6) BRIEF RESUME OF THE WORK
INTRODUCTION:
“The mind that is wise mourns less for what age takes away; than what it leaves behind”
-William Wordsworth
Alzheimer’s disease is a chronic progressive and degenerative brain disorder that is accompanied by profound effects on memory, cognition and ability for self care. Although Alzheimer’s disease can occur in people young as 40, it is common before age 65.1
According to the World Health Organization “it is estimated that there are currently about 18 million people worldwide with Alzheimer’s disease”. “This figure is projected to nearly double by 2025 to 34 million. Much of this increase will be in the developing countries, and will be due to the ageing population. Currently, more than 50 per cent of people with Alzheimer’s disease live in developing countries and, by 2025, this will be over 70 per cent.”2
In the year 2000, India had 3.5 million Alzheimer’s patients as against the United States’ 4.5 million. With our population graying faster (India’s 60-plus population was around 80 million in 2000), the growth rate being fastest among the 80+ segment among all other segments, the number of Alzheimer’s patients has been growing at a phenomenal rate. The percentage of 60+ persons in the total population has seen a steady rise from 5.1 percent in 1901 to 6.8 per cent in 1991. It is expected to reach 8.9 per cent in 2016. Projections beyond 2016, made by the United Nations, have indicated that 21 per cent of the Indian population will be 60+ by 2050. In China, the population of 60+ is projected to increase from 130 million in 2000 to 370 million in 2050. According to Alzheimer's Australia ,the projected increase of dementia between 1995-2041in Australia is 254 percentage.3
6.1) NEED FOR THE STUDY
Diseases can rarely be eliminated through early diagnosis or good treatment, but prevention can eliminate disease.
-Denis Burkitt
Alzheimer’s disease can occur at any age, even young as 40 years, but its occurrence is much more common as the years go by. In fact , the rate of occurrence of the disease increases exponentially with age, which means that it occurs very rarely among those 40-50 years old, increases between 60 and 65 years, and is very common over 80 years. More than 35 million people worldwide – 5.5 million in the United states have Alzheimer disease, a deterioration of memory and other cognitive domains that lead to death within 3 to 9 years after diagnosis. Alzheimer’s disease is the most common form of dementia, accounting for 50 to 56% of cases autopsy and in clinical series. The incidence of disease doubles every 5 years after 65 years of age4.
An estimated 5.3 million Americans of all ages have Alzheimer's disease (2010). This figure includes 5.1 million people aged 65 and older and 200,000 individuals under age 65 who have younger-onset Alzheimer's. In Texas alone, there are currently, 340,000 peopleliving with Alzheimer's disease. By 2025, that number is expected to rise to 470,000.One out of eight people age 65 and older (13 percent) has Alzheimer's disease.Women, who on average live longer than men, are more likely than men to have Alzheimer's disease. The greatest risk factor for Alzheimer's disease is advancing age, but Alzheimer's is not a normal part of aging.5
A 2-year, prospective, epidemiologic study incidence of Alzheimer’s disease in rural community in India, subjects aged ≥ 55 years utilizing repeated cognitive and functional ability screening.Incidence rates per 1000 person-years for AD with CDR ≥ were 3.24 (95% CI: 1.48-6.14) for those aged ≥ 65 years and 1.74 (95% CI: 0.84-3.20) for those aged ≥ 55 years. Standardized against the age distribution of the 1990 US Census, the overall incidence rate in those aged ≥ 65 years was 4.7 per 1000 person-years, substantially lower than the corresponding rate of 17.5 per 1000 person-years in the Monongahela Valley.6
A study was conducted on the prevalence of AD and other dementias in a rural elderly Hindi-speaking population in Ballabgarh in northern India. A community survey of a cohort of 5,126 individuals aged 55 years and older, 73.3% of whom were illiterate.. A totalof 536 subjects (10.5%) who met operational criteria for cognitive and functional impairment and a random sample of 270 unimpaired control subjects (5.3%) underwent standardized clinical. Prevalence rate of 0.84% (95% CI, 0.61 to 1.13) for all dementias with a CDR score of at least 0.5 in the population aged 55 years and older, and an overall prevalence rate of 1.36% (95% CI, 0.96 to 1.88) in the population aged 65 years and older. The overall prevalence rate for AD was 0.62% (95% CI, 0.43 to 0.88) in the population aged 55+ and 1.07% (95% CI, 0.72 to 1.53) in the population aged 65+. Greater age was associated significantly with higher prevalence of both AD and all dementias, but neither gender nor literacy was associated with prevalence. The study shows that the prevalence of AD and other dementias was low, increased with age, and was not associated with gender or literacy.7
Based on the review of the literature and personal experience of the investigator during practice in the field of nursing service, found that older adults are not having adequate knowledge about Alzheimer disease. The gap of knowledge on one side and growing risk of mortality and morbidity on other side necessitate a need to systematically educate the older adults to identify risk factors of Alzheimer’s disease .So the investigator felt to impart teaching program on knowledge and prevention of Alzheimer’s disease which may help them to know more about Alzheimer’s disease and improve their quality of life.
