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Nursing Field Notes / Neuro · Degenerative · Med-Surg
🧠 NEURO SET NG-255 Neuro Overview NG-069 Alzheimer's NG-244 Dementia vs Delirium NG-258 Parkinson's NG-253 MS NG-245 Guillain-Barré

Alzheimer's Disease 🧩

Progressive · irreversible · plaques outside, tangles inside — short-term memory goes FIRST

NG-069 NEURO · DEMENTIA ADHD-friendly visual edition

Alzheimer's is the most common cause of dementia — a slow, one-way loss of brain tissue driven by amyloid plaques between neurons and neurofibrillary tangles inside them. It starts in the hippocampus, which is why short-term memory goes first while childhood memories stay vivid for years. Nothing cures it. Almost everything you will be tested on is about safety, how you speak to the person, and keeping the caregiver standing. For the basic neuroanatomy behind this page, see NG-255 Neuro Overview — it is not repeated here.

📄 Simple Nursing original — opens in Drive →

🧩 PLAQUES + TANGLESAmyloid plaques OUTSIDE the neurons, tau tangles INSIDE them. Both are irreversible.
🕐 SHORT-TERM FIRSTHippocampus goes early. New memories fail while old ones survive — that is the signature.
🛡️ SAFETY IS THE PRIORITYWandering, falls, poisoning, burns. Lock the exits and the chemicals, clear the floor, light the halls.
💊 SLOWS, NEVER CURESCholinesterase inhibitors buy time on symptoms. “This will cure me” = needs further teaching.
🧬

WHAT'S HAPPENING

CAUSE

Plaques outside, tangles inside, and a brain that is physically shrinking.

FIGURE 1 · WHAT THE BRAIN ACTUALLY LOOKS LIKE — normal vs Alzheimer'sCoronal (front-facing) slices, drawn to the same scale · read LEFT → RIGHT · atrophy = tissue LOST, so the brain weighs less① NORMAL BRAINCoronal slice (cut front-to-back), viewed from the front② ALZHEIMER'S BRAINSame slice, same magnification — late diseaseThick cortex, shallow sulciSlit-like lateral ventriclesPlump HIPPOCAMPUS — where new memories are madeCortex THINNED · sulci WIDEVentricles ENLARGEDHIPPOCAMPUS SHRUNKEN — this is why SHORT-TERM memory goes firstGyri NARROWED

Atrophy means tissue is LOST — the brain physically shrinks and gets lighter. The ventricles look bigger only because there is less brain around them.

🧪 Definition — say it in one sentence

Alzheimer's disease is a progressive, irreversible degenerative brain disease in which amyloid plaques and neurofibrillary tangles destroy neurons and their synapses, causing worsening memory loss, personality change and, eventually, total dependence.

Dementia is the umbrella term for that loss of brain function. Alzheimer's is the most common cause of it — roughly 60–80% of cases.

🧠 De-M-entia = DaMage to the brain. Alzheimer's is one cause of that damage.
FIGURE 2 · PLAQUES and TANGLES — the two lesions that define the diseaseHugely magnified · read LEFT (normal) → RIGHT (Alzheimer's)① HEALTHY NEURONMagnified · straight internal “scaffolding”, clear space around it② ALZHEIMER'S NEURONSame magnification · tangles INSIDE, plaques OUTSIDEStraight microtubulescarry nutrients up and down the cellClean space between neurons— signals cross the synapse normallyNEUROFIBRILLARY TANGLESTwisted tau protein INSIDE the cell.The scaffolding collapses → the cell dies.AMYLOID PLAQUESSticky beta-amyloid clumps OUTSIDEthe cells — they jam the synapsesPlaques are OUTSIDE (like plaque on teeth) · Tangles are INSIDE (like tangled headphones in a pocket)

Plaques jam the space between neurons so signals cannot cross; tangles collapse the scaffolding inside the cell so the neuron starves and dies. Both are happening years before the first symptom.

🧬 The mechanism in four beats

Beta-amyloid protein builds up between neurons → PLAQUES
↓
Tau protein twists inside neurons → TANGLES collapse the transport scaffolding
↓
Synapses fail → acetylcholine falls → memory and learning fail
↓
Neurons die → cortex and hippocampus ATROPHY → ventricles enlarge
🧠 Plaque · Tangle · Transmitter · Tissue. Four Ts in a row, each one worse.

