Alzheimer's Disease Mgmt & Caregiver Care Materials

ALZHEIMER’S DISEASE MANAGEMENT AND CAREGIVER CARE

Faculty:

L. Austin Fredrickson, MD, FACP 

L. Austin Fredrickson is an Associate Professor of Internal Medicine at Northeast Ohio Medical University, where he serves as core faculty and teaches diagnostics, therapeutics, clinical skills, and health humanities. He is board-certified in general internal medicine and practices rural primary care. 

Ashley Walsh, PharmD

Ashley Walsh is a graduate of the University of Connecticut, School of Pharmacy. She received her Doctor of Pharmacy in 2013. Ashley Walsh has a Bachelor of Science in Pharmacy Studies and a Bachelor of Science in Molecular and Cell Biology from the University of Connecticut. She has practiced as a pharmacist since 2013.

Liz Fredrickson, PharmD, BCPS

Liz Fredrickson, PharmD, BCPS, is an Associate Professor of Pharmacy Practice and Pharmaceutical Sciences at the Northeast Ohio Medical University (NEOMED) College of Pharmacy, where she is course director of the Parenteral Products and Basic Pharmaceutics Lab courses.

Kristina (Tia) Neu, RN

Kristina (Tia) Neu is a licensed Registered Nurse and author currently developing in-service training for healthcare professionals. She is a National Board-Certified Health & Wellness and Lifestyle Medicine Coach. Her work experience includes several areas of the healthcare profession, such as psychiatric nursing, medical nursing, motivational health coaching, chronic case management, dental hygiene, cardiac technician, surgical technician, and clinical director of a Clinically Integrated Network (CIN).

Pamela Sardo, PharmD, BS

Pamela Sardo, PharmD, BS, is a freelance medical writer and licensed pharmacist. She is the founder and principal at Sardo Solutions in Texas. Pam received her BS from the University of Connecticut and her PharmD from the University of Rhode Island. Pam’s career spans many years in retail, clinics, hospitals, long-term care, Veterans Affairs, and managed health care responsibilities across a broad range of therapeutic classes and disease states.

Abstract

The factors causing Alzheimer’s disease are not fully known but likely include age, brain changes, family history, and lifestyle. Growing scientific evidence shows that healthy lifestyle habits reduce people’s risk for Alzheimer’s. Clinicians understand that early diagnosis and intervention are imperative to assist patients with Alzheimer’s disease. Early diagnosis preserves daily function, slows cognitive decline, and delays disease progression. Memory problems are often the first symptom of cognitive decline. Although there is no cure for Alzheimer’s disease, treatment aims to manage symptoms and maintain brain health. Ongoing clinical trials are focusing on more treatments for preclinical and early stages. Caregivers are essential to medication management for patients. Burdened with maintaining or improving the quality of life of a loved one and tasked with caring for patients with a progressive disease, caregivers face their own challenges. Counseling caregivers offers the education and support necessary to optimize patient care and well-being.

Accreditation Statements

In support of improving patient care, RxCe.com LLC is jointly accredited by the Accreditation Council^TM for Continuing Medical Education (ACCME^®), the Accreditation Council for Pharmacy Education (ACPE^®), and the American Nurses Credentialing Center (ANCC^®), to provide continuing education for the healthcare team.

This activity was planned by and for the healthcare team, and learners will receive 3 Interprofessional Continuing Education (IPCE) credits for learning and change.

Joint Universal Activity Number: The Joint Accreditation Universal Activity Numbers assigned to this activity are as follows:

Pharmacists: JA4008424-0000-26-143-H01-P

Credits: 3 contact hour(s) (0.3 CEU(s)) of continuing education credit.

Credit Types:

IPCE Credits - 3 Credits

AAPA Category 1 Credit™️ - 3 Credits

AMA PRA Category 1 Credit™️ - 3 Credits

Pharmacy - 3 Credits

Type of Activity: Knowledge

Media: Computer-Based Training (i.e., online courses)

Estimated time to complete activity: 3 contact hour(s) (0.3 CEU(s)), including Activity Pre-Test, Post-Test, and Activity Evaluation.

Release Date: July 12, 2026 Expiration Date: July 1, 2029

Target Audience: This educational activity is for Physicians, Physician Assistants, and Pharmacists.

