of having AD.8 Common symptoms in this stage include: 7

  • Difficulty producing the right word or name.
  • Experiencing increased trouble with planning or organizing.
  • Forgetting material that was just read.
  • Having difficulty performing tasks in social or work settings.
  • Losing or misplacing a valuable object.
  • Difficulty remembering names when introduced to new people.

Mild Cognitive Impairment

The mild cognitive impairment (MCI) stage is typically the longest stage and can last for many years. In this stage, a person will have impairment in either memory or nonmemory domains, such as executive ability or language function. Initially these individuals may continue to work, socialize, and function independently, but this is likely to decline as AD progresses. People with MCI may progress to dementia at a rate of 10% per year, however, risk factors for progression to dementia and the severity of impairment at the time of diagnosis can greatly influence the prognosis of Alzheimer’s disease.8 

The following symptoms should be considered for MCI: 7

  • Being forgetful of events or personal history.
  • Being unable to recall information such as their address or telephone number, and the high school or college attended.
  • Demonstrating personality and behavioral changes, including suspiciousness and delusions or repetitive behavior like handwringing or tissue shredding.
  • Experiencing changes in sleep patterns, such as sleeping during the day and becoming restless at night.
  • Experiencing confusion about the time, day, or location.
  • Feeling moody or withdrawn, especially in socially or mentally challenging situations.
  • Having trouble controlling their bladder and bowels.
  • Requiring help choosing proper clothing for the season or the occasion.
  • Showing an increased tendency to wander and become lost.

To determine that MCI is due to Alzheimer’s disease, a healthcare professional must rule out other brain diseases or other causes such as medications, depression, or significant life changes that could account for cognitive decline.7

Dementia

In the dementia stage, symptoms are severe, and a person will have incapacitating memory impairment. They will lose the ability to carry on a conversation, respond to their environment, and will eventually lose control of their body movements.8 

Up to 40% of people in this stage will experience delusions. Visual hallucinations are more common, although they can also have auditory and olfactory hallucinations. Disruptive behaviors occur in almost 50% of people with dementia. They also may experience disruptive sleep patterns and have fragmented sleep. 8 In this stage, people may also have the following: 7

  • Become vulnerable to infections, especially pneumonia.
  • Experience changes in physical abilities, including walking, sitting and, eventually, swallowing.
  • Have difficulty communicating.
  • Lose awareness of recent experiences as well as of their surroundings.
  • Require around-the-clock assistance with daily personal care.

The person living with Alzheimer’s may not be able to initiate engagement as much during the dementia stage, but they can still benefit from interaction in ways that are appropriate, like listening to relaxing music or receiving reassurance through gentle touch.

Treatment Options

There is no cure for Alzheimer’s disease. Only symptomatic treatment is available.8 There are two categories of drugs approved for treating Alzheimer’s disease: cholinesterase inhibitors and partial N-methyl D-aspartate (NMDA) antagonists.13

Cholinesterase Inhibitors

Cholinesterase inhibitors increase the level of acetylcholine, a chemical used by nerve cells to communicate with each other that is important for learning, memory, and cognitive functions. Three drugs in this category; donepezil, rivastigmine, and galantamine, are FDA-approved for treating Alzheimer’s disease.8

Drug NameCharacteristics
Donepezil Donepezil binds to acetylcholinesterase reversibly and inhibits acetylcholine hydrolysis, leading to a higher ACh concentration at the synapses.13 The drug is well-tolerated with mild and transient cholinergic side effects related to the gastrointestinal and nervous systems.13
Rivastigmine Rivastigmine is a pseudo irreversible inhibitor of AChE and butyrylcholinesterase (BuChE) that binds to the two active sites of AChE (anionic and stearic sites), which results in preventing ACh metabolism.13The drug is used in mild to moderate AD cases. It improves cognitive functions and daily life activities.13Oral administration is associated with adverse effects like nausea, vomiting, dyspepsia, asthenia, anorexia, and weight loss.13 
Galantamine Galantamine (GAL) is a standard first-line drug for mild to moderate AD cases.13GAL is a selective tertiary isoquinoline alkaloid with a dual mechanism of action in which it acts as a competitive inhibitor of AChE and can bind allosterically to the α-subunit of nicotinic acetylcholine receptors and activate them.13It improves behavioral symptoms, daily life activities, and cognitive performance with good efficacy and tolerability.13

