1. ALZHEIMER’S DISEASE:
A Study of Alzheimer’s Disease Pathology and Nursing Management of Unmet Needs
By Jennifer Krueger, RN, BSN Alverno College, MSN 621
April 29, 2010

2. tutorial Instructions
To navigate throughout this tutorial:
Click on the icon in the lower left corner of each slide to return to the Table of Contents page at any time.
Table
of Contents
Only use the left or right arrows located
in the upper right hand corner of each
slide, to progress to the next slide or return
to the previous slide.
Back
Forward
(Unless specifically indicated, images were obtained from Microsoft Clipart, 2011)

3. CASE STUDY--Rosie
Meet, Rosie! Rosie is 84 years old and lives with her daughter, son-in-law, and two grandchildren. She moved in with her daughter six months ago, after her husband passed away. While Rosie is in excellent physical health, her family has noticed some changes in her personality and decision-making skills.
Throughout this tutorial, you will answer questions about Rosie as they relate to each section. When you come to a slide with Rosie’s picture, answer the question. Then click the forward arrow in the upper right corner of the slide to continue.

4. LEARNING OBJECTIVES:
Explain the basic pathology of Alzheimer’s Disease including the influence of stress, inflammation, aging and genetics.
Recognize challenging behavior as communication of unmet needs.
Identify nursing interventions that will influence/reduce challenging behaviors in patients with Alzheimer’s Disease.

5. Nursing Management of Unmet Needs
TABLE OF CONTENTS
Click on a box to find out more about each topic…
Just the Facts
Pathophysiology
Immune
and
Stress Response
Genetically Speaking
What are Challenging
Behaviors?
Nursing Management of Unmet Needs
References

6. JUST THE FACTS Did You Know?
Alzheimer’s Disease is the most common cause of dementia in older adults;
60-80% of all cases. (Omnicare, 2010)
Approximately 13% of all persons older than 65 years old have Alzheimer’s
Disease. (Omnicare, 2010)
In million people were affected by Alzheimer’s Disease. (Omnicare, 2010)
The risk of developing the disease increases with age, and approximately 50% of
all people over the age 85 have Alzheimer’s Disease. (Porth and Maftin, 2009)
Currently, there are no specific diagnostic tests to diagnose Alzheimer’s Disease;
diagnosis is made by excluding other possible causes of dementia symptoms.
(Porth and Maftin, 2009)

7. JUST THE FACTS Did You Know?
There are normal a changes in the brain, associated with aging…
Weight of brain decreases.
Neuron loss, mostly in the cortex in the superior temporal area.
Neurons atrophy with changes in neurotransmission.
Despite changes, cognitive abilities remain intact.
Changes in personality or cognitive deficits are considered not normal in the older adult.
Many times, plaques and tangles associated with Alzheimer’s Disease are found in older adults with no cognitive impairment.
(Porth and Maftin, 2009)

8. JUST THE FACTS What Is Alzheimer’s Disease?
A disease involving neuropathic and neurotransmitter changes.
A disease causing cortical atrophy with loss of neurons particularly in the parietal and temporal lobes of the brain.
A progressive disease leading to death within 8 to 10 years after diagnosis.
Ranges in stages of very mild cognitive decline to very severe cognitive decline.
Click here to see a normal brain…
Click here to see a brain affected by Alzheimer’s Disease
(Porth and Maftin, 2009)
(Alzheimer’s Association, 2011)
(Image credit : Jannis Productions, Stacy Jannis. Picture used with permission from the Alzheimer’s Association)

9. JUST THE FACTS Stages Of Alzheimer’s Disease
Click on each stage to learn more…. (Stages are as defined by the Alzheimer’s Association)
Stage 1
No Impairment. Person does not show any signs and symptoms to a medical professional or family members.
Very Mild Cognitive Decline. Patient may feel like they have memory lapses, forgetting familiar words or objects. Family, friends and medical professionals do not detect any signs or symptoms.
Stage 2
Mild Cognitive Decline (Early-stage). Family and friends may start noticing problems with name-finding, planning or organizing. A medical professional may detect problems with memory or concentration.
Stage 3
Moderate Cognitive Decline (Mild or early-stage). A careful medical interview should be able to detect problems in several areas including, knowledge of current events, impaired ability to perform challenging mental arithmetic (counting backward from 75 by 7s), managing finances, memory of personal history, may be moody and withdrawn.
Stage 4
(Alzheimer’s Association, 2011)
(Porth and Maftin, 2009)