How to Earn Credit: From July 12, 2026, through July 1, 2029, participants must:

Read the “learning objectives” and “author and planning team disclosures;”

Take the “Educational Activity Pre-Test;”

Study the section entitled “Educational Activity;” and

Complete the Educational Activity Post-Test and Activity Evaluation. The Educational Activity Post-Test will be graded automatically. Following successful completion of the Educational Activity Post-Test with a score of 70% or higher, a statement of participation will be made available immediately. (No partial credit will be given.)

CE and CME Credits: Credits for this course will be uploaded to CPE Monitor^® for pharmacists and pharmacy technicians. Physicians may receive AMA PRA Category 1 Credits™ and apply them toward Maintenance of Certification (MOC) requirements. Physician Assistants may earn AAPA Category 1 CME credits, reportable through PA Portfolio. All learners must verify their individual licensing board’s specific requirements and eligibility criteria.

Statement of Need

Healthcare professionals routinely encounter patients and caregivers affected by Alzheimer’s disease; however, there is no uniform approach to recognizing early warning signs or to distinguishing the disease from normal aging. Gaps remain in medication counseling and caregiver education. Caregivers often seek help with adherence, adverse effects, and understanding community resources. Early identification and timely counseling can improve outcomes and help families plan for care needs. This activity aims to strengthen practical patient-centered counseling, interprofessional referrals, and improve recognition of symptoms and treatment.

Learning Objectives: Upon completion of this educational activity, participants should be able to:

Recognize early symptoms of Alzheimer’s disease

Describe the difference between Alzheimer’s and age-related changes

List Alzheimer’s risk factors

Summarize medications used for Alzheimer’s symptom management and disease treatment

Identify resources and education to provide caregivers during counseling

Disclosures

The following individuals were involved in planning, developing, and/or authoring this activity: L. Austin Fredrickson, MD, FACP; Ashley Walsh, PharmD; Kristina (Tia) Neu, RN; and Pamela Sardo, PharmD, BS. None of the individuals involved in developing this activity has a conflict of interest or financial relationships related to the subject matter. There are no financial relationships or commercial or financial support relevant to this activity to report or disclose by RxCe.com or any of the individuals involved in the development of this activity. 

© RxCe.com LLC 2026: All rights reserved. No reproduction of all or part of any content herein is allowed without the prior, written permission of RxCe.com LLC.

Educational Activity Pre-Test

Blood-based biomarkers (BBMs) may enable early detection of Alzheimer's disease in patients with measurable cognitive decline; however, BBM tests may be skewed by comorbid medical conditions or other factors. Which of the following is most likely to skew a BBM test?

Patient is under 65 years of age

Patient has severe chronic kidney disease

Patient has a family history of Alzheimer's disease

Patient is anxious or depressed from time to time

Which of the following is an early sign of Alzheimer’s disease?

Difficulty completing familiar tasks, such as the rules of a favorite game

Becoming irritable when a routine is disrupted, such as bedtime

Misplaces belongings but is able to retrace steps to find them

Sometimes needs help recording a favorite television show

Which of the following medications require monitoring with magnetic resonance imaging to assess the risk of intracerebral hemorrhage?

Brexpiprazole

Galantamine

Rivastigmine

Lecanemab

Educational Activity

Alzheimer's Disease Management and Caregiver Care

Highlights The Alzheimer’s disease continuum includes six stages ranging from preclinical (stage 1) to severe dementia (stage 6). Blood-based biomarkers (BBMs) can detect early Alzheimer's disease and help streamline diagnostic processes. As Alzheimer's disease progresses, care transitions to a caregiver who is usually a family member Caregivers can enhance their coping skills and resilience by connecting with other caregivers in similar roles and with help from members of the patient’s healthcare team.

Introduction

Alzheimer’s disease is a progressive disease that involves cognitive decline, memory loss, and personality changes that lead to a patient’s inability to perform simple daily tasks. There are pharmacological treatments that can manage the symptoms of Alzheimer’s disease, but the patient will invariably need attention and care from a daily caregiver. This course will generally describe pharmacotherapy, patient and caregiver characteristics, counseling and support opportunities, and the need for respite care for the caregiver. Treatment plans for patients with Alzheimer’s involve interaction between the patient and the healthcare team. Team members connect with other healthcare team members and provide resources and assistance to caregivers as they help manage a patient’s condition and medications.

