Introduktion: Beteendemässiga och psykiska symptom (BPSD) är vanligt förekommande hos personer med Alzheimers sjukdom. Det påverkar den enskilde, närstående och vårdgivare negativt. Läkemedelsbehandling ska inte ses som ett förstahandsalternativ utan fokus ska istället ligga på omvårdnadsinterventioner. Syftet var att beskriva omvårdnadsinterventioner som kan lindra beteendemässiga och psykiska symptom hos personer med Alzheimers sjukdom. Metoden var litteraturstudie där tio artiklar inkluderades efter kritisk granskning. Artiklarnas innehåll analyserades och sex kategorier med omvårdnadsinterventioner bildades: musikterapi, fysisk aktivitet, ljusterapi, kognitiv rehabilitering, terapeutiska samtal samt djurterapi. Resultatet visade att det fanns omvårdnadsinterventioner som påverkade BPSD för stunden men inget som varade över tid. Slutsats: Studien visar att det finns begränsat med forskning där omvårdnadsinterventioner ger god effekt på BPSD hos personer med Alzheimers sjukdom. / Introduction: Behavioral and Psychological Symptoms of Dementia (BPSD) are common in people with Alzheimer’s disease. This affects the individual, family members and caregivers adversely. Drug treatment should not be seen as a first choice, but the focus should instead be on nursing interventions. The aim was to describe nursing interventions that can alleviate behavioral and psychological symptoms in people with Alzheimer's disease. The method was a literature review in which ten articles after critical review were included. The contents of the articles were analyzed and six categories of nursing interventions were formed: music therapy, physical activity, light therapy, cognitive rehabilitation, therapeutic conversation and animal assisted activity. The results showed that there were nursing interventions that affected BPSD for the moment but nothing that lasted over time. Conclusion: The study shows that there is limited research in which nursing interventions gives good effect on BPSD in people with Alzheimer's disease.