⚠️ Risk factors — what raises it and what lowers it

  • #1 non-modifiable risk factor: a FAMILY HISTORY of Alzheimer's.
  • Advancing age — the single biggest overall risk.
  • Down syndrome, previous significant head injury, low education/cognitive reserve.
  • The vascular set: hypertension, diabetes, smoking, obesity, high cholesterol.
  • Lowers risk: regular physical exercise, mental activity, social contact, treating hearing loss, controlling blood pressure and glucose.
🧠 “Regular exercise reduces the risk of Alzheimer's.” That exact sentence shows up as a correct answer — remember it.

🧪 Diagnosis — a diagnosis of exclusion

  • There is no single blood test that says “Alzheimer's” at the bedside. Definitive confirmation is still histological — plaques and tangles at autopsy.
  • MRI / CT show cortical atrophy, widened sulci and enlarged ventricles.
  • Cognitive screening tools (e.g. MMSE, MoCA) track the decline over time.
  • First, rule out the reversible causes: B12 deficiency, hypothyroidism, depression, medication side effects, normal-pressure hydrocephalus and — most importantly on the ward — delirium.
DO THIS FIRST NG-244 Dementia vs Delirium — never assume a sudden change is “just the dementia”.
📉

THE STAGES

CLUES

Three stages, always in the same direction. Know what is lost at each.

FIGURE 3 · THE THREE STAGES — and what is lost at eachFunction on the vertical axis, time on the horizontal · read LEFT → RIGHT · the slope only ever goes downFUNCTIONTIME (years) →STAGE 1 — No impairmentBrain changes are already happeningNobody can tell — including the personDiagnosis is not possible yetSTAGE 2Forgetfulness · SHORT-TERM memory lossRepeats questions, loses objectsMisses appointments, word-finding pausesStill knows who people areSAFETY starts to matter hereSTAGE 3LONG-TERM memory loss · total dependenceDoes not recognize familyCannot do ADLs · incontinentLoses speech, then swallowingAspiration and infection end lifeProgressive · irreversible · currently no cure. Every drug we have SLOWS the slide — none reverses it.

Stage 2 is where nursing interventions matter most — the person is still at home, still mobile, and that combination is exactly what makes wandering and household hazards dangerous.

📉 What changes, in the order it changes

DomainEarlyMiddleLate
MemoryShort-term: repeats questions, loses things Forgets recent events, names of grandchildrenLong-term gone; may not know spouse or self
LanguageWord-finding pausesSubstitutes wrong words, loses threads Few words, then mute
ADLsIndependent, needs remindersNeeds step-by-step cueing and supervision Total care, incontinent
BehaviorAnxiety, withdrawal, denial Wandering, sundowning, suspicion, aggressionApathy, immobility
What kills—Falls, wandering, dehydration Aspiration pneumonia and infection
🧠 Short-term memory first, swallowing last. That is the arc of the disease.

🚨 The late-stage complication that actually ends life

Late Alzheimer's takes out the swallow. Silent aspiration → aspiration pneumonia is the most common immediate cause of death.

Watch for a wet, gurgly voice after swallowing, coughing at meals, pocketing food in the cheek, a long delay before the swallow, or a low-grade fever with new crackles.

Never “just try a sip of water” to test a swallow in someone with a suspected dysphagia — request a formal swallow evaluation.

🧠 Wet voice = wet lungs coming.

⭐ Two exam-favorite behaviors

Wandering — purposeful-looking walking with no safe destination. It is a need (bored, in pain, needs the toilet, looking for something familiar), not misbehavior.

Sundowning — confusion and agitation that worsen in the late afternoon and evening. See Figure 7 for the clock and the fixes.

🧠 Wandering has a reason. Find the reason and the wandering settles.
🛡️

SAFETY FIRST

CARE 1

The highest-priority nursing care on this page. Learn it as a checklist.