Overview of Alzheimer's Disease

An estimated 7.2 million Americans were living with Alzheimer’s disease (AD) in 2025.¹ Almost two-thirds of these patients are women (4.5 million).¹ By 2060, researchers expect this estimate to reach 13.8 million Americans aged 65 years and older who will be living with an AD diagnosis.¹

Alzheimer’s is a progressive disease that begins with mild memory loss and leads to a patient’s inability to complete simple daily tasks.¹ Currently, there is no cure.¹ Available interventions have demonstrated modest success, by only temporarily managing symptoms or slowing disease progression.^2,3 Patients often respond differently to treatments and eventually experience a decrease in treatment efficacy.^2,4,5 This means that AD drug development is still urgently needed.³

Mostly, family members care for patients with AD at home.^4,6 Family members commit to becoming caregivers for several reasons. Caregivers may find personal fulfillment and satisfaction from helping a relative.⁷ Caregivers can develop new skills and competencies and improve family relationships.⁷ Despite these positives, caregiving is challenging as patients become more dependent on supervision and personal care.⁸ Caregiving demands may limit the caregivers’ ability to take care of themselves. Neglecting their own health increases the risk of anxiety, depression, and a lower quality of life.⁹

Pathophysiology of Alzheimer's Disease

Scientists lack a complete understanding of AD’s underlying biology.^10,11 It is a progressive brain disease that occurs when abnormal proteins (e.g., beta-amyloid and phosphorylated tau) accumulate in the brain and neurons degenerate.^10,11 Expectantly, as people age, they lose neurons in the brain. However, patients with AD experience far greater neuron loss.¹² This loss is not a normal part of aging.¹² Other disease hallmarks include brain tissue damage, inflammation, and brain atrophy.^10-12

The Alzheimer’s disease continuum includes six stages. Stages 1 and 2 are preclinical. Mild cognitive impairment (MCI) occurs at stage 3. Dementia progresses from mild to moderate to severe in stages 4, 5, and 6, respectively.^13,15 The first brain areas affected by AD are the entorhinal cortex and the hippocampus, which are involved in memory.^13,15 Later, the disease affects areas in the cerebral cortex responsible for language, reasoning, and social behavior.^13,15 This progression is presented in the Figure below.¹⁴ Importantly, patients with AD pathology may not all progress to clinical phases.¹³

Brain Anatomy¹⁴

Source: National Institute on Aging, National Institutes of Health

Dementia or Alzheimer's Disease

Dementia is an umbrella term for characteristic difficulties with memory, language, problem-solving, and other thinking skills.¹⁶ The most common type of dementia is AD.¹ In AD, dementia involves changes in behavior, reasoning, remembering, and thinking.¹ People can also have dementia-like symptoms without having AD.¹⁷

Causes for dementia-like symptoms include the following:¹⁷

Depression

Delirium

Excessive alcohol consumption

Lyme disease

Medication side effects

Thyroid problems

Untreated sleep apnea

Often, treatment can reverse these conditions. People concerned about dementia should seek medical advice because the differences between normal age-related cognitive changes, medication-induced changes, and AD’s warning signs are subtle.¹⁷

A team approach to patients with these complex symptoms helps optimize outcomes. These patients require interventions to address unmet needs related to home support, personal safety, daily activities, legal assistance, advance care planning, and care financing. The individuals and their caregivers are faced with comorbid conditions, incontinence, hygiene, mobility, and other issues. It can be a challenge to connect the affected person and caregiver with needed services. Table 1 describes examples of opportunities to collaborate or refer.

Table 1

Integration of Interprofessional Team-Based Dementia Care¹⁸

Team Member	Care Issue
	Co-morbidity	Hygiene	Nutrition	Sleep	Anxiety/ depression	Communication	Caregiver respite
Primary Care Provider	√			√	√		√
Nurse	√	√	√	√	√	√	√
Home Care Services	√	√
Occupational Therapist		√	√
Behavioral Health Therapist					√
Speech Therapist						√
Nutritionist			√
Social Worker					√	√	√

Warning Signs and Risk Factors of Alzheimer's Disease

Age, family history, and genetics are risk factors for AD. The greatest risk factor is age.¹ Only 5.2% of people ages 65 to 74 have AD compared to 13.8% of people ages 75 to 84, and 33.3% of people ages 85 or older.¹⁰ In spite of this, age is insufficient on its own to cause AD.¹

Family history plays a role in the development of AD. People with a first-degree relative (parent or sibling) diagnosed with AD are more likely to develop the disease. People with more than one first-degree relative with AD have an even higher risk.¹

