Lost and Found

Learning Objectives

• Describe Alzheimer’s disease, including  incidence, pathology, symptoms and progression.
• Discuss risk factors for development of  Alzheimer’s disease.
• Describe the appropriate EMS interaction with the Alzheimer’s patient, including the approach, assessment and management.
• Discuss advances in Alzheimer’s disease research.

Key Terms
Acetylcholine:  A chemical in the brain that conducts nerve impulses between nerve cells and their target organ.
Dementia: A progressive decline in mental functioning that interferes with daily life.
Plaques: A buildup of proteins between nerve cells believed to cause loss of neurons and vascular damage.
Tangles: Cellular debris made up of dead cells and protein deposits.

This clinical review feature article is presented in conjunction with the Department of Emergency Medicine Education at the University of Texas Southwestern Medical Center, Dallas.

The address of the call was a familiar one, but today we knew time was of the essence. Mary, an Alzheimer’s patient living with her family, had wandered off on a cold, wet morning. Our concern was exacerbated by the fact that Mary left home without a jacket or hat to keep her warm, and forecasters were predicting dangerously low temperatures and increased precipitation. The location of Mary’s neighborhood also put her at risk of a mountain lion attack. The later it got, we knew she could be facing other potentially life-threatening hazards. We realized the farther away from home she wandered, the more disoriented she would get. We had to locate her quickly.

She was always very pleasant on past EMS calls, but as her disease advanced, there had been a noticeable change in her mood, behavior and ability to communicate. As we searched frantically, statistics reminded us that 60% of those with Alzheimer’s will wander, with risk of serious injury or death if not found in the first 24 hours.1 As day turned to night, we all hoped and prayed for the best outcome.

Understanding Alzheimer’s
Alzheimer’s disease is the seventh leading cause of death in the U.S., and 10 million baby boomers will develop this disease.1 Like Mary, it’s estimated that 5.3 million Americans of all ages are living with the disease named for German physician Alois Alzheimer, MD.1 In 1906, Alzheimer first described the symptoms of the disease in a 51-year-old woman. His patient came to him with memory and judgment problems that progressively grew worse, causing disability and eventually her death. He later identified dramatic changes in the brains of patients afflicted with the disease.

Alzheimer’s disease is a progressive and fatal brain disorder that accounts for 50—80% of dementia, a general term for memory loss severe enough to interfere with daily life. The disease has no cure and no survivors. As it advances, it continues to destroy brain cells, causing permanent memory loss.

Researchers believe the two abnormal structures that are hallmark traits of Alzheimer’s–plaques and tangles (formed inside a dying cell)–block communication among nerve cells, disrupting activities cells need to survive. Those afflicted with Alzheimer’s have rapid cell and tissue death that usually begins in the areas most important to learning and memory. Alzheimer’s patients die an average of four to six years after diagnosis, but the duration of the disease may vary from three to 20 years.

Researchers haven’t isolated the trigger that causes brain cells to fail but have identified risk factors that increase the likelihood of developing Alzheimer’s. The greatest known risk factor is increasing age. Most of those with the disease are 65 years old or older. The likelihood of developing it doubles every five years after the age of 65. Dementia identified in people younger than 65 is considered “younger-onset” Alzheimer’s. Family history may be a contributing factor, because research has demonstrated that those carrying a specific gene may have increased risk. There’s also a strong correlation between sustaining a serious head injury and later developing Alzheimer’s. Conditions that damage the heart or blood vessels, such as high blood pressure, heart disease, stroke, diabetes and high cholesterol, may also be factors.

As the American population ages, EMS and other health-care professionals will face a flood of Alzheimer’s patients. Deaths attributed to this disease are up 47%, and one in seven Americans over the age of 65 will develop the illness.1 Assessment and treatment of an Alzheimer’s patient can be challenging, because the disease can mimic many other medical conditions. EMS providers will need excellent communication skills and a good understanding of the disease process to successfully interact and treat these patients.

Assessing Alzheimer’s Patients
Symptoms may depend on how far the disease has progressed and range from mild cognitive decline (e.g., “senior moments” or memory lapses) to severe loss of speech and the ability to walk and eat. Behavioral and psychiatric symptoms may affect the way patients feel and act. It’s important to remember that patients are dealing with confusion, anxiety and irritability. They may be suspicious, angry or delusional. Before your physical assessment can begin, you’ll have to create a bond and build trust through compassion and understanding of their disease and situation.