A doença de Alzheimer é uma doença neurodegenerativa que causa perdas de memória, danos cognitivos e no comportamento, sendo considerada uma das causas principais de demência entre a população. Esta doença é caracterizada por uma intensa perda neuronal colinérgica, de forma que tanto os inibidores da enzima acetilcolinesterase (AChE) quanto compostos antioxidantes possam ser empregados como neuroprotetores. Nesse sentido, plantas da família Lycopodiaceae vêm sendo estudadas como fonte de novos alcalóides anticolinesterásicos desde a descoberta da huperzina A, isolada a partir da planta chinesa Huperzia serrata. Este trabalho foi realizado com o objetivo de caracterizar e isolar os alcalóides majoritários de Huperzia acerosa, H. heterocarpon, H. quadrifariata, H. reflexa, Lycopodiella cernua, Lycopodium clavatum e L. thyoides, de ocorrência no estado do Rio Grande do Sul, bem como avaliar as atividades anticolinesterásicas e antioxidantes in vitro e in vivo para os extratos. Extratos de alcalóides totais de espécies de L. clavatum e L. thyoides ocorrentes no Brasil e Argentina foram comparados quanto ao seu conteúdo químico, aliado à atividade anticolinesterásica. A atividade inibitória para AChE e butirilcolinesterase (BuChE) dos alcalóides isolados também foi ensaiada, juntamente com a determinação das propriedades citotóxicas exercidas pelos extratos sobre uma linhagem de gliomas C6. Todos os extratos de alcalóides foram analisados através de CG-EM, sendo os perfis de fragmentação dos compostos comparados através de dados da literatura. L. clavatum e L. thyoides possuem perfil químico similar, com licopodina e acetildiidrolicopodina como alcalóides principais, enquanto que L. cernua possui apenas dois alcalóides, cernuína e licocernuína. Os extratos de alcalóides de H. acerosa, H. quadrifariata e H. reflexa também foram analisados, sendo detectados tanto compostos do grupo licopodano quanto do grupo flabelidano, juntamente com outros alcalóides cujas estruturas ainda são desconhecidas. Os alcalóides encontrados em H. heterocarpon não puderam ser elucidados a partir de dados de fragmentação, uma vez que eles não coincidiram com nenhum perfil da literatura. Nesse estudo verificamos que dentre os extratos analisados, H. quadrifariata e H. reflexa promoveram a maior inibição para a enzima AChE obtida de eritrócitos humanos, com IC50 de 2,0 e 0,11 μg/mL, respectivamente, enquanto que H. heterocarpon foi o único extrato com maior seletividade para a BuChE (IC50 = 8,3 μg/mL). Além disso, dentre os alcalóides isolados licopodina, acetildiidrolicopodina, cernuína, licocernuína e clavolonina, apenas acetildiidrolicopodina e cernuína possuem inibição importante, sendo que nenhum deles possui efeito butirilcolinesterásico significativo. Também foi estimada a atividade anticolinesterásica para os extratos de alcalóides totais de L. clavatum e L. thyoides empregando-se homogenatos de córtex, hipocampo e estriato de ratos como fonte enzimática, sendo determinadas suas curvas de inibição com distintos tempos de incubação em uma faixa de concentrações. Também foi verificada para os dois extratos uma inibição do tipo competitiva/não-competitiva, bem como seu perfil antioxidante in vitro pelos métodos de descoloração do radical DPPH, degradação da 2-deoxirribose, TRAP e óxido nítrico. Após um tratamento agudo em camundongos de 14 meses com os extratos, foram verificados os efeitos antioxidantes através do método de TBA-RS, e para as enzimas catalase e superóxido dismutase. Do mesmo modo, verificamos que os mesmos extratos promoveram uma diminuição na atividade da acetilcolinesterase, quando administrados por via intraperitoneal. Nessa metodologia, os extratos mais potentes foram H. quadrifariata e H. reflexa, corroborando o efeito in vitro encontrado para os mesmos. Os extratos purificados de alcalóides de L. clavatum e L. thyoides com habitat no Brasil e Argentina foram comparados quanto ao seu perfil químico e biológico. Nesse estudo, foi verificado que os alcalóides licopodina e acetildiidrolicopodina são os compostos majoritários para todas as espécies, tendo L. clavatum maior atividade anticolinesterásica em relação a L. thyoides, tanto a espécie brasileira quanto a espécie argentina. / Alzheimer’s disease is a neurodegenerative disease which causes memory loss, cognitive and behavioral damages, considered to be the leading cause of dementia among the elderly. This disease is characterized for an intense cholinergic loss, and the use of acetylcholinesterase (AChE) inhibitors together with antioxidant compounds as neurprotectors is a strategy for the treatment. In this sense, Lycopodiaceae plants are well studied as a source of new anticholinesterasic alkaloids since the discovery of huperzine A, isolated from Chinese Huperzia serrata. This work was conducted with the objective of characterize and isolate the main alkaloids from Huperzia acerosa, H. heterocarpon, H. quadrifariata, H. reflexa, Lycopodiella cernua, Lycopodium clavatum and L. thyoides, with occurrence in Rio Grande do Sul state, and also evaluate the anticholinesterasic and antioxidant activities in vitro and in vivo for the extracts. Alkaloidal extracts from L. clavatum and L. thyoides species with habitat in Brazil and Argentina were compared to their chemical content, together with their anticholinesterasic activity. The inhibitory effect for AChE and butyrylcholinesterase (BuChE) for the isolated alkaloids was also evaluated, together with the determination of the cytotoxic properties exherced by the extracts in a gliome C6 cell line. Every alkaloidal extract was analyzed by means of GC-MS, and the fragmentation patterns for the compounds were compared with those from literature. L. clavatum and L. thyoides have similar chemical profile, with lycopodine and acetyldihydrolycopodine as main alkaloids, while L. cernua has only two alkaloids, cernuine and lycocernuine. The alkaloidal extracts of H. acerosa, H. quadrifariata e H. reflexa were also analyzed, and compounds from lycopodane and flabellidane groups were detected, along with other alkaloids whose structures are still unknown. The alkaloids found in H. heterocarpon could not be elucidated with fragmentation dates so far, since they did not coincide with those found in literature. We also verified that among the extracts, H. quadrifariata and H. reflexa promoted a higher inhibition for AChE obtained from human erythrocytes, with a IC50 value of 2,0 e 0,11 μg/mL, respectively, while H. heterocarpon extract was the only more selective for BuChE (IC50 = 8,3 μg/mL). Moreover, among the isolated alkaloid lycopodine, acetyldihydrolycopodine, cernuine, lycocernuine and clavolonine, only acetyldihydrolycopodine and cernuine possess an important inhibition, and none significantly inhibited butyrylcholinesterase. It was also assessed the anticholinesterase effect for the alkaloidal extracts of L. clavatum and L. thyoides employing cortex, hippocampus and striatum rat brain homogenates as enzymatic sources, being determined the incubation time-inhibition curves over a concentrations range. It was also verified for both extracts an inhibitory effect of the competitive/non competitive mixed type, as well as their in vitro antioxidant profile using the methods of DPPH radical decoloration, 2-deoxyrribose degradation, TRAP and nitric oxide. After an acute treatment in 14 months-aged mice, we verified the antioxidant effects though TBA-RS and also the enzymes catalase and superoxide dismutase. In the same way, we found out that the same extracts reduced the acetylcholinesterase activity when administered by intraperitoneal injection. Using this methodology, the most potent extracts were H. quadrifariata and H. reflexa, corroborating the in vitro effect found for them. The purified alkaloidal extracts of L. clavatum and L. thyoides with habitat in Brazil and Argentine were compared to their chemical and biological profile. In this study, we found out that lycopodine and acetyldihydrolycopodine are the main alkaloids found for all species, and L. clavatum possesses a better inhibition against AChE when compared to L. thyoides for both Brazilian and Argentinean collected species.