Many genes increase the risk of AD, but the apolipoprotein E (APOE) gene has the strongest impact.^1,19 People with the e4 allele are more likely to have beta-amyloid accumulation and AD at a younger age than those with the e2 or e3 allele.¹ Studies suggest that geographical background and genetic ancestry alter the extent to which APOE-e4 contributes to cognitive decline. Additionally, patients with Down Syndrome have an increased risk of developing AD.¹ Scientists believe this is related to having three copies of chromosome 21 (trisomy 21). The gene encoding the amyloid precursor protein (APP) is located on chromosome 21.¹ In patients with AD, an enzyme cleaves APP into beta-amyloid fragments, which accumulate as plaques in the brain.¹ Also, an estimated 1% of people have a rare genetic mutation causing AD. Inheriting this mutation, called dominantly inherited AD, guarantees disease development within a normal lifespan. Researchers are conducting studies to better understand the role of genetics in the development of AD.^1,19

Table 2 lists ten early warning signs identified by the Alzheimer’s Association.²⁰

Table 2

10 Early Signs of Alzheimer’s Disease*
Signs	Alzheimer’s Disease Examples	Age-related Changes
Memory loss disrupting daily life	Forgetting recently learned information	Forgetting appointments, but remembering later
Challenges with planning or solving problems	Difficulty following a familiar recipe	Occasional errors when managing household bills
Difficulty completing familiar tasks	Unable to remember the rules of a favorite game	Sometimes needing help with the settings on the microwave
Confusion with time or place	Trouble understanding something not happening immediately	Confusion about the day of the week, but figuring it out later
Trouble understanding visual images and spatial relationships	Difficulty reading and driving	Cataracts causing vision changes
New problems with words in speaking or writing	Uses wrong names for familiar objects	Difficulty finding the right word
Misplacing things and losing ability to retrace steps	Placing belongings in unusual places	Misplacing belongings sometimes, but able to retrace steps to find them
Poor judgment	Paying less attention to grooming	Neglecting to change car oil
Withdrawal from work or social activities	Changes in the ability to hold or follow conversations	Sometimes feeling uninterested in social obligations
Changes in mood and personality	Easily upset, confused, suspicious, depressed, fearful, anxious	Becoming irritable when a routine is disrupted

*Adapted from the Alzheimer's Association²⁰

Modifiable Risk Factors of Alzheimer's Disease

Thankfully, growing evidence suggests healthy behaviors may reduce the risk of cognitive decline.^1,21,22 Patients can improve brain health by doing the following:^1,21,22

Consuming alcohol in moderation

Getting enough sleep

Increasing physical activity

Maintaining a healthy weight

Managing blood sugar

Preventing and managing hypertension and hypercholesterolemia

Quitting smoking

Staying engaged

Diagnostic Biomarkers

The brain undergoes pathological changes even before symptoms appear.^1,21 These changes include the accumulation of extracellular cortical plaques that can manifest decades in advance. Progressive brain damage occurs during a prolonged preclinical phase. Even patients in stage 1 have positive biomarkers in brain positron emission tomography (PET) and/or cerebrospinal fluid (CSF) and plasma biofluid data.^1,21 Without biomarkers, Alzheimer’s is often misdiagnosed. Blood-based biomarkers (BBMs) are advantageous compared with PET and CSF testing.¹ They are less expensive, more accessible, and more acceptable to patients.²³ Blood-based biomarkers may enable early detection of Alzheimer's disease and help streamline diagnostic processes.²³ However, BBMs may not be appropriate, in several patient situations, such as the following:²⁴

comorbidities that may affect BBM levels (e.g., acute brain injury, severe chronic kidney disease)

concomitant medications that may impact BBM levels (e.g., neprilysin inhibitors, drugs disrupting the blood-brain barrier)

limited life expectancy

The Alzheimer’s Association 2025 diagnostic guideline is a framework appropriate for any practice setting.²⁴ It focuses on BBMs, most commonly used as indicators of brain amyloid.²⁴ Markers such as glial fibrillary acid protein and neurofilament light chain were excluded in the updated guideline.²⁴ The guideline discusses plasma assays for phosphorylated-tau (p-tau) and amyloid beta fibrils (Aβ), measuring analytes such as the following:²⁴

P-tau127

Ratio of p-tau217 to non-p-tau217 x 100

P-tau181

P-tau231

Aβ42/Aβ40

Overall, the Alzheimer’s Association good practice statement recommends holding off on a BBM test until a comprehensive clinical evaluation by a provider.²⁴ Diagnosing can include BBMs, but providers should avoid using them as a standalone test.²⁴

The clinical practice guideline recommends that providers obtain a brain magnetic resonance imaging (MRI) and routine Tier 1 laboratory tests for all patients evaluated for cognitive impairment.²⁴ These Tier 1 tests are referred to as the “cognitive lab panel” because they check for common conditions that can contribute to cognitive and behavioral impairments.²⁴

Table 3 below outlines the Tier 1 laboratory Tests.