Start by introducing yourself. Call them by their name, remain calm and reassure the patient from the time you arrive. Always face the patient as you approach, make eye contact and avoid touching them unexpectedly. Speak slowly and distinctly, using simple words, and keep confusion, noise and stimulation to a minimum. Ask only one question at a time so you don’t confuse them, and allow plenty of time for comprehension. If they don’t seem to understand what you’ve said, repeat the question again using the same wording. Give short, one-sentence explanations, and be patient and cheerful. When people with dementia find themselves in a new place or new situation, they may feel lost and frightened. Reassure them about where they are and that you’re there to help. Alzheimer’s patients need compassion, dignity and respect, which will help get them–and you–through a difficult situation.

After gaining their confidence, slowly begin a physical assessment. Explain what you’re doing with each small step and why. Family members can be helpful during a medical evaluation by explaining procedures and applying some medical equipment. Alzheimer’s disease can imitate many other medical and trauma conditions, such as head injury, stroke, hypoglycemia, hypoxia, fever, intoxication or toxic ingestion. Complete a thorough assessment to rule out other treatable causes of confusion.

Ensure the patient has an adequate airway, breathing and circulation, and manage hypoxia with oxygen. Get two sets of vital signs. Manage hypotension with IV fluids. People with dementia often forget to eat, especially if they live alone, so test for hypoglycemia by drawing blood samples and measuring blood glucose levels. Administer 50% dextrose if the blood glucose is less than 60 mg/dL. Consider narcan (naloxone) if narcotics ingestion is a possibility.

Perform a 12-lead ECG to rule out cardiac abnormalities. Measure carbon monoxide (CO) levels using a portable CO meter, if available, to rule out environmental causes. Removal of the patient’s clothing may be challenging, but a complete head-to-toe assessment should be performed, especially if the person has been wandering. Ask them to help.

A careful neurological examination using the Cincinnati Prehospital Stroke Scale will alert you to the warning signs of stroke: facial droop, arm drift and slurred speech. Gather and examine a complete medical history to determine other treatable causes of an acute onset of confusion. Providers should be familiar with the common drugs (and their side effects) used in the treatment of Alzheimer’s disease.

Although researchers have made enormous strides over the past 20 years in understanding how the disease affects the brain, there isn’t an effective treatment to cure or stop the progression of the disorder.

The FDA has approved five drugs that may offer positive benefits for up to one year in certain patients (see Table 1, p. 55). These five drugs delay the breakdown of acetylcholine. This chemical in the brain facilitates communication among nerve cells and is important for memory. Other medications used to treat Alzheimer’s disease include anti-depressants, as well as anti-anxiety, insomnia and anti-psychotic drugs.

Wandering
EMS providers may encounter Alzheimer’s patients in a number of unusual situations outside the patient’s home. It’s common for those suffering from dementia to wander away on foot and become lost. Others have taken car keys and driven off without their caregiver’s knowledge. EMS may respond to a confused person who shoplifted because they simply forgot to pay.

Wandering is considered an emergency, and 70% of people with dementia wander repeatedly. There are many causes for wandering: stress, restlessness, agitation, anxiety, fear, inability to recognize familiar people and places, time-related confusion or side effects of medication. Often, these patients can’t remember their name or address and may become lost in their own neighborhood. People may walk along busy roadways or into dangerous, unsafe areas. They often wander with a purpose or goal in mind. Providers should search the immediate area around the residence, as well as prior homes and workplaces. Also, look short distances off sidewalks and thoroughfares. File a missing persons report with law enforcement immediately.

The Alzheimer’s Association works closely with public safety officials to address wandering. The Alzheimer’s Association’s MedicAlert + Safe Return program is a 24-hour nationwide emergency response service for individuals with Alzheimer’s, or related dementias, who wander or have a medical emergency.

The program enrolls individuals by creating a personal health record that includes the patient’s medical condition, allergies, medications, photograph, physical description and caregiver contact information. A medical identification bracelet or medallion is included with the words “MedicAlert” imprinted in purple on one side and “Memory Impaired” and the Safe Return’s 24-hour, toll-free telephone number on the other.

In the event of a missing person, MedicAlert will fax or e-mail the responding agencies a complete profile of the missing person, along with their photograph. Medical identification bracelets hold a wealth of medical information, and responders should always check for them when encountering a confused person.