The most common side effects of cholinesterase inhibitors are gastrointestinal-like nausea, vomiting, and diarrhea.8 Because of increased vagal tone, bradycardia, cardiac conduction defects, and syncope can occur. These medications are contraindicated in people with severe cardiac conduction abnormalities.8

Partial N-Methyl D-Aspartate 

Partial N-Methyl D-Aspartate receptor (NMDAR) antibody encephalitis is believed to have a dominant role in the pathophysiology of AD.13 NMDAR stimulation results in calcium influx, which activates signal transduction, and consequently, triggers gene transcription that is essential for the formation of long-term potentiation (LTP), which is important for synaptic neurotransmission, plasticity, and memory formation.13 Memantine is the only approved drug in this category to treat moderate to severe AD.13 

Memantine is a low-affinity uncompetitive antagonist of the NMDAR, a subtype of glutamate receptor that prevents over-activation of the glutaminergic system involved in the neurotoxicity in AD cases.13 The drug is safe and well-tolerated; it blocks the excitatory receptor without interfering with the normal synaptic transmission due to memantine’s low affinity.13

Other treatment considerations include:

  • Environmental and behavioral changes
    • Simple approaches such as maintaining a familiar environment, monitoring personal comfort, providing security objects, redirecting attention, removing doorknobs, and avoiding confrontation can help manage behavioral issues.8
  • Avoid tricyclic antidepressants to treat anxiety, depression, or psychosis. These drugs should be avoided because of their anticholinergic activity. Antipsychotics should only be used for acute agitation if the person with AD or their caregiver has exhausted all other avenues to reduce agitation. These drugs may have limited benefits, and their risks should be considered prior to administering the medication.8 
Reality Orientation Therapy

Reality Orientation (RO) therapy was first described as a technique to improve the quality of life of confused elderly people.16 Reality Orientation involves presenting orientation and memory information relating to time, place, and person. This type of therapy is thought to provide an individual with a greater understanding of their surroundings, possibly resulting in an improved sense of control and self-esteem. It is also effective in slowing down cognitive decline.16

During RO sessions, the person with dementia is encouraged to discuss various subjects related to recent events and their daily routine.15 Encouraging the individual to engage socially through personal interests an important part of the therapy. 15 There are two main types of reality orientation therapy: immersive, 24-hour facilities and classroom therapy.16 

Immersive 24-Hour Therapy

People who live in a dedicated facility, like a memory care unit of assisted living or a skilled nursing facility may receive 24-hour therapy. 16 In this type of therapy, current date, time, location, and current events are emphasized with every interaction a healthcare professional has with them. Healthcare professionals can also watch television or read the newspaper to reinforce reality. There may also be multiple clocks, signs declaring the date, and an emphasis on seasonal festivals to help ground social interaction with reality.

Classroom Therapy 

Classroom therapy means individuals attend group sessions to engage in orientation-related activities. These sessions last about 30 minutes and meet once or twice a day. The “reality orientation board” is often a focus in the classroom setting. This board displays the date, day of the week, weather, name of the next meal, and other current details. 16 During the session, the individual is encouraged to socialize and discuss current events and daily routines.

Reminiscence Therapy

Reality orientation therapy is also related to and used in combination with reminiscence therapy (RT). Reminiscence therapy is a form of talk therapy that is also known as life review therapy. It is often used to treat severe memory loss or dementia and works by encouraging people to revisit moments from their past. Reminiscence therapy targets certain parts of the brain and stimulates the parts that deal in long-term memory and cognition. It encourages discussion of memories that have been stored away and helps stimulate those memories through sensory organs. This causes the brain to react differently than usual, most notably impacting emotions or behavior, resulting in older adults becoming more engaged with people and their surroundings. 

Reminiscence therapy often uses props or sensory stimulation to spark memories. Smells such as perfumes or sounds such a music from a person’s past are examples that may be used to help spark a memory. This form of therapy can be individual or in a group setting.