Table 3

Tier 1 laboratory tests
Cognitive Panel Tests	Evaluating
TSH	Abnormalities are common in older adults and may cause treatable neuropsychiatric symptoms
Vitamin B12
Homocysteine	Hyperhomocysteinemia associated with functional B12 deficiency is not always detected by B12 plasma levels Cardio and cerebrovascular risk
CBC with differential	Hyper/hyponatremia Hypomagnesiumia Hyper/hypocalcemia Anemia
CMP (including Ca, Mg, LFTs)	Dehydration suggested by BUN:Cr > 20:1 Hyper/hypoglycemia Uremia Hepatic dysfunction
ESR	Inexpensive screens for inflammation/autoimmunity, infection, or neoplasm
CRP
BUN = blood urea nitrogen; Ca = calcium; CBC = complete blood count; CMP = comprehensive metabolic panel; Cr = creatinine; CRP = C-reactive protein; ESR = erythrocyte sedimentation rate; LFTs = liver function tests; Mg = magnesium; TSH = thyroid-stimulating hormone

Early Detection of Alzheimer's Disease

Early diagnosis of AD provides medical, emotional, and social benefits.^1,25 Patients diagnosed early have the best chance to benefit from treatment. Earlier access to treatment results in reduced cognitive and functional decline. Treatments to address the symptoms may help decrease memory loss and confusion. Also, patients have an opportunity to participate in clinical trials to advance research. Early detection gives patients time to prioritize their health. Optimizing and controlling modifiable risk factors may preserve cognition.²⁵ Patients who benefit from early detection also have more time to plan their futures and confront their lives complicated by AD.^1,25

Receiving an early AD diagnosis validates the observed symptoms and may reduce anxiety for patients. Family and loved ones have an opportunity to maximize time together. Planning for the future may reduce family burden and prevent disagreements. Patients can review legal documents, discuss finances, and identify care preferences. Families can address safety issues, such as driving or wandering, which are problems associated with later stages.²⁵

Dementia is one of the costliest conditions in society.²⁶ Early detection can reduce healthcare system costs through proactive interventions.^1,25 The Alzheimer’s Association studied the impact of an early diagnosis on potential cost savings. They reported that the United States economy could save an estimated $7 trillion in medical and long-term care costs for patients with AD.^1,26 These large cost savings result from a smaller spike in costs immediately before and after diagnosis (during the MCI phase) and lower medical and long-term costs for people diagnosed and managing MCI and dementia.¹

Healthcare professionals in the community, hospitals, and other settings can refer patients at risk for AD to available inpatient or outpatient services.²⁷ Easy-open caps or pill organizers may be recommended.²⁸ Simplify communication with short sentences and avoid lengthy explanations. During consultation, allow the patient plenty of time (possibly 20 seconds) to respond to questions.²⁸

Counseling Caregivers of Patients with Alzheimer's Disease

Inevitably, as the population ages, the number of caregivers grows. Scientists advocate for home-based care because it benefits patients with AD. Family members providing informal care at home can increase patients’ lifespan and delay disease progression.²⁹

Family caregivers focus on the patient, so they may be less likely than the general population to practice self-care and preventative healthcare. Caregivers report sleep disturbances, poor eating habits, lack of exercise, failure to rest when ill, and postponing or avoiding scheduling medical appointments for themselves. Also, family caregivers have an increased risk for depression and are more likely to have a chronic illness (e.g., hypercholesterolemia, hypertension, obesity, or overweight).³⁰

A recent study looked at the transformative process of becoming a caregiver and the evolving role.³¹ It requires ongoing adaptation shaped by the disease’s progression, the relationship between caregiver and patient, and support systems. Connecting with peers who share similar caregiving experiences can decrease stress and improve quality of life. This connection reduces isolation and fosters mutual resilience.³¹