With the invention of global positioning systems (GPS), personal tracking devices have been developed to keep a watchful eye on Alzheimer’s patients. Comfort Zone is a Web-based application that maps a person’s location 24 hours a day. The person wears or carries a special locator device.

The device communicates with the Comfort Zone Web application and family members can access information about the person’s location using the Internet or a monitoring center. If the person travels outside a designated preset zone, the system will automatically send e-mail or text alerts to family or professional caregivers.

A diagnosis of Alzheimer’s disease doesn’t mean a person should immediately stop driving, but eventually, as the disease progresses, they’ll be unable to drive. Such behaviors as hitting curbs, confusing the brake and gas pedals, having poor lane control, being unable to find familiar destinations, not understanding street signs, and becoming angry and confused while driving are a good indication that the time to stop driving may have arrived. Loss of independence is an emotional issue but a necessary one to confront.

Some states require physicians to report Alzheimer’s diagnoses to the health department, which passes the information on to the department of motor vehicles (DMV). Then, the DMV may revoke driving privileges. If EMS responders encounter these drivers on the road or at accident scenes, they should contact family members. Never allow a patient to drive off alone.

Disaster Planning
People with dementia, already anxious and confused, are especially vulnerable to the chaos and emotional trauma of a disaster. Disaster planning should include quickly relocating these individuals to a safe place. Remember that, in many cases, the use of wheelchairs or walkers may require specialized transport vehicles.

People with dementia often have a limited ability to understand directions or explanations and may get frustrated and overwhelmed quickly. Primary caregivers should have the following:

• Copies of the patient’s medical records;
• A photograph of the patient;
• Extra medication (including oxygen);
• Telephone numbers for doctors; and
•  A small emergency kit.

The kit should include:

• A couple of sets of easy on/off clothing;
• Velcro® shoes;
• Spare eyeglasses;
• Incontinence products;
• Legal documents;
• Insurance information;
•  Social Security card;
• Favorite items; and
• Bottled water and food.

Adding an iPod loaded with favorite music, a book on tape, magazines and small games may also help distract the person and minimize their anxiety and distress.

Also, remember a disaster is an abrupt change in an Alzheimer’s patient’s routine and environment. This change may cause increased agitation, wandering or an increase in behavioral symptoms, such as hallucinations, delusions and sleep disturbance.

Remain calm and non-confrontational when working with dementia patients. They’ll usually respond to the emotional tone you set. Use simple language, make good eye contact, provide one-on-one instruction and be respectful and understanding of their medical condition.

Research
New advances in magnetic resonance imaging (MRI) have given researchers the ability to see inside the brain of Alzheimer’s patients at various stages in the development of the disease. Imaging with radioactive tracers helps identify the disease in the early stages as plaques begin to grow between nerve cells.

Early recognition of cell sickness will lead to better treatment before cell death occurs. Early detection also empowers patients to get the maximum benefits from current treatments, have some control over the plan for their future and talk with loved ones to modify their lifestyle and improve brain health. A consistent theme of “early detection for early intervention” has emerged as a key element in Alzheimer’s research and treatment. Make an appointment with your doctor if you or anyone else you know is experiencing any of the following symptoms:

• Memory changes that disrupt daily life;
• Challenges in planning or solving problems;
• Difficulty completing familiar tasks at home, at work or at leisure;
• Confusion over time or place;
• Trouble understanding visual images and spatial relationships;
• New problems with words in speaking and writing;
• Misplacing things and losing the ability to retrace steps;
• Decreased or poor judgment;
• Withdrawal from work or social activities; or
• Changes in mood and personality.1

 A concerted effort is being made by researchers to develop antibodies that attack the disease before plaques and tangles begin to form. Drugs that slow or stop nerve cell death are crucial to finding a cure for Alzheimer’s disease. Although several drugs show promise in animal studies, it will take time to prove effectiveness for humans. Currently, researchers are studying the effects of diet, dietary supplements, exercise and lifestyle choices on slowing the progression of the disease.

Conclusion
Calling 9-1-1 is the first option or the last resort for families in crisis, so make your first response the right response when interacting with dementia patients. Awareness of dementia and Alzheimer’s disease helps providers understand what patients and families are going through and will help you provide the best medical care and customer service. JEMS

Reference
1. The Alzheimer’s Association. www.alz.org.