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PSYCHOLOGICAL IMPACTS OF ALZHEIMER’S DISEASE AND
POSSIBILITIES FOR REHABILITATION
Quelen Cristiane Fragoso dos Santos1
Matias Trevisol2
Abstract: The impacts resulting from Alzheimer’s Disease characterize the loss of progressive
cognitive functions, memory, language and learning failures, which, over time, tend to worsen as
the disease progresses. Rehabilitation possibilities seek to improve the worsening of the disease,
seeking an approach that integrates knowledge in the period (2010 - 2020), in medicine, neurology and
psychology. Objective: to carry out a literature review on the impacts and possibilities of rehabilitation
of Alzheimer’s disease. Method: searches were performed from April to September 2021, in the
following databases: SciELO and PepsiCo, observing the publication date and whether the text was in
accordance with the search theme. Results: Ten articles were found that highlighted the impacts and
possibilities of rehabilitation of Alzheimer’s disease, in which it was evident how important it is still
to research the subject.
Keywords: Alzheimer’s Disease. Rehabilitation. Neurology.
1 Bachelor’s degree in Psychology from the University of Western Santa Catarina (UNOESC,
2021) and postgraduate degree in Neuropsychology and Cognitive-Behavioral erapy from the Faculty
of Venda Nova do Imigrante (FAVENI, 2022). Currently pursuing a postgraduate degree in Mental
Health from the Brazilian Academy of Integrative Functional Health, and a master’s degree in Clinical
and Health Psychology from FUNIBER. Works on the front lines in clinical care, neuropsychological
assessment and rehabilitation, focusing on integrative and humanized mental health care.
2 Master’s degree in Business Administration from UNOESC Chapecó (2018). Postgraduate
degree in Psychoanalysis (2025). Specialist in Human Resources Management from UNOESC Chapecó
(2014). Bachelor’s degree in Psychology from UNOESC São Miguel do Oeste (2012). Professor at the
University of Western Santa Catarina (UNOESC), São Miguel do Oeste Campus, Pinhalzinho Unit,
where he serves as Coordinator of the Psychology Course. He also works as a clinical psychologist
in a private practice, with over 13 years of experience. Counselor of the XII Plenary of the CRP-12.
Member of the Guidance and Ethics Commission of the CRP-12.
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INTRODUCTION
The increase in the population, proportionally elderly, is a worldwide phenomenon, as are
many diseases in this age group, Alzheimer’s disease (AD) is one of the most feared as age advances.
This strong threat affects millions of people around the world and moves many resources related to
the market and research in the area. Many individuals remain invisible or desensitized to the diagnosis
and treatments available for the disease. AD causes sick people and their families to experience the
most fearful pains: the loss of oneself, the forgetfulness of one’s loves, isolation and loneliness. Thus,
by understanding the psychological impacts of Alzheimer’s disease, we will be able to think about
possibilities for rehabilitation.
This study sought to review the knowledge and research carried out in the last decade in
order to alleviate the pain and ignorance that involve the many aspects of AD. With a specic search
from the Psychological perspective to better understand how the pathology impacts our way of living
and not just permeates aging. This review contains information based on recent scientic evidence
about AD and its complexity so that new knowledge can be disseminated in a famous way, where
we have possibilities far beyond a diagnosis and more effective solutions in the prevention or even
reversal of the disease.
ALZHEIMER’S DISEASE
The researcher who had his name assigned to name the disease was born in Bavaria,
Germany, in 1864. Aloysius Alzheimer became nancially independent through marriage, dedicated
himself to clinical-neuropathological research (GOEDERT; GHETTII, 2007). In 1907, Alzheimer
published a case of presenile dementia from both a clinical and anatomopathological point of view
(ALZHEIMER, 1907), thus recognizing the originality of his discovery (CAIXETA, 2012).