Caregiver Support with Respite Care

On an airplane, the crew advises passengers to put their oxygen masks on before helping others. Only when caregivers prioritize themselves can they effectively support the individual in their care.³² Caregiving is often rewarding, but it can become stressful and tiresome.³³ One option for caregivers is to maintain their health. This may occur through short breaks. Research demonstrates that a few hours per week of respite, or consistent breaks away from caregiving responsibilities, can improve a caregiver’s well-being.^34,35 Adult daycare or short-term nursing home care services offer respite care. Family, friends, government agencies, or volunteers can also provide respite care.^34,36

Healthcare team members can encourage caregivers to recuperate while emphasizing that their patients are receiving care in a safe environment. Caregivers can use their time away to run errands, catch up with friends and family, or just relax.³⁶ Caregivers may feel guilty about needing outside help or enjoying the time provided by respite.^33,36

Tips healthcare team members can give to caregivers to help alleviate their burnout or guilt include the following:^36,37

Advise caregivers that their feelings of guilt, anger, and frustration are normal, and by facing them, they can work through them

Advise caregivers that taking a break can recharge them as they continue to cope

Encourage caregivers to make new connections and speak with other caregivers who have used respite

Propose that caregivers inform others of their request for time away

Support and remind caregivers that their caregiving tasks are helpful

Healthcare team members can provide caregivers with education on how to request help from family and friends. Importantly, caregivers should make their limits and needs known. Suggestions to offer caregivers include the following:³⁵

Being ready to answer when someone asks the caregiver, “What can I do to help?” the caregiver should name a time block or task they need help with

Be empathetic and remind the caregiver to ask for future assistance if someone is unable to help at a specific time

E-mail, text, or call friends and family when help is needed, if caregivers are reluctant to ask directly

Set up a shared online calendar for others to sign up, share tasks, or provide regular respite

Developing a Care Plan

Besides prearranged breaks, caregivers can also use respite care in unexpected situations. Emergencies, unplanned circumstances, or unexpected trips necessitate immediate care by an alternative caregiver.^36,38 On these occasions, caregivers should have an easily accessible written care plan.^36,38

Care plans summarize a patient’s medical conditions and specific care needs.³⁸ Care plans should include medication doses and administration schedules. Health insurance information, the identities of healthcare providers and their contact information, and a list of emergency contacts are recommended to include. Care plans improve overall medical management for patients, and caregivers should update them regularly to keep content up to date.³⁸

Care Plan Resource Caregivers can use the comprehensive care plan template provided by the Disease Control and Prevention (CDC) at the following link: cdc.gov/caregiving/media/pdfs/Complete-Care-Plan-Form-5081.pdf

Resources for Caregivers

Online support groups and resources offer caregivers an opportunity to share experiences, get support, and find new resources. The CDC recommends the following support resources:³⁹

The Dementia Dialogues® is a free, 5-module, evidence-informed nationally registered training course. The link to its website is https://osa-sc.org/programs/dementia-dialogues

The Family Caregiving Alliance offers an opportunity to discuss caregivers’ stresses, challenges, and rewards. The link to its website is caregiver.org/connecting-caregivers/support-groups

The AARP Caregiver Support Starts Here. The link to its website is https://www.aarp.org/caregiving/211-help/

Alzheimer's Association’s Alzheimer's and Dementia Caregiver Support provides caregiver support. The link to its website is https://www.alz.org/help-support/caregiving

National Institute on Aging Caregiving resource. The link to its website is https://www.nia.nih.gov/health/caregiving

Since caregiving can lead to burnout, prevention is crucial to avoid depression.⁴⁰ Burnout symptoms include the following:³⁶

Difficulty coping with daily demands

Exhaustion

Frustration

Impatience

Overwhelming feelings

Healthcare team members can play a key role in helping caregivers identify and recognize their own warning signs of frustration. This can help alert caregivers that they need to take immediate action to calm down. Common warning signs include the following:⁴¹

Chest pains

Compulsive eating

Desire to strike out

Excessive alcohol consumption

Headache

Increased smoking

Knot in throat

Lack of patience

Shortness of breath

Stomach cramps

There are a variety of ways for caregivers to calm themselves. It may seem overly simplistic, but caregivers can slowly count to ten and take deep breaths. They can take a walk or relocate to another room to collect their thoughts. Caregivers can also talk with a friend, listen to music, meditate, pray, sing, or take a relaxing bath.⁴¹

Managing Medications

Approximately 87.7% of people aged 62 to 85 are prescribed medication, with 35.8% of them taking at least five medications.⁴² It is therefore not surprising that the vast majority of caregivers need help or advice about medications.⁴²

Eight medications are FDA-approved for AD.^43-51 Six manage symptoms (brexpiprazole, donepezil, galantamine, rivastigmine, memantine, and memantine + donepezil), and two (lecanemab and donanemab) slow cognitive decline.^1,52 After a time, the caregiver may comment that the patient is getting less benefit from the medication.