10. JUST THE FACTS Stages Of Alzheimer’s Disease
Click on each stage to learn more….(Stages are as stated by the Alzheimer’s Association)
Moderately Severe Cognitive Decline (Moderate or mid-stage). Major gaps in memory and cognitive function. Will need some assistance with day to day activities. Will not remember address or phone numbers. Able to remember significant details about self and is usually able to use the toilet and feed self.
Stage 5
Severe Cognitive Decline (Moderately severe or mid-stage). Memory continues to worsen. Significant changes in personality may emerge. Will need help with dressing, toileting; may be incontinent. Tends to wander or get lost.
Stage 6
Stage 7
Very Severe Cognitive Decline (Severe or late-stage). Final stage of disease. Loses all ability to respond to their environment, including the ability to speak and control movement.
(Alzheimer’s Association, 2011)
(Porth and Maftin, 2009)

11. JUST THE FACTS Let’s Review!
Two years ago, Rosie started to feel like she was forgetting
simple things; birthdays, phone numbers and names of friends.
Since moving in with her daughter, Rosie has been choosing
inappropriate clothing for the season and is refusing to participate
in her normal social activities. She seems moody at times and has
been forgetting to take her daily medications.
Rosie is most likely in what stage of Alzheimer’s Disease:
Click on the correct shape below!
Stage 1
Stage 4
Stage 5
Stage 7
Sorry, try again!
Rosie’s cognitive
ability is affected.
Stage 1, is “No,
Impairment”.
You’re Correct!
Rosie is most likely
in the early stages of
Alzheimer’s Disease.
Sorry, try again!
Rosie’s impairment is not
as severe as Stage 5.
Sorry, try again! Rosie’s
impairment is not as severe
as Stage 7.

12. PATHOPHYSIOLOGY Anatomy 101: The Brain
What area does what?
Parietal
Lobe
Occipital
Lobe
Frontal
Lobe
Temporal
Lobe
(Image credit: Alzheimer’s Disease Education and Referral Center, NIA. Picture used with permission from the Alzheimer’s Association)
Roll Over Each Lobe To Find Out!
(Porth and Maftin, 2009)

13. PATHOPHYSIOLOGY Anatomy 101: A Brain Cell
Neuron: A brain cell affected by Alzheimer’s Disease
Click on a box to label
the parts of a neuron!
Schwann cells surrounds axon
Nissl Bodies
Cell Body
Axon Terminals
Dendrite
Axon
Nucleus
The three main parts of a neuron:
Axon: The extension from the neuron cell body that takes information away from the cell body.
Cell Body (S0ma): The part of the cell that contains the nucleus.
Dendrite: Extensions from the neuron cell body that takes information to the cell
body.
(Porth and Maftin , 2009)

14. PATHOPHYSIOLOGY Pathological Aspects
The major pathological features of Alzheimer’s Disease are the presence of
neuritic plaques, neurofibrillary tangles, and amyloid angiopathy .
NEUROFIBRILLARY
TANGLES
AMYLOID
PROCESSING
NEURITIC PLAQUES
Click on a box to learn about each feature contributing to the progression
of Alzheimer’s Disease.
(Porth and Maftin, 2009)

15. PATHOPHYSIOLOGY Pathological Aspects
NEURITIC PLAQUES
Neuritic plaques are clusters of protein fragments, arranged around a central amyloid core.
The most common type of deposits have fragment residues of amino acids in length.
Plaques are associated with degeneration of neurons at the synaptic junction,
affecting cell to cell communication.
As Alzheimer’s Disease progresses, plaque formation
increases.
Synaptic Junction
(Porth and Maftin, 2009)
(Wippolid, Carins, Vo, Holtzmann and Morris, 2007)

