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Clinical Governance and Practice Improvement

National investigation agency has proposed a set of interventions to be implemented by National Academies which will comprise of experts who will make a committee and provide a n AHRQ systematic review . The results from the interventions will be used as the primary evidence base for implementations and recommendations to be be put into action in public health care sector comprising of the steps for preventing , delaying of mild cognitive impairment (MCI) and clinical Alzheimer's-type dementia (CATD)

The expert testimony which was provided in the public health workshop , after the after the release of the draft AHRQ systematic review. This helped in a feedback mechanism to be established and inform the general public about the therapeutic strategies.

 What Is Alzheimer’s Dementia

Alzheimer’s dementia is a disease in which a combination of two brain disorders is known to worsen the brain memory. 70% of the patients with dementia have Alzheimer’s disease, also it affects the people age 65 or above. Thus most senior citizens loose out their memories as the disease progresses. In this disease it was observed that elevated levels of cathepsin D (Cat D) mRNA were found using insitu hybridization in 90 percent of the pyramidal neurons in lamina by V and 70 percent in lamina III as compared to neurologically normal controls.

There are so many abnormalities that usually are a representation of a alteration in the normal amyloid precursor protein processing.

It was nearly inquired for a century the cause or the reasons for Alzheimer’s disease or AD, but no reason could be found. In this paper the provision for all the clinical and basic evidence is taken care of in development and occurrence of AD is given.

The pathological events in the brain get triggered in Alzheimer’s dementia and there is impairment of cerebral perfusion, thus leading to initiation in the microvasculature and affecting the normal delivery of glucose and oxygen . This consequently leads to breakdown of metabolic energy of brain cells and also alteration of biosynthetic pathways and synaptic pathways (Forstmeier, Maercker, Savaskan & Roth, 2015). For the cognitive cause there are majorly two factors are proposed which are:

  • Advance Ageing: This factor includes a very normal process of ageing, which includes a very normal but potentially menacing process of increased ageing by lowering the cerebral blood flow.
  • Lowering of cerebral perfusion: This factor mainly includes factors like vascular risk factor. This factor usually adds up to an increased burden which lowers the perfusion of brain , which in a state of metabolic compromise that is it places neurons is very vulnerable state which in turn leads to death pathway.

The above mentioned two factors basically leads to a term called CATCH. CATCH refers to a critically attained threshold of cerebral hypo perfusion of the neural activity of the brain. It means it is a self-sustaining insufficiency which is a progressive circulatory insufficiency. This insufficiency later on leads to destabilized neutrons, synapses, neurotransmission or any cognitive function which in turn creates a neurodegenerative process which would characterize by the formation of senile plaques or neurofibrillary tangles, amyloid angiopathy and even Lewy bodies in some cases.

The huge impact of AD on patients is accompanied with similar impact on families, society, and the health care system. But there are no such biological markers to identify the people who have increased risk for AD. Also use of public health strategies for prevention of AD and the treatments to address the pathology of the disease or stop the further progression of the disease. There are a lot of scientific and empirical proofs for AD being caused by obesity. This prevention and treatment could actually prove to be a very causative pathway. This prevention and treatment for obesity if done on time then the person could have lesser chance of getting an AD. The clinical evidence of obesity being a factor or taking obesity related factors like insulin resistance, hyperglycemia or any other kind of diabetes. So, evidence regarding efficacy or anti-obesity treatments can help with this disease.

Also, it very evidently proven that there is an increased evidence that the glutamate mediated neurotoxicity is a major factor involved in the pathogenesis of the Alzheimer’s dementia.

 A very recent study has given some more non questionable clinical evidences on aluminum being a very important and possible risk factor. Human ingestion of aluminum according to this study in Ontario have proven to be a self-sufficient proof that aluminum is a very important factor contributing to the risk of AD syndrome. It says Aluminum acts as a pathogenesis of AD which conducted a clinical trial which contains aluminum that have trivalent metal ions with binding compound called deferoxamine.

Interventions for Cognitive and Behavioral Improvements and Comparison with Other Studies

The study design was a 2 year trial in which 63 patients were kept under observations. In this those 63 patients who had probable risk of AD were selected which involved participants who were living at home and had age near about 65 years.

48 of them were selected for initial testing and main evidence was a video recorded things of their day to day activities or home behavior in the videos. The main outcome recorded was that daily tasks and habits involved in the lifestyle for that group without any help or treatment was 1.72% and 0.82% as compared of patients who were treated with desferrioxamine. This is enough proof that aluminum acts as a pathogen in AD syndrome and needs to be taken care of.