6.2) REVIEW OF LITERATURE
Researches never conducted a study in an intellectual vacuum; their studies are usually undertaken within the context of an existing knowledge base. According to Polit and Hungler the review of literature refers to an extensive exhaustive and systematic examination of publication relevant to the research project8.
The sources selected to obtain more information on the selected topic are Medline search, internet search & published journals.
Related literatures are organized under the following headings
1.Studies related to knowledge on Alzheimer’s disease.
2.Studies related to prevention of Alzheimer’s disease.
3.Studies related to structured teaching program on Alzheimer’s disease.
1.STUDIES RELATED TO KNOWLEDGE ON ALZHEIMERS DISEASE
A study was conducted to find out the factors which are related to developing of AD in Iranian population. In this case-control study, 115 elderly patients (mean age of 70±8.18 years) withDSM-IV based final diagnosis compared with 115 non-demented counterparts matched for age, sex, and socioeconomic status regarding lifestyle, family history, andhistory of bio-psychosocial health.It is found that all differences between the twogroups were non-significant except for history of hypertension (P=0.018) whichwas most prevalent in AD group. Risk of the incident AD for the hypertensivegroup was 1.71 (1.08-2.70) compared to the non-hypertensive group. These results confirm the previously reported relationship between AD andvascular factors. Prevention, early detection, and treatment of hypertension may have some implications in the primary and secondary prevention of Alzheimer’s disease.9
A study was conducted on early detection of Alzheimer’s disease by using Wechsler adult intelligence scale third edition in Japan.The JWAIS-III was given to 43 AD patients 12 males and 31 females, mean age,80.9 ±6.3 years, who fulfilled the diagnostic criteria for AD on the diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) and the national institute of neurological and communicative disorders and stroke and the Alzheimer’s disease and related disorders association. Severity of dementia of the patients was classified according to functional assessment staging (F) as follows 9 patients in F3 (borderline), 15 in F4 (mild AD), 12 in F5 (moderate AD), 7 in F6 (somewhat severe AD) and none in F7 (severe AD). i) Mean intelligence quotients (IQS) were: Full scale IQ 84.3 ± 14.0, verbal IQ 84.6 ± 12.5 and performance IQ 86.9 ± 15.5. Comparison of IQs and subtest scores of the patients aged 75 years or older assessed by standard scores for 70 to 74 years of age, which is the upper limit of the indicated age range on the WAIS-R (the previous version of the WAIS-III), with those assessed by standard scores for the appropriate age revealed that the former were significantly lower in IQ and all subject scores. ii) Significant differences were noted among the severities of dementia in the scores of 7 subtests for similarities, comprehension, arithmetic, digit span, letter-number sequencing, digit symbol and symbol search.iii) When both the digit symbol subtests scores of 7 points or more and the digit symbol paring supplementary test scores exceeding 10% of the cumulative percentile were regarded as normal, 11 of 15 (73.3%) patients in F4 (mild AD) could be detected. These findings suggest that i) expansion of indicated age range in the WAIS-III allows a more valid assessment of cognitive function in AD patients, ii) a marked decline in abstract thinking and verbal problem-solving ability and relative preservation of perceptual organization are characteristics of cognitive impairment in Ad patients and iii) a combination of the digit symbol subtest with the pairing supplementary test is useful for the early detection of AD.10
2.STUDIES RELATED TO PREVENTION OF ALZHEIMERS DISEASE