When reality orientation and reminiscence therapy are combined as memory training exercises, they can be beneficial in helping to stimulate cognitive function, thereby slowing the decline that is associated with Alzheimer’s disease.15

Conclusion

Alzheimer’s disease is an irreversible neurological disorder that likely develops from multiple factors such as genetics, lifestyle, and environment. The success of Alzheimer’s disease treatment is dependent on early diagnosis, monitoring for disease progression, treatment modalities, and the presence of other medical conditions. There are three stages to AD, and the rate of progression through the stages is specific to each person. Although AD is irreversible, there are medications to help manage symptoms; namely cholinesterase inhibitors and partial N-methyl D-aspartate (NMDA) antagonists.1 As AD progresses, other treatments such as reality orientation and reminiscence therapy can be used to help improve engagement to people and surroundings and help slow cognitive decline. 13

References
  1. Alzheimer’s Association. On the Front Lines: Primary Care Physicians and Alzheimer’s Care in America.; 2020. https://www.alz.org/media/Documents/alzheimers-facts-and-figures.pdf
  1. Bello AM, Olalekan SK, Azizah U, et al. Alzheimer’s Disease: An Update and Insights Into Pathophysiology. Frontiers in Aging Neuroscience. 2022;14. Accessed August 1, 2022. https://www.frontiersin.org/articles/10.3389/fnagi.2022.742408
  1. CDC. What is alzheimer’s disease? | CDC. www.cdc.gov. Published June 2, 2020. https://www.cdc.gov/aging/aginginfo/alzheimers.htm#:~:text=Alzheimer
  1. Alzheimer’s disease: Symptoms, stages, causes, and treatment. www.medicalnewstoday.com. https://www.medicalnewstoday.com/articles/159442#stages
  1. 2022 Alzheimer’s disease facts and figures. Alzheimer’s & Dementia. 2022;18(4). doi:10.1002/alz.12638
  1. Kerwin D, Abdelnour C, Caramelli P, et al. Alzheimer’s disease diagnosis and management: Perspectives from around the world. Alzheimer’s & Dementia: Diagnosis, Assessment & Disease Monitoring. 2022;14(1). doi:10.1002/dad2.12334
  1. https://www.facebook.com/NIHAging. Alzheimer’s Disease Diagnostic Guidelines. National Institute on Aging. Published 2011. https://www.nia.nih.gov/health/alzheimers-disease-diagnostic-guidelines
  1. Anil Kumar, Tsao JW. Alzheimer Disease. Nih.gov. Published August 18, 2019. https://www.ncbi.nlm.nih.gov/books/NBK499922/
  1. Medical Tests. Alzheimer’s Disease and Dementia. Published 2020. https://www.alz.org/alzheimers-dementia/diagnosis/medical_tests#:~:text=Genetics%20and%20Alzheimer
  1. Neugroschl J, Wang S. Alzheimer’s Disease: Diagnosis and Treatment Across the Spectrum of Disease Severity. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine. 2011;78(4):596-612. doi:10.1002/msj.20279
  1. 10 Warning Signs of Alzheimer’s. www.cdc.gov. Published December 20, 2019. https://www.cdc.gov/aging/healthybrain/ten-warning-signs.html
  1. ‌Alzheimer’s Association. What Is Alzheimer’s? Alzheimer’s Disease and Dementia. Published 2022. https://www.alz.org/alzheimers-dementia/what-is-alzheimers
  1. ‌Breijyeh Z, Karaman R. Comprehensive Review on Alzheimer’s Disease: Causes and Treatment. Molecules. 2020;25(24):5789. doi:10.3390/molecules25245789
  1. ‌Silva MVF, Loures C de MG, Alves LCV, de Souza LC, Borges KBG, Carvalho M das G. Alzheimer’s disease: risk factors and potentially protective measures. Journal of Biomedical Science. 2019;26(1). doi:10.1186/s12929-019-0524-y
  1. ‌Camargo CHF, Justus FF, Retzlaff G. The Effectiveness of Reality Orientation in the Treatment of Alzheimer’s Disease. American Journal of Alzheimer’s Disease & Other Dementiasr. 2015;30(5):527-532. doi:10.1177/1533317514568004
  1. ‌Spector A, Davies S, Woods B, Orrell M. Reality Orientation for Dementia. The Gerontologist. 2000;40(2):206-212. doi:10.1093/geront/40.2.206‌
  1. Chiu HY, Chen PY, Chen YT, Huang HC. Reality orientation therapy benefits cognition in older people with dementia: A meta-analysis. International Journal of Nursing Studies. 2018;86:20-28. doi:10.1016/j.ijnurstu.2018.06.008
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