16. PATHOPHYSIOLOGY Pathological Aspects
NEUROFIBRILLARY
TANGLES
Are primarily composed of a protein called Tau wound around each other in a helical fashion.
They are resistant to chemical or enzymatic breakdown and remain in brain tissue after the
neuron dies.
Tangles destroy cell transport systems leading to neuron death.
Tangles have also been identified in other forms of dementia, although usually without
plaque formation, as found in Alzheimer’s Disease.
The relationship between tangles and plaques is not completely
understood.
Click on the picture to
learn more
about Tau…
(Alzheimer’s Association, 2011)
(Lippens, Sillen, Landrieu, Amniai, Sibille, Babier, Leroy, Hanoulle & Wiersuzeski, 2007)
(Wippolid, Garins, Vo, Holtzmann and
Morris, 2007)
(Porth and Maftin, 2009)
Here

17. PATHOPHYSIOLOGY What About Tau?
Tau protein is important in the structural stabilization of nerve cells, allowing transport of
necessary proteins and enzyme-containing vesicles essential for cell maintenance
and function.
Tau is only present in neurons.
Too much or too little Tau leads to neuronal dysfunction.
If Tau collapses, as it does in Alzheimer’s Disease, it twists into helical strands becoming
neruofibillary tangles.
When tangles form, cells begin to die.
(Alzheimer’s Association, 2011)
(Lippens et al, 2007)
(Wippolid et al, 2007)

18. Protofibrils and fibrils
PATHOPHYSIOLOGY Pathological Aspects
AMYLOID
PROCESSING
There are many types of amyloid proteins present in the body; B-amyloid is unique to the brain.
B-amyloid is a protein fragment that is snipped from a larger protein called Amyloid Precursor Protein (APP) which is associated with the cell membrane.
APP processing can follow two pathways, benign and harmful. As the harmful pathway progresses, B-amyloid protein fragments start sticking together forming oligomers.
Oligomers start to grow larger becoming protofibrils and fibrils; eventually other proteins and material are added forming neuritic plaques.
Click on each arrow below to progress the amyloid pathway to neuron death!
Neuron death
APP
B-amyloid fragments
Oligomers
Protofibrils and fibrils
Neuritic plaques
(Menon and Lutsep, 2010)
(Porth and Maftin, 2010)

19. PATHOPHYSIOLOGY Pathological Aspects
Click on the video to learn more !
"
(Retrieved from YouTube, 2011 and embedded with permission of the Alzheimer's Disease Education and Referral Center, a service of the National Institute on Aging, 2008).

20. PATHOPHYSIOLOGY Pathological Aspects
What does this all mean?
As plaques and tangles accumulate, neurons die. The cortex of the brain atrophies, initially damaging areas involved in thinking, planning and remembering.
As the disease progresses, the parietal and temporal lobes of the brain are particularly affected; these areas are related to communication and interpretation of sensory input.
Eventually, plaques and tangles spread to large portions of the brain causing severe atrophy
and cortical damage .
(Alzheimer’s Association, 2011)
(Porth and Maftin, 2009)
Click here
Tangle and plaque involvement are represented by shaded blue areas.
Images credit: Alzheimer’s Disease Education and Referral Center, NIA. Picture used with permission from the Alzheimer’s Association.)

21. PATHOPHYSIOLOGY Let’s Review!
Rosie has Stage 4 Alzheimer’s Disease. What three major factors
contribute to the progression of her symptoms?
Neurofibrillary tangles, confusion and dehydration.
B. Neuritic plaques, neuron repair and synapse junctions.
Neuritic plaques, neurofibrillary tangles and
amyloid processing.
D. Amyloid angiopathy, neuritic plaques and a history of falling. A. B. C. D.
Sorry, try again!
Confusion is a symptom
of AD. Dehydration is not
a major factor
contributing to the
progression of AD.
Sorry, try again!
Of these three,
only neuritic plaques
is a factor
contributing to AD.
You’re Correct!
Neuritic plaques, neurofibrillary
tangles and amyloid processing
are the 3 major factors contributing
to Alzheimer’s Disease.
Sorry, try again!
Falling is not a major
factor contributing
to the progression
of a AD.