A study was conducted on risk assessment and primary preventionof Alzheimer’s disease in Hamilton Canada. In addition to nonmodifiable genetic risk factors,potentially modifiable factors such as hypertension, hyperlipidemiaand environmental exposures have been identified as risk factorsfor Alzheimer disease.Here some studies are selectedwhich published from January 1996 toDecember 2005 that met the following criteria: dementia(all-cause,Alzheimer disease or vascular dementia) as the outcome; longitudinalcohort study; study population broadly reflective of Canadiandemographics; and genetic risk factors and general risk factors(e.g., hypertension, education, occupation and chemical exposure)identified. Of 3424 articles on potentially modifiable risk factorsfor dementia, 1719 met our inclusion criteria; 60 were deemedto be of good or fair quality. Of 1721 articles on genetic riskfactors, 62 that met our inclusion criteria were deemed to beof good or fair quality. On the basis of evidence, for the primary preventionof Alzheimer's disease, there is good evidence for controllingvascular risk factors, especially hypertension (grade A), andweak or insufficient evidence for manipulation of lifestylefactors and prescribing of medications (grade C). There is goodevidence to avoid estrogens and high-dose (> 400 IU/d) ofvitamin E for this purpose (grade E). Genetic counseling andtesting may be offered to at-risk individuals with an apparentautosomaldominant inheritance (grade B).11
A study was conducted on anti-inflammatory drugs for the prevention of Alzheimer’s disease USA.Alzheimer’s disease, the most prevalent dementia, is a prominent source of chronic illness in the elderly. Laboratory evidence suggests that nonsteroidal anti-inflammatory drugs (NSAIDs) might prevent the onset of Alzheimer’s disease. For the 3 case-control and 4 cross-sectional studies, the combined risk estimate for development of Alzheimer’s disease was 0.51 (95% CI = 0.40–0.66) for NSAID exposure. In the prospective studies, the estimate was 0.74 (95% CI = 0.62–0.89) for the 4 studies reporting lifetime NSAID exposure and it was 0.42 (95% CI = 0.26–0.66) for the 3 studies reporting a duration of use of 2 or more years.Based on analysis of prospective and nonprospective studies, NSAID exposure was associated with decreased risk of Alzheimer’s disease. An issue that requires further exploration in future trials or observational studies is the temporal relationship between NSAID exposure and protection against Alzheimer’s disease.12
3.STUDIES RELATED TO STRUCTURED TEACHING PROGRAMME ON ALZHEIMERS DISEASE
A study was conducted on caregiver training program; and report the 8-year outcome in Australia. Prospective, randomized control trial and longitudinal follow-up over approximately 8 years.96 persons less than 80 years old with mild to moderate dementia and their cohabitingCaregivers. All patients received a 10-day structured memory retraining and activity program.Caregivers in the immediate and wait-list caregiver training groups received a structured, residential,intensive 10-day training program, boosted by follow-ups and telephone conferences over 12 months.Those in the wait-list group entered the program after waiting 6 months. The third group of caregiversreceived 10 days’ respite (while patients underwent their memory retraining program) and 12 monthsbooster sessions as for the other groups.64% of patients whose caregivers were in the immediate training group, 53% of wait-list group patients and 70% of memory retraining patients had died. Nursing home admission had occurred in 79% of the immediate training, 83% of the delayed and 90% of the memory retraining group. Eight-year survival analysis indicated that patients whose caregivers received training stayed at home significantly longer (p = 0.037) and tended to live longer (p — 0.08).Caregiver training program demonstrably can delay institutionalization.13
A study was conducted on therapeutic conversation to improve mood in nursing home residents with Alzheimer's disease in Florida USA. To test a newly developed, empirically based modified counseling approach, 30 nursing home residents with AD were randomly assigned to a modified counseling (Therapeutic Conversation) treatment group or usual care control group. Mini-Mental State Examination mean scores were 10.60 (SD = 6.99) for the treatment group and 12.26 (SD = 7.43) for the control group. Individual treatment was provided three times per week for 16 weeks. On the posttest, treatment group participants evidenced significantly less negative mood than the control group on the Montgomery – Asberg Depression Rating Scale and the Sadness and Apathy subscales of the Alzheimer's Disease and Related Disorders Mood Scale. The study suggest that a therapeutic counseling approach can beeffective in treating the dysphoria commonly found in individuals with AD.14
6.3) STATEMENT OF THE PROBLEM
“A study to assess effectiveness of structured teaching program on knowledge and its prevention of Alzheimer’s disease among the older adults in selected old age homes at Mangalore”.