By this experimental model this was very clear that aluminum acts as a neurotic in the pathogenesis of the AD syndrome. This means that the toxic concentrations is affected in the regions of brain affected by Alzheimer’s. The brain biopsies clearly shows the neurofibrillary tangles from very early affected tissues or brain cells in postmortem the gray matter was found. (Brookmeyer, Johnson, Ziegler-Graham & Arrighi, 2007)

Major proportion of the workers agreed that increased levels of aluminum are present in brain cells affected with Alzheimer’ dementia ,there were people who believed that precise aluminum can actually be helpful which helps in the degenerative process of AD.

This type of neurofibrillary tangles were composed of helical paired segments . Also aluminum is a dementing ion which induces changes in learning and brain memory that possibly contributes to dementia (Forstmeier, Maercker, Savaskan & Roth, 2015)

The approach of Cognitive behavioural therapy (Chen, Borson & Scanlan, 2000) includes a talking session, the ultimate aim of which is to help patients with Alzheimer’s dementia and understanding the links between feelings ,thoughts and behaviours of the diseased individual . This will help to introduce some positive changes in the patients to avoid further progression of the disease.

According to Livingston et al, a large number of approaches are used and the level of evidence was studies along with grading their recommendation based on the Oxford Centre for Evidence-Based Medicine criteria. The most widely accepted approach was behavioural management techniqueswhich relied on the caregiver, including psychoeducation (Shin, Carter, Masterman, Fairbanks & Cummings, 2005)and training was given for interaction with the dementia patients. Then some techniques focused upon pleasant activities and problem solving, multisensory stimulation, active music therapy and cognitive stimulation.

These therapeutic stimulations were identified by UK National Collaborating Centre for Mental Health and on basis of evidence it was concluded that, behavioural management had a significant effect on reducing behavioral challenges whereas cognitive behavioural therapy (CBT) promises greater assurance for reducing the stress and anxiety in individuals suffering from this disease.

The treatment involved two strategies i.e. increasing engagement in pleasant activities and secondly use of behavioural problem-solving strategies. The individuals in both intervention groups showed significant improvements in stress and anxiety symptoms when compared with other group not given this therapy , and these improvements sustained for six months after the completion of the trial .

The treatment involving pleasant events resulted in a huge impact (d = 0.9–1.7 for 3 different depression measures) showing significant clinical improvement accounting to 52 % as compared to 20 % in the control groups.

Also it was observed that caregivers’ depression scores (Yaffe, 2002) improved significantly , but no improvement was noticed in caregivers belonging to the control groups. Increased engagement of the patients in physical, social and other leisure activities not only reduces depression but also it was shown that this helped to reduce the amount of daytime sleep taken by the patients, and also for improving night-time sleep patterns. The ultimate result of this pleasure activity engagement was that it helped in reducing unnecessary wandering and roaming around of individuals and reduced aggression and agitation which was noticed otherwise before the therapy .

References for Cognitive-Behavioral Therapy for Alzheimer’s Dementia

Forstmeier, S., Maercker, A., Savaskan, E., & Roth, T. (2015). Cognitive behavioural treatment for mild Alzheimer’s patients and their caregivers (CBTAC): study protocol for a randomized controlled trial. Trials16(1).

Brookmeyer, R., Johnson, E., Ziegler-Graham, K., & Arrighi, H. (2007). Forecasting the global burden of Alzheimer's disease. Alzheimer's & Dementia3(3), 186-191.

Chen, J., Borson, S., & Scanlan, J. (2000). Stage-Specific Prevalence of Behavioral Symptoms in Alzheimer's Disease in a Multi-Ethnic Community Sample. The American Journal Of Geriatric Psychiatry8(2), 123-133.

 Shin, I., Carter, M., Masterman, D., Fairbanks, L., & Cummings, J. (2005). Neuropsychiatric Symptoms and Quality of Life in Alzheimer Disease. The American Journal Of Geriatric Psychiatry13(6), 469-474.

Yaffe, K. (2002). Patient and Caregiver Characteristics and Nursing Home Placement in Patients With Dementia. JAMA287(16), 2090.

Remember, at the center of any academic work, lies clarity and evidence. Should you need further assistance, do look up to our Nursing Assignment Help

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