FIGURE 4 · SAFE-PROOFING THE HOME — the four things you checkRead the panels ① → ④ · every item shown is a testable intervention① BATHROOM — grab bars + labeled tapsHOTCOLDLabel HOT vs COLD in wordsGrab bars in the tub and shower② FLOORS + LIGHT — clear the pathNO throw rugs, NO clutterNight light · well-lit halls③ EXITS — locked, alarmed, out of sightKeyed deadbolt, mounted HIGHSAFE RETURNSafe-return ID bracelet④ LOCK UP the dangerous thingsMEDSBLEACHMeds · chemicals · sharps · matches — LOCKED, not left in a pill dispenser

Every single item in these four panels has shown up as an exam answer. Learn them as a checklist you could walk through someone's house with.

🚨 Fall-proofing — the floor and the light

  • Remove throw rugs and clutter from the floor. This is answer #1 on almost every version of the question.
  • Grab bars in the shower, tub and beside the toilet; a shower chair; a non-slip mat.
  • Night lights and well-lit halls — especially the route from bed to bathroom.
  • Bed low, brakes on, call bell in reach, non-skid footwear.
  • Handrails on both sides of stairs — and lock the stairwell door if falls are the risk.
🧠 Rugs · Rails · Rooms lit.

🚨 Wandering — lock down the exits, not the person

  • Safe-return ID bracelet worn at all times, with name and contact number.
  • Keyed deadbolts mounted HIGH or LOW on doors leading outside — out of the usual line of sight. Door alarms or chimes.
  • Camouflage exits: a curtain or a full-length mirror over the door reduces exit-seeking.
  • Provide a safe place to walk — a looped hallway or an enclosed garden. Walking is the need; give it somewhere to go.
  • Notify neighbors and local police that the person may wander.

Never use physical restraints to stop wandering. Restraints increase agitation, injury, incontinence and deconditioning — and are a last resort with an order, not a first move.

🧠 Lock the door, not the patient.

🔒 Poison, burns and medications

  • Lock up cleaning chemicals, bleach, medications, sharps, matches, lighters, firearms and car keys.
  • Do NOT leave medications in a pill dispenser for someone with moderate dementia — they may take the whole week's supply or none of it. Someone else administers them.
  • Label HOT and COLD taps in words and colors; set the water heater to a safe temperature.
  • Turn off or remove the stove knobs; consider an automatic shut-off kettle.
  • Supervise smoking, or stop it.
🧠 If it burns, poisons, cuts or drives — it gets locked away.

✅ Set the living space up to do the remembering

  • Pictures and symbols, not words, on doors — a toilet picture on the bathroom door.
  • Frequently used items within easy reach and always in the same place.
  • A large clock and a day/date board; open the curtains in the morning.
  • Familiar objects and family photographs at the bedside — they anchor the person.
  • Keep the same routine, the same room and the same staff wherever possible. Novelty is the enemy.
  • Allow free movement within a safe space rather than confining the person to a chair.
🧠 The environment becomes the memory. If the room reminds them, they don't have to.
FIGURE 7 · SUNDOWNING — agitation has a TIME OF DAYClock face, midnight at the top · bar LENGTH and COLOR = how agitated (see key, bottom left)00:0003:0006:0009:0012:0015:0018:0021:00AGITATIONover 24 hourspeak 16–20hnoonmidnightWHY IT HAPPENSFading daylight removes visual cuesFatigue at the end of the dayShift change → new faces, more noiseHunger, pain, a full bladder, constipationToo much stimulation all at onceWHAT YOU DOTurn lights ON before dusk — close blindsKeep the routine and the staff the sameQuiet, low-stimulation environmentToilet, food, pain check BEFORE 16:00No caffeine or naps late in the dayBAR COLOR = AGITATION LEVELcalmrestlessagitated

Sundowning is predictable, which means it is preventable. Everything in the right-hand column is done BEFORE 16:00, not after the agitation starts.

💬

HOW TO TALK AND CARE

CARE 2

Acknowledge · redirect · never argue. And look after the caregiver.