6.4) OBJECTIVES
The objectives of the study are:
1. To assess the knowledge and its prevention of Alzheimer’s disease among older adults.
2. To develop and administer STP on Alzheimer’s disease among older adults.
3. To evaluate the effectiveness of STP on Alzheimer’s disease among older adults.
4. To find out the association between the pretest knowledge score of Alzheimer’s disease among the older adults with theirselected demographic variables.
6.5) OPERATIONAL DEFINITIONS
1.Effectiveness:
In this study effectiveness refers to determine the extent to which the structured teaching program has achieved the desired effect as expressed by gain in post test knowledge scores.
2.Structured teaching program:
In this study structured teaching program refers to systematically structured teaching strategy designed to provide information on Alzheimer disease and its prevention among older adults.
3.Knowledge:
In this study, knowledge refers to fact of knowing or level of understanding about Alzheimer’s disease among older adults which will be assessed in the terms of structured knowledge questionnaire.
4.Alzheimer’s disease:
In this study Alzheimer’s refers to progressive neurologic disease accompanied by impairment in memory, judgment, decision making, orientation to physical surroundings and language.
5.Prevention:
In this study prevention refers to the activities carried out bythe older adults to minimize the chances of getting Alzheimer’s disease.
6.Older adult:
In this study older adult refers to those who are residing in old age home between theage group of 45 - 60.
7.Old age home:
In this study old age home refers to the housing facility intended for old people.
6.6) ASSUMPTIONS
The study assumes that:
- Alzheimer’s disease will affect the quality of life.
- Older adults will have less knowledge regarding Alzheimer’s disease and its prevention.
- The STP will enhance the knowledge and prevention of Alzheimer’s disease among older adults.
- Improvement of knowledge may help older adult to minimize the chance of getting Alzheimer’s disease.
6.7) DELIMITATION
The study is delimited to:
- The older adults who are residing in old age home.
- Specific duration of time(6 weeks).
6.8) VARIABLES
Variables are an attribute of a person or objects that varies or takes different values. Independent variable: Structured teaching program.
Dependent variable: Knowledge and its preventive measures of Alzheimer’s disease among older adults.
Extraneous variable: In this study, extraneous variable refers to the selected demographic variables such age, sex, educational status, previous occupation, source of information.
6.9 HYPOTHESIS
All hypotheses will be tested at 0.05 levels of significance:
H1- Mean post test knowledge score will be significantly higher than mean pre-test knowledge score.
H2- There will be a significant association between the pretest knowledge score of older adults with theirselected demographic variables.
7.0) MATERIALS AND METHODS
7.1) Source of data
The data will be collected from the older adults who are residing in the old age homes at Mangalore.
7.1.1) Research Design
Pre experimental - one group pre test post test design.
O1 / X / O2Key:
O1: Assess the knowledge of Alzheimer’s disease and its prevention among older adults.
X: Administering structured teaching program on knowledge of Alzheimer’s disease and its prevention among older adults.
O2: On third day evaluate the effectiveness of structured teaching program on Alzheimer’s disease and its prevention among older adults.
7.1.2) Setting
The study will be conducted in the selected old age homes at Mangalore.
7.1.3) Population
The older adults who are residing in old age homes.
7.2) METHOD OF DATA COLLECTION
7.2.1) Sampling Technique
Purposive sampling technique.
7.2.2) Sample Size
In this study the sample size will be 40 older adults who are residing in old age homes.
7.2.3) Inclusion CRITERIA
- Older adults those who are willing to participate.
- Older adults between the age group of 45 to 60 years.
7.2.4) Exclusion Criteria
- Older adult those who have any serious illness.
- Older adults those who are not able to read and write English or Kannada.
- Older adults those who are not available at the time of data collection.
7.2.5) INSTRUMENTS INTENTED TO BE USED
The instruments intended to be used in this study are:-
Tool1: Demographic proforma to assess the demographic variables.
Tool 2: Structured knowledge questionnaire.
7.2.6) Data collection method
Prior to the data collection written consent will be obtained from the concerned authority. Sample will be selected by those who will fulfill the inclusion criteria and it should be confidential. The researcher will select 40 samples by purposive sampling technique. Researcher will explain the purpose of the research to the sample and will take informed consent from them. The data will be collected by conducting pretest to assess the knowledge on Alzheimer’s disease and its prevention among older adults and then structured teaching program will be conducted.On 3rdday post test will be conducted to evaluate the effectiveness of teaching. The tools for data collection will include demographic proforma and structured knowledge questionnaire.