22. may form oligomers that
PATHOPHYSIOLOGY Let’s Review!
Inside Rosie’s brain, neurofibillary tangles are forming. Which
protein fragment may be snipped from the larger APP,
eventually leading to the formation of oligomers?
Neuritic plaques
Amyloid Precursor Protein
C. A-amyloid
D. B-amyloid A. B. C. D.
Sorry, try again!
Neuritic plaques are
formed from clusters
of protein fragments.
Sorry, try again! Amyloid
Precursor Protein is APP.
Sorry, try again!
Alpha amyloid is
Not correct.
You’re Correct!
B-amyloid fragments
may form oligomers that
eventually form
neuritic plaques, in
people with AD.

23. IMMUNE AND STRESS RESPONSE
Alzheimer’s Disease and the IMMUNE RESPONSE…
What is the IMMUNE RESPONSE?
“The collective response of cells and molecules of the Immune System” (Porth and Maftin, 2009).
The Immune System includes:
1. Innate and Adaptive immunity (barriers to microbes/antigen recognition).
2. Cells ( Leukocytes, Lymphocytes, and Dendritic Cells).
3. Cytokines (Proteins that stimulate cells of the immune system to respond).
The Immune Response
Cells
Immunity
Cytokines
(Porth and Maftin, 2009)

24. IMMUNE AND STRESS RESPONSE
Alzheimer’s Disease and the IMMUNE RESPONSE
An activated IMMUNE RESPONSE will begin the INFLAMMATORY PROCESS.
There are two types of inflammatory process:
Acute: Short in duration. Characterized by exudate seeping into tissues, heat,
swelling, pain.
Chronic : Long in duration, lasting days to years. Presence of WBC’s, fibrosis and
tissue necrosis.
Redness,
Swelling Heat
Pain,
Systemic Response
Inflammatory Response
(Porth and Maftin, 2009)

25. IMMUNE AND STRESS RESPONSE
Alzheimer’s Disease and the IMMUNE RESPONSE….
The exact role the IMMUNE RESPONSE plays in AD is still uncertain; however it has been attracting attention in research in four ways:
As a first responder to initial pathological AD events.
2. Assisting in clearing of the toxic by-products of APP processing.
3. Provider of protection to neurons.
4. As a possible target for treatment strategies.
Click here four times!
(Cohen, 2009)

26. IMMUNE AND STRESS RESPONSE
Alzheimer’s Disease and the IMMUNE RESPONSE
Facts about “Microglia”; the first responders to initial Central Nervous System
damage….
Microglia are immune cells of the Central Nervous System (CNS). They are considered to be in a “resting state” until activated.
Upon CNS injury, microglia are triggered from the
substances released from the damaged tissue.
Activated microglia release growth factors,
anti-inflammatory factors, and protective
substances (cytokines) to restore
damaged tissue.
Click on the
picture
to learn
more about
Microglia and AD.
Here
(University of Washington, 2008)

27. IMMUNE AND STRESS RESPONSE
Alzheimer’s Disease and the IMMUNE RESPONSE
Microglia and Alzheimer’s Disease…
Microglia immune response contributes to the progression of Alzheimer’s Disease, although exact contributions are not really known.
In people with Alzheimer’s disease microglia
are found in close association with B-amyloid.
Microglia respond to abnormal APP
processing by assisting in the clearing of toxic
by-products.
Their role in the CNS may be far more complex
than previously appreciated.
(Cohen, 2009)
(Mandrekar-Colucci and Landreth, 2010)

28. IMMUNE AND STRESS RESPONSE
Alzheimer’s Disease and the STRESS RESPONSE
What is the STRESS RESPONSE?
Stress is a state of symptoms arising from the “coordinated activation of the
neuroendocrine and immune system”(Porth and Maftin, 2009). It was first described by Hans Selye, an
endocrinologist in the 1930’s. He called it the General Adaptation Syndrome (GAS).
(Porth and Maftin, 2009)
Stressors
Stressors
Activation of
GAS
Hormones and Neurotrans-mitters
Releases
Activating the GAS releases hormones and neurotransmitters alerting the body
to stressors. Adaptations are made within the body to return it to a
balanced state.
(Porth and Maftin, 2009)

29. IMMUNE AND STRESS RESPONSE Let’s Review!
Which type of cell inside Rosie’s Central Nervous System clear toxic by-products of APP processing?
A. Neurons
B-amyloid
C. Monocyte
D. Microglia A. B. C. D.
Sorry, try again!
Neurons are brain
cells.
Sorry, try again!
B-amyloid is a
protein fragment.
Sorry, try again!
Monocytes are white
blood cells related to
Microglia.
You’re Correct!
Microglia clear
toxic by-products of
APP processing.