FIGURE 5 · HOW TO TALK TO SOMEONE WITH ALZHEIMER'SRead LEFT (what not to do) → RIGHT (what to do) · the ladder underneath is the exam answer, in order❌ WHAT MAKES IT WORSEEvery line here raises anxiety✅ WHAT MAKES IT BETTEREvery line here lowers anxiety“What would you like towear today?”“Your husband died in 2016.”“Hurry up, we're late.”“Would you like the BLUEone or the RED one?”“You miss him. Tell meabout him.” Then redirect.OPEN questions · too many choicesCorrecting reality · rushing · arguingYES/NO or TWO choices · plenty of timeAcknowledge the feeling, then REDIRECTResult: frustration → agitationResult: calmer, still an ADULTTHE 3-STEP RESPONSE TO AGITATION — in this order, every time1ACKNOWLEDGE the feeling“You're worried about him. Thatsounds hard.”➜2REDIRECT to an activityCrossword, folding towels, lookingat photos, a walk➜3NEVER argue or “orient” themDo not present reality orrationalise — it re-injures them

The three-step ladder at the bottom is, almost word for word, the answer to every “agitated client with dementia” question you will see.

⭐ The classic exam scenario — and the exact right answer

“My husband is picking me up soon.” — but her husband died ten years ago.

Correct response: Acknowledge the feeling, then redirect to a new activity. “You're looking forward to seeing him. Tell me about him — was he a good dancer? Come and help me fold these while you tell me.”

Do NOT present reality (“He died in 2016”) and do NOT rationalise or argue. She will grieve him as if for the first time, every time — and you will have created an agitated patient.

🧠 Feelings first, facts never.

✅ How to phrase everything

  • Yes/no questions, not open-ended ones. “Would you like tea?” not “What would you like to drink?”
  • Limit the choices to two. Decreasing the number of choices decreases the anxiety.
  • Do not rush. Allow plenty of time for ADLs and for answers. Rushing produces resistance.
  • One short sentence at a time. Approach from the front, at eye level, and say your name and theirs every time.
  • Break tasks into single steps: “Put your arm in the sleeve.” Then wait.
  • Treat the person as an ADULT — never baby talk, never “sweetie”, never talking over them to the family.
🧠 Two choices, one step, all the time in the world.

🍽️ Eating — the exam answer is “less on the plate”

  • Give half the sandwich now and the other half later. A crowded plate is overwhelming and the person eats nothing.
  • One food at a time · finger foods · high-calorie, easy-to-hold options.
  • Simple, uncluttered place setting: no patterned tablecloth, one utensil, a plain plate with contrasting color to the food.
  • Quiet room, TV off, sit with them, cue each bite.
  • Monitor weight — unplanned weight loss is common and is a real finding, not just “not hungry”.
🧠 Half a sandwich beats a whole one refused.

👗 Dressing and daily choices

Lay out coordinated outfits and let the person choose one of two. That preserves autonomy without producing decision paralysis.

Choose clothing that is easy to manage — elastic waists, slip-on shoes, front closures, Velcro instead of buttons and laces.

🧠 Choice, but bounded. Dignity without overwhelm.

🎯 Activities that work

  • Repetitive, familiar, no-fail tasks: folding towels, sorting cards, winding wool, sweeping.
  • Crossword puzzles, simple games and reminiscence with old photographs and old music — music is often the very last thing to go.
  • Short walks in a safe, enclosed area.
  • Keep sessions short and stop before frustration starts.
  • Occupying the hands is the single best alternative to a restraint.
🧠 Busy hands, quiet mind.

🫂 The caregiver is your second patient

Caregiver burnout is not a soft topic — exhausted caregivers are how patients end up dehydrated, over- or under-medicated, injured, or admitted at 3 a.m.

  • Ask directly about the caregiver's sleep, mood, health, work and finances.
  • Arrange respite care, adult day programs and home health early, not at crisis point.
  • Refer to a support group and to the Alzheimer's Association / local equivalent.
  • Discuss advance directives, power of attorney and goals of care EARLY, while the person can still take part in the conversation.
  • Name the grief. Watching someone disappear while they are still alive is a real bereavement.
  • Screen for elder abuse and neglect — exhaustion is a risk factor for both.
🧠 Two patients, one appointment. If the caregiver falls over, so does the plan.
💊

DRUGS AND TEACHING

CARE 3

What the medications can do, what they cannot, and the answers that get marked wrong.