Table 4

Medications Used for Alzheimer’s Disease
Classification	Medication	Administration and Frequency	Side Effects
Atypical antipsychotic	Brexpiprazole43	Oral tablet, daily	Common cold symptoms, dizziness, hyperglycemia, hypertension, stroke
Cholinesterase inhibitors	Donepezil44	Oral tablet, ODT, or solution, daily	Diarrhea, fatigue, insomnia, muscle cramps, nausea, vomiting, weight loss
	Galantamine45	Oral extended-release capsule, daily, or oral tablet or solution, twice daily	Decreased appetite, diarrhea, dizziness, headache, nausea, vomiting, weight loss
	Rivastigmine46,47	Oral capsule or solution, twice daily, or transdermal patch, replaced daily	Anorexia, nausea, decreased appetite, diarrhea, indigestion, muscle weakness, vomiting, weight loss
NDMA antagonist	Memantine48	Oral extended-release capsule, tablet, or solution, daily	Confusion, constipation, diarrhea, dizziness, headache
NDMA antagonist + cholinesterase inhibitor	Memantine + Donepezil49	Oral extended-release capsule, daily	Anorexia, diarrhea, dizziness, ecchymosis*, headache, nausea, vomiting
Monoclonal antibodies	Donanemab50	IV, 30 minutes every 4 weeks	ARIA, brain swelling and bleeding, infusion-related reactions
	Lecanemab51	IV, over 1 hour every 2 weeks	ARIA, brain swelling and bleeding, headache, cough, diarrhea, nausea, vomiting, fever, chills, body aches, fatigue, high blood pressure, low blood pressure, and low oxygen
ARIA = amyloid-related imaging abnormalities Ecchymosis = small bruising from leaking blood vessels IV = intravenous NDMA = N-Nitrosodimethylamine ODT = orally disintegrating tablets

Mild to Moderate Disease

In mild-to-moderate AD, cholinesterase inhibitors (e.g., donepezil, galantamine, and rivastigmine) are used to reduce cognitive and behavioral symptoms.^1,44-47 However, these are not the only medications the patient may be prescribed. Caregivers of individuals with Alzheimer’s may be faced with unplanned responsibilities (e.g., multiple physicians, multiple medications, and multiple office or clinic visits).⁴² Counseling with caregivers may include discussing with them the risks of drug interactions. For example, donepezil and galantamine have the potential to interfere with anticholinergic medications;⁵³ and patients taking rivastigmine should avoid using beta-blockers, for example, due to the risk of bradycardia.^46,47

In addition, unlike orally administered medications indicated for AD, lecanemab and donanemab are administered intravenously (IV), which requires trained medical professionals and must be administered in a clinical setting.^50,51 They also require monitoring with magnetic resonance imaging (MRI) to assess the risk of intracerebral hemorrhage.⁵⁴ Intracerebral hemorrhage has been reported in patients also taking antithrombotics, antiplatelets, or anticoagulants.^39,40

A caregiver may express frustration at having to take the patient for scans, screenings, IV injections, or monitoring. This is an opportunity for team members to explain, in simpler terms, that before initiating treatment, the healthcare team needs to screen patients with PET scans or CSF to confirm amyloid-beta pathology.⁵⁵ After initiating treatment, monitoring is needed to avoid potentially risky concurrent therapies.⁵⁴

Lecanemab and donanemab have a boxed warning for amyloid-related imaging abnormalities (ARIA).^50,51 Typically, ARIA resolves over time, and patients with temporary, localized brain swelling are asymptomatic.^54,56 Amyloid-related imaging abnormalities can be signals of serious and life-threatening events. Symptoms associated with ARIA include headache, confusion, visual changes, dizziness, nausea, and difficulty walking.^54,56 Shared decision-making can determine whether a treatment’s potential benefits outweigh its risks.^54,56

Moderate to Severe Disease

Caregivers may read about memantine and ask questions. It can decrease symptoms, potentially enabling patients to maintain independent daily functioning longer.^48,49 Since memantine acts differently from cholinesterase inhibitors, combining it with a cholinesterase inhibitor is acceptable (e.g., donepezil + memantine).⁴⁹ Patients taking memantine, alone or in combination with donepezil, should avoid concurrent use of N-methyl-D-aspartate (NMDA) antagonists (e.g., ketamine, dextromethorphan) and medications that alkalinize urine (e.g., carbonic anhydrase inhibitors and sodium chloride).^48,49 Donepezil’s drug interactions mentioned earlier also apply to the combination medication.^48,49