30. IMMUNE AND STRESS RESPONSE Let’s Review!
Inside Rosie two complementary systems are triggered in the
pathology of AD. Which two systems are involved?
Immune and Stress
Digestive and Immune
C. Skeletal and Stress
D. Neurological and Respiratory A. B. C. D.
You’re Correct!
Although how, is
not exactly known!
Sorry, try again!
This is not correct.
Sorry, try again!
This is not correct.
Sorry, try again!
This is not correct.

31. GENETICALLY SPEAKING Alzheimer’s and Genetics Late-Onset Early-Onset
There are two types of Alzheimer’s Disease, early-onset and late onset; both have genetic links:
Late-Onset
Early-Onset
Rare; only 5% of all people who have AD.
Develops in people ages years old.
Some cases of early-onset AD are inherited; they are called Familial AD (FAD).
FAD is caused by gene mutations on specific chromosomes 21, 14, and 1.
These mutations form abnormal amyloid precursor protein (APP), causing increased amounts of B- amyloid.
If a person inherits either chromosomes, 21,14, or 1 they will almost always develop AD.
Most cases of AD are Late-Onset.
Develops after age 60.
Gene mutations found in early-onset are not found in late-onset.
A specific gene for late-onset has not been identified.
A pre-disposing genetic risk does exist related to, apolipoprotein E (APOE) gene, found on chromosome 19.
(National Institute of Aging, 2008)

32. GENETICALLY SPEAKING Genetic Research and Alzheimer’s Disease
Research in AD genetics has intensified regarding questions related to “What makes
the disease process begin?” and “What role do AD risk-factor genes interacting with other
genes, lifestyle and/or environmental factors affect the risk of developing AD?”
Focuses on prevention and treatments.
Scientist believe four to seven more AD risk-factor genes exist and are working to discover
them.
A major goal is to develop accurate reliable screening tests; however they may never be
able to predict with 100% accuracy.
(National Institute of Aging, 2008)

33. risk factor gene related
GENETICALLY SPEAKING Let’s Review!
Rosie has late-onset Alzheimer’s Disease. What predisposing risk
factor gene may have interacted with lifestyle and environmental factors
increasing Rosie’s chances of developing Alzheimer’s Disease?
Chromosome 21.
B. APOE gene.
Amyloid Precursor Protein (APP).
D. Chromosome 1. A. B. C. D.
Sorry, try again!
Chromosome 21 is
related to early-onset
AD.
You’re Correct!
APOE gene has
been identified as a
risk factor gene related
to late-onset AD.
Sorry, try again!
APP is related to the
formation of tangles
found in both late &
early-onset AD.
Sorry, try again!
Chromosome 1 is related to early-onset AD.

34. WHAT ARE CHALLENGING BEHAVIORS?
“People only see what they are prepared to see….” (Ralph Waldo Emerson
ThinkExist.com, 2011)
Rosie’s has progressed to Stage 6 of Alzheimer’s Disease. She started to wander
from home and became very verbally abusive. Her family was no longer able to care for
her at home and placed her in a long-term care facility. Nursing staff has reported Rosie
to be verbally abusive, fearful, and combative with bathing. She also continually calls out
“ I want to go home!”.
Click Here
Click Here
Problem
Behaviors
Challenging
Behaviors
Rosie
What Do You See?

35. Combative Aggressive Behavior Repetitive Behavior/Repetitive Questions
WHAT ARE CHALLENGING BEHAVIORS?
What are typical CHALLENGING BEHAVIORS exhibited by people
who have Alzheimer’s Disease?
Agitation
Suspicious Behavior
Verbal Abuse
Combative Aggressive Behavior
Yelling
Depression
Fear and Anxiety
Wandering
Repetitive Behavior/Repetitive Questions
Click Here!
(Alzheimer’s Association,2011)