FIGURE 6 · HOW CHOLINESTERASE INHIBITORS WORK — and what they can't doMagnified synapse · read LEFT (no drug) → RIGHT (on the drug)① ALZHEIMER'S BRAIN — untreatedToo little ACh reaches the receptors② ON A CHOLINESTERASE INHIBITORThe enzyme is blocked, so ACh lingersAChEAChEFew green ACh molecules · 1 of 4 receptors activatedMore ACh survives · 3 of 4 receptors activatedKEYacetylcholine (ACh) — the memory transmitterAChE — the enzyme that destroys AChthe DRUG plugging the enzymepostsynaptic receptorDonepezil · rivastigmine · galantamineThey SLOW symptoms — they do NOT stop plaques, tangles or the disease.Side effects = too much ACh everywhere else: nausea, diarrhea,poor appetite, vivid dreams, BRADYCARDIA and fainting.

The honest summary: these drugs make a modest difference to symptoms for a while. They do not touch the plaques, the tangles or the trajectory.

💊 The drug classes you are expected to know

ClassExamplesWhat it doesWatch for
Cholinesterase inhibitorsDonepezil · rivastigmine · galantamine Block the enzyme that destroys acetylcholine → more ACh at the synapse. Mild–moderate disease. Nausea, vomiting, diarrhea, weight loss, insomnia and vivid dreams, BRADYCARDIA, dizziness and syncope
NMDA receptor antagonistMemantine Dampens excess glutamate signaling. Moderate–severe disease; often combined with a cholinesterase inhibitor.Dizziness, headache, confusion, constipation
Symptom managementAntidepressants · low-dose antipsychotics Only for depression, or for severe agitation/psychosis when non-drug measures have failed Antipsychotics carry an increased risk of death in elderly dementia patients — lowest dose, shortest time, non-drug measures first
🧠 Donepezil = “Don't lose ACh.” Memantine = the one for the More advanced patient.

🚨 The cholinesterase-inhibitor safety points

  • Check the apical pulse before giving. These drugs slow the heart — hold and report a rate below the parameter set (commonly <60/min) or new dizziness/fainting.
  • Give with food to reduce nausea; monitor weight.
  • Start low, go slow — most side effects are dose-related.
  • Caution with a history of asthma/COPD, peptic ulcer, seizures or urinary obstruction.
  • Effects are gradual. Teach families not to expect a change in days.
🧠 More ACh = more of everything cholinergic: slower heart, wetter gut, wetter eyes. That is the side-effect list.

⭐ The “needs further teaching” answers

  • ❌ “This medication will cure my mother's Alzheimer's.” — nothing cures it.
  • ❌ “Once her memory improves we can stop the drug.”
  • ❌ “I'll set out her whole week of pills in this dispenser so she can be independent.”
  • ❌ “If she says her husband is coming I should remind her that he died.”
  • ❌ “A restraint will keep her from wandering at night.”
  • ✅ “Regular exercise may reduce the risk.” · ✅ “I'll keep her routine and her room the same.”
🧠 Any option containing cure, restrain, argue with reality, or hurry the patient is wrong.

✅ Priority nursing diagnoses, in order

1
Risk for injury — wandering, falls, poisoning, burns
↓
2
Risk for aspiration / imbalanced nutrition
↓
3
Self-care deficit — assist, don't take over
↓
4
Caregiver role strain
🧠 Safety → swallowing → self-care → support.
🧩 PLAQUES OUT · TANGLES INAmyloid plaques BETWEEN neurons, tau tangles INSIDE them. Hippocampus and cortex atrophy, ventricles enlarge.
🕐 SHORT-TERM MEMORY FIRSTNew memories fail while old ones survive. Long-term memory loss = late stage.
🛡️ SAFETY BEATS EVERYTHINGNo throw rugs · grab bars · night lights · high keyed deadbolts · safe-return bracelet · lock chemicals and meds.
💬 ACKNOWLEDGE → REDIRECTNever present reality, never rationalise, never rush. Yes/no questions, two choices, half the sandwich.
🌇 SUNDOWNINGAgitation peaks late afternoon and evening. Light the room before dusk, keep the routine, toilet and feed BEFORE it starts.
❌ NEVER RESTRAINRestraints worsen agitation and injury. Occupy the hands instead. And no full-week pill dispenser left unsupervised.