Dining in a restaurant with a loved one who has dementia can be an ordeal, especially if the expectations of the caregiver do not match those of the patient and the restaurant environment is not suitable for patients with dementia. The size of the dining area, lighting, background music or noise, décor of the room, number of customers, variety of the items on the menu, number of plates and cutlery on the table, in addition to flowers, candles, and other decorations on the table are all potent distractors. There are so many stimuli; the patient can be overwhelmed with information overload and not able to focus on the main purpose of the event: have dinner and especially enjoy the other person’s company. In this case scenario, we present a 62-year-old man diagnosed with behavioral variant frontotemporal dementia (bvFTD). His daughter “invited” him to have dinner with her at a very fancy restaurant to celebrate her promotion at work. Unfortunately, whereas the evening started very well, it had a catastrophic ending. We discuss what went wrong in the patient/daughter interaction and how the catastrophic ending could have been avoided or averted.

Repetitive questioning is a major problem for caregivers, particularly taxing if they are unable to recognize and understand the reasons why their loved one keeps asking the same question over and over again. Caregivers may be tempted to believe that the patient does not even try to remember the answer given or is just getting obnoxious. This is incorrect. Repetitive questioning is due to the underlying disease: The patient’s short term memory is impaired and he is unable to register, encode, retain and retrieve the answer. If he is concerned about a particular topic, he will keep asking the same question over and over again. To the patient each time she asks the question, it is as if she asked it for the first time. Just answering repetitive questioning by providing repeatedly the same answer is not sufficient. Caregivers should try to identify the underlying cause for this repetitive questioning. In an earlier case study, the patient was concerned about her and her family’s safety and kept asking whether the doors are locked. In this present case study, the patient does not know how to handle the awkward situation he finds himself in. He just does not know what to do. He is not able to adjust to the new unexpected situation. So he repeatedly wants to reassure himself that he is not intruding by asking the same question over and over again. We discuss how the patient’s son-in-law could have avoided this situation and averted the catastrophic ending.

Diabetes mellitus is common among older people. Hypoglycemia is a sign of poorly controlled diabetes mellitus and may lead to irritability, agitation, anxiety, hunger, and an excessive food intake, which in turn may make the control of diabetes more difficult. Excessive, inappropriate food intake is also a sign of Fronto-Temporal Dementia (behavioral variant: bvFTD). In this case study, we describe the events leading to an altercation that developed between an older diabetic patient with bvFTD and the staff in an Assisted Living Facility. His first dose of insulin was given early that morning while he was still asleep. He, subsequently, woke up feeling hungry, agitated, and irritable. This, in turn, exacerbated the hyperorality associated with bvFTD. We examine what went wrong in the patient/caregiver interaction and how this potentially catastrophic situation could have been avoided or defused.