36. WHAT ARE CHALLENGING BEHAVIORS?
In long-term care settings CHALLENGING BEHAVIORS might be exhibited…
At change of shift.
With bathing/showering.
In the evening.
With different or new caregivers.
With nursing treatments.
During the night.
After being contradicted.
After being given complicated instructions.
After a day out with family.
When frustrated with simple tasks.
Click Here!
(Alzheimer’s Association,2011)

37. WHAT ARE CHALLENGING BEHAVIORS?
Why do CHALLENGING BEHAVIORS occur?
May be related to deterioration of brain due to disease pathology in areas that regulate
impulse control, emotions and sensory processing.
May be related to pain that can be felt, but not articulated or specifically identified.
May be related to an underlying medical condition, like a urinary tract infection or pneumonia.
May be related to side effects of medications.
May be triggered by environmental conditions, for example lighting, noise or agitated
behaviors of others.
Click on the picture to find out!
(Alzheimer’s Challenging Behavior Task Force, 2010)

38. WHAT ARE CHALLENGING BEHAVIORS?
Whatever the source, a caregiver’s response may improve or make the behavior worse. In this way, “behaviors are best seen as a dynamic interaction between the person with dementia, the caregiver and the specific environment.”
(Alzheimer’s Challenging Behavior Task Force, 2010)
Stressors in Environment
Response of Caregiver
Challenging Behavior
Influences
Rosie
(Alzheimer’s Challenging Behavior Task Force, 2010)

39. WHAT ARE CHALLENGING BEHAVIORS?
Let’s Review!
Since moving into the long-term care facility, Rosie’s challenging behavior
of yelling and resisting bathing has worsened. What factors may be
affecting her behavior?
Caregiver’s response to the bathing experience.
Progression of AD affecting Rosie’s Parietal and Temporal lobes of her brain.
Environment of shower room, including lighting, sounds and temperature.
D. All of the above. A. B. C. D.
Sorry, try again!
This could be a
contributing factor.
Sorry, try again! This could be a contributing factor.
Sorry, try again!
This could be a contributing factor.
You’re Correct! All of these factors could be influencing Rosie’s behavior.

40. Stressors in Environment
NURSING MANAGEMENT OF UNMET NEEDS
What are unmet needs?
Physical Needs: Pain, illness, hunger, thirst, constipation, fatigue, response to
incontinence, side effects related to medications, impaired vision or hearing.
Affective Needs: Intolerance of environmental stressors (overstimulation from
noise, lighting, etc.), boredom, loneliness, balance of sensory-stimulating verses
sensory-calming activities, meaningful human interaction.
Stressors in Environment
(Alzheimer’s Association, 2011)
(Alzheimer’s Challenging Behaviors Task Force, 2010)
(Kovach, C., Logan, B., Noonan, P., Schlidt, A.,
Smierz, J., Simpson, M., & Wells, T., 2006)
Rosie
“When behavioral symptoms are unnoticed, dismissed or not understood as symptoms of
unmet needs, the needs of the older person with dementia are missed…” (Kovach et al, 2006).

41. NURSING MANAGEMENT OF UNMET NEEDS
What is YOUR response?
Do you CONSISTENTLY DO A COMPLETE PHYSICAL ASSESSSMENT with anyone
experiencing behavioral problems, especially when symptoms appear suddenly?
Do you DISMISS BEHAVIOR SYMPTOMS, as “typical or normal behavior” for that person?
Do you CONSIDER ENVIRONMENTAL STRESSORS OR PHYSICAL NEEDS WITH anyone
experiencing behavior problems?
Do you CONSIDER PERSONAL PREFERENCES with every activity? (What did the person
enjoy/like prior to be moved to the facility?
Response of Caregiver
(Alzheimer’s Challenging
Behavior Task Force, 2010)
(Alzheimer’s Association, 2011)
(Kovach et al, 2006)
Rosie
“….failure to recognize behavior as symptoms leads to the under treatment of many needs.” (Kovach et al, 2006).