The interprofessional team members are optimally positioned to ask a caregiver to share the patient's symptoms with them. This offers the pharmacist opportunities to recommend medications that may alleviate symptoms. Brexpiprazole, for example, treats agitation associated with AD but has a boxed warning for increased mortality in elderly patients with dementia-related psychosis.⁴³

Managing Behavioral Symptoms

Aggression, agitation, anxiety, depression, restlessness, sleeplessness, and wandering are common AD symptoms that a caregiver may discuss with the healthcare team.⁵⁷ Treating these symptoms may help patients maintain dignity and independence for longer and relieve caregiver stress.

Managing behavior changes can also make everyday life less stressful for a person with Alzheimer’s, their caregivers, and their loved ones. Caregivers can be counseled on doing any of the following when confronted with behavioral changes:⁵⁸

​Be patient, try not to show frustration, and avoid arguing.

Caregivers should reassure the person that they are there to help.

Learn how to communicate with someone with Alzheimer’s (see the resource below).

Redirect their attention to a new object or activity, such as listening to music, reading a book, or going for a walk.

Create a comforting home setting by reducing noise and clutter and keeping well-loved objects (such as photos) around the home.

Try to keep the person on a routine by bathing, dressing, and eating at the same time each day.

Find ways for the person to be physically active, which can improve mood and sleep.

Resource Communicating With Someone Who Has Alzheimer’s Disease https://www.nia.nih.gov/health/alzheimers-changes-behavior-and-communication/communicating-someone-who-has-alzheimers

Patient Case

Mrs. L., a 74-year-old woman, is brought to the clinic by her daughter. The daughter reports that over the past year, Mrs. L. has become increasingly forgetful, repeats questions, misplaces household items, and misses paying bills. The daughter informs the nurse that Mrs. L also struggles with driving directions and managing her medications.

What screening and evaluation should occur?

The physician assesses reversible causes of memory loss, such as medication effects, thyroid dysfunction, vitamin B12 deficiency, depression, and sleep problems. A cognitive screen results support mild Alzheimer’s disease.

What is a medication option for this patient?

Once daily donepezil is initiated to manage cognitive symptoms, and counseling the daughter on expected benefits, common adverse effects, and the need for adherence.

What team members might be appropriate for this family?

The pharmacist reviews the medications and identifies an over-the-counter anticholinergic used as a sleep aid. The pharmacist recommends discontinuation and informs the physician. The nurse coordinates follow-up, and the patient is referred to a social worker to connect the family with a support group, caregiver education, and transportation resources. The daughter is encouraged to use a pill organizer and to contact the team if symptoms worsen.

Summary

Alzheimer’s is a progressive disease that begins with mild memory loss and leads to a patient’s inability to complete simple daily tasks. Currently, there is no cure. Available interventions temporarily manage symptoms or slow disease progression for some patients. Scientists lack a complete understanding of AD’s underlying biology. It is a progressive brain disease occurring when abnormal proteins accumulate in the brain and neurons degenerate. Age, family history, and genetics are risk factors for AD. Many genes increase AD’s risk. The APOE gene has the strongest impact.

Early diagnosis of AD provides medical, emotional, and social benefits. Patients diagnosed early have the best chance to benefit from treatment. Dementia is one of the costliest conditions in society. Early detection helps reduce these costs.

Family caregivers are less likely than the general population to practice self-care and preventative healthcare. Caregivers report sleep disturbances, poor eating habits, lack of exercise, failure to rest when ill, and postponing or avoiding scheduling medical appointments for themselves. Also, family caregivers have an increased risk of depression and are more likely to have a chronic illness. Caregivers can enhance their resilience and reduce isolation by connecting with others in a similar role.

Healthcare team members can encourage caregivers to take time for themselves by suggesting respite and other self-care and recuperation activities. Caregivers can use their time away to run errands, catch up with friends and family, or just relax.

Approximately 87.7% of people aged 62 to 85 are prescribed medication, with 35.8% of them taking at least five medications. It is therefore not surprising that the vast majority of caregivers need help or advice about medications. Healthcare team members can screen patient profiles for inappropriate medications and recommend discontinuation to the prescriber.

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