Alzheimer's Disease & Dementia

The patient with Alzheimer's doesn't forget how to feel — they forget how to tell you. Your nursing care pivots on understanding what stage drives which safety priority.

Alzheimer's disease is the most common cause of dementia, accounting for 60-80% of cases. It follows a progressive, irreversible pattern of cognitive decline through predictable stages. In early (mild) disease, the patient has short-term memory loss, misplaces objects, and gets lost in familiar places — safety risks center on medication management and driving. In moderate disease, aphasia, apraxia, and agnosia emerge: the patient can't name objects, can't perform learned motor tasks, and can't recognize familiar faces. Wandering peaks here, making this the highest-risk stage for elopement. Sundowning — increased confusion and agitation in late afternoon — is managed with structured routines, adequate lighting, and limiting stimulation, not restraints. In severe (late) disease, the patient is bedbound and nonverbal; priorities shift to aspiration prevention, skin integrity, and comfort care. Nursing assessment uses standardized tools like the Mini-Mental State Exam (MMSE; score ≤23 suggests cognitive impairment) or the Montreal Cognitive Assessment (MoCA). Reality orientation works in early stages; validation therapy is preferred in moderate-to-severe stages because correcting a confused patient increases agitation. Communication should be simple, one-step commands with yes/no questions. Environmental safety — locked units, ID bracelets, consistent routines, and decluttered spaces — is the nurse's primary intervention across all stages.

Key Distinctions

Don't confuse delirium with dementia: delirium is acute onset and reversible, dementia is gradual and irreversible — a sudden change in cognition in a dementia patient should trigger a delirium workup. Students mix up reality orientation (appropriate early stage) with validation therapy (appropriate moderate-to-severe) — using the wrong approach worsens behavior. Sundowning is not the same as nocturnal delirium; it is a predictable late-afternoon pattern managed environmentally, not pharmacologically.

Clinical Pearl

Think "3 A's of moderate Alzheimer's": Aphasia (can't find words), Apraxia (can't do), Agnosia (can't recognize). When you see the 3 A's, wandering risk is at its peak.