42. NURSING MANAGEMENT OF UNMET NEEDS
Possible BARRIERS….
Time
Disengaged Staff
Float Staff
Lack of Knowledge
Response of Caregiver
Barriers
Rosie
(Alzheimer’s Challenging Behavior Task Force, 2010)
(Simpson, Stevens, & Kovach, 2007)

43. NURSING MANAGEMENT OF UNMET NEEDS
To manage a CHALLENGING BEHAVIOR….
Assess for physical needs and intervene as necessary:
Pain
Thirst
Physical illness
Hunger
Constipation
Incontinence
Vision
Hearing
(Kovach et al, 2006)
“It takes an average of 23 minutes to manage disruptive behaviors. Agitated
behaviors are contagious, so it is advantageous to get them under control as soon as
possible” (Alzheimer’s Challenging Behavior Task Force, 2010).

44. NURSING MANAGEMENT OF UNMET NEEDS
To manage a CHALLENGING BEHAVIOR….
Assess for affective needs and intervene as necessary:
Environment (lighting, noise level, movement)
Overstimulation/Understimulation
Boredom
Loneliness
Need for human contact
Fear
New or different staff
(Kovach et al, 2006)
“It takes an average of 23 minutes to manage disruptive behaviors. Agitated
behaviors are contagious, so it is advantageous to get them under control as soon as
possible” (Alzheimer’s Challenging Behavior Task Force, 2010).

45. NURSING MANAGEMENT OF UNMET NEEDS
To manage a CHALLENGING BEHAVIOR….adapt YOUR response:
Stop the activity that could be contributing to the behavior.
Try to distract with something enjoyable.
Stay calm.
Don’t argue.
Respond to the emotions underlying the behavioral need.
Ask yourself, “If safety is not an issue, can the behavior be accepted?”
Stop
Distract
Stay Calm
Respond
Is it OK?
“It takes an average of 23 minutes to manage disruptive behaviors. Agitated
behaviors are contagious, so it is advantageous to get them under control as soon as
possible” (Alzheimer’s Challenging Behavior Task Force, 2010).
(Alzheimer’s Association, 2011)
(Kovach et al, 2006)

46. NURSING MANAGEMENT OF UNMET NEEDS
To manage a CHALLENGING BEHAVIOR….
Person-Centered Care:
“Care provided according the residents’ needs, desires and preferences”
(Alzheimer’s Challenging Behaviors Task Force, 2010).
Adapting the environment by encouraging “a continuous process of listening, trying new things, seeing how they work and changing in an effort to individualize care”(Alzheimer’s Challenging Behaviors Task Force, 2010).
“Person-Centered care seeks to maximize choice and autonomy, and thus can
reduce the presence of challenging behaviors”(Alzheimer’s Challenging Behaviors Task Force, 2010).
Rosie’s Choices:
Click on Rosie for her choices!
Likes to go to bed 22:30pm.
Prefers waking up at 9:30.
Does not like showers, baths only.
Coffee, black, 2 sugars.
Likes gardening, and quilting.
Rosie

47. NURSING MANAGEMENT OF UNMET NEEDS
Let’s Review!
The next time Rosie becomes verbally abusive at her care-givers while
being given a shower, the nurse should…
Ensure Rosie’s showering routine is designed around her preferences.
Assess Rosie for physical needs, specifically pain.
Stop the shower and stay calm.
D. All of the above. A. B. C. D.
Sorry, try again!
Sorry, try again!
Sorry, try again!
You’re Correct!
Assessing for pain,
stopping the shower, staying calm and being person-centered may meet Rosie’s unmet needs.

48. behavior may be related to an unmet need, like pain.
NURSING MANAGEMENT OF UNMET NEEDS
Let’s Review!
As Rosie’s nurse, what can you do to affect Rosie’s possibility of
exhibiting future, challenging behaviors?
Call Rosie’s physician and ask them to increase the dosage of Rosie’s
scheduled anti-psychotic.
Plan to dismiss Rosie’s behavior as normal.
Identify Rosie’s challenging behavior as an unmet need and be prepared to assess both physical and affective stressors.
D. Insist with Rosie she needs to stop behaving this way. A. B. C. D.
Sorry, try again!
This should not be your
first choice.
Sorry, try again!
By dismissing Rosie’s
behavior as normal, you
may miss an unmet
need.
You’re Correct!
Rosie’s challenging
behavior may be related to an unmet need, like pain.
Sorry, try again!
Arguing with Rosie may make the situation worse.

49. REFERENCES
Alzheimer’s Association. (2011). The challenging behaviors of Alzheimer’s disease. Portland, OR:
Author.
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