Patients with dementia, particularly Alzheimer’s disease, may not recognize that their clothes are dirty. They may see the food stains and discoloration of the clothes and yet because of their agnosia are unable to integrate these observations and deduce that their clothes are dirty and need to be changed. They will, therefore, resist attempts to get them to change clothes, especially if these clothes happen to be their favorite ones. This often causes caregivers to become frustrated, especially, if it represents a change in the patient’s previous habits of only wearing clean clothes. In this case study, we present a 72-year-old woman with moderate Alzheimer’s disease who lives with her daughter, who adamantly refuses to change the clothes she has been wearing for a few days and which are now clearly dirty. We report the interaction, highlight what went wrong in the patient–daughter interaction, and discuss how the catastrophic ending could have been avoided or averted.

Insomnia is a common problem in older people, especially in patients with mild cognitive impairment (MCI) whose circadian rhythm is often compromised. Insomnia exerts such a toll on caregivers that it is frequently the primary reason for seeking to institutionalize their loved ones. Three different types of insomnia are recognized: sleep-onset or initial insomnia, sleep maintenance or middle insomnia, and early morning awakening or late insomnia. Nocturnal hypoglycemia, as a cause of middle insomnia, is the main focus of this case study. Other types of insomnia are also briefly reviewed. The management of insomnia is then discussed including sleep hygiene, the usefulness and potential drawbacks of dietary supplements, nonprescription over-the-counter preparations and prescription hypnotics. Sleep architecture is then briefly reviewed, emphasizing the importance of its integrity and the role of each sleep stage.

Driving is a symbol of autonomy and independence, eagerly awaited during adolescence, cherished during adulthood and reluctantly rescinded during old age. It is nevertheless an individual’s privilege, not right, especially as driving may affect other drivers and pedestrians on the road. It is therefore not only the individual patient who is at stake but essentially the entire community. In this case scenario, we describe the situation that arose when a patient with multi-infarct dementia wanted to go for a drive and his son and grandson tried to convince him that he could no longer drive. What went wrong in the caregivers/patient interaction is presented. The futility of arguing with patients who have dementia is highlighted as well as the suspiciousness it may generate. Alternate actions that can be useful to avoid/avert the situation from escalating and having a catastrophic ending are discussed. Testing/evaluating patients with dementia for fitness to drive is also reviewed and a list of select resources is included.

Mild cognitive impairment (MCI) is the middle ground between normal, age-appropriate memory impairment, and dementia. Whereas patients with MCI are able to cope with the memory deficit, those with dementia are not: Their memory impairment and other cognitive deficits are of sufficient magnitude to interfere with the patients’ ability to cope independently with daily activities. In both MCI and dementia, there is evidence of declining cognitive functions from a previously higher level of functioning. In both the conditions, there is also an evidence of dysfunction in one or more cognitive domains. There are two subtypes of MCI depending on whether memory is predominantly affected: amnestic type and nonamnestic/behavioral type. Not all patients with MCI transition to dementia, some recover. In this case scenario, we present a 68-year-old man with MCI who lives with his wife. They are getting ready to host dinner. His wife asks him to vacuum the dining room while she runs an urgent errand. We describe how this simple task vacuuming a room ended in a catastrophe with the patient spending the night in jail and his wife hospitalized. We discuss what went wrong in the patient/wife interaction and how the catastrophic ending could have been avoided.

Choices are often difficult to make by patients with Alzheimer Dementia. They often become acutely confused when faced with too many options because they are not able to retain in their working memory enough information about the various individual choices available. In this case study, we describe how an essentially simple benign task (choosing a dress to wear) can rapidly escalate and result in a catastrophic outcome. We examine what went wrong in the patient/caregiver interaction and how that potentially catastrophic situation could have been avoided or defused.