Stella (2016) conceptualizes persistent and progressive memory dysfunctions as dementia,
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characterized by the decline in intellectual capacity, severe enough to interfere with social and
professional activities of daily living, and may represent a clinical condition of a neurodegenerative
nature, depending on the disorder and state of consciousness or wakefulness, which can be caused by
the impairment of the central nervous system (BOTTINO, 2018). The term dementia comes from the
Latin, dementia (de+mentia), which means “absence of mind”. In the twentieth century, this concept
was modied by researchers, as what had been inherited from the eighteenth century associated the
term with an irreversible and terminal state.
AD is a progressive neurodegenerative disease, being the most prevalent dementia in
population-based clinical studies, with prevalence and incidence of 50 to 75% of cases (HERRERA
et al., 2002; NITRINI et al., 2004). Clinical manifestation that includes progressive deterioration of
intellectual abilities and cognitive decline. Most cases begin after 65 years of age (late), however, in
some younger individuals (early) at 25 years of age. Age and low education are important risk factors
for late onset. (HESTAD; KVEBERG; ENGEDAL, 2005).
Other risk factors for late onset are the presence of the e4 allele of the aposto gene, history of
head trauma with loss of consciousness, lack of control of cardio-vascular risk factors (hypertension,
diabetes mellitus, dyslipidemia), sedentary lifestyle, and low cognitive demand throughout life
(AMERICAN PSYCHIATRIC ASSOCIATION, 1995). Early-onset AD is usually associated with
genetic mutations, and is most commonly described and related to the gene responsible for the amyloid
precursor protein (app) on chromosome 21.
Regardless of the age of onset, neuropathological ndings in AD patients are very similar:
presence of neuritic (senile) plaques and neurobrillary tangles, along with neural loss, dystrophic
nutrients, and glucose on histological examination. AD involves, among several processes, the
progressive decline of cholinergic neurotransmission in some specic regions, such as the hippocampus
and cerebral cortex. As the dysfunction progresses, cholinergic dysfunction leads to reduced ability to
perform activities of daily living, impairments in attention, memory, and the appearance of mood and
behavior changes. (MAIA, 2012).
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The pathophysiology of Alzheimer’s disease is currently based on the amyloid cascade
hypothesis. Increasingly established evidence points to the accumulation of beta-amyloid peptides
and, consequently, the formation of toxic amyloid plaque as the main characteristic in the pathogenesis
of AD. In earlier stages, amyloid plaques destroy cholinergic neurons in the basal forebrain, causing
memory disturbances and providing the basis for symptomatic treatment that boosts acetylcholine. It
can be said that the deposit of B-amyloid material ends up destroying the brain diffusely. Therefore, one
of the basic mechanisms related to the development of AD refers to a problem of excessive formation
of B-amyloid or insufcient removal of it. Patients predestined to develop AD have abnormalities in
genes that encode amyloid precursor protein (PPA) or in the enzymes that cleave this protein into
smaller peptides, which through the release of toxic amino acids and their deposits, neurons are
directly injured. (HERRERA et al., 2002).
Support for the amyloid cascade hypothesis comes from genetic studies of the rare autosomal
dominant hereditary forms of AD. Cases linked to the early onset of the disease and mutation in at
least three chromosomes: 21, 14 and 1. The relationship occurs in Down syndrome (trisomy 21) in
which practically all individuals, after 50 years of age, have AD (TANZI and BERTMAN 2005).
Another part of the amyloid cascade hypothesis refers to the possibility that there is something
wrong with the protein that binds to amyloid to remove it, called Apo-E. Their connection prevents
the development of AD. However, a genetic abnormality in its formation makes Apo-E ineffective in
efciently removing B-amyloid and it starts to accumulate and damage neurons (ANDRADE, 2012).
Annunciato (2018) describes that in the year 2000, the number of people with AD in the
United States was 4.5 million. The percentage of individuals with AD doubled approximately every 5
years, in age 60 years and older, representing 1% at 60 years of age and around 30% at 85 years of age.
Without advances in treatment, the number of symptomatic cases in the US is expected to increase to
123.2 million in 2050, with a high cost for patient care being estimated.
The identication of risk factors and the disease in its initial stage corroborate the agile
and adequate referral and specialized care; something essential for a better therapeutic result and
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prognosis of the cases. So the question arises, why diagnose an incurable disease early? By doing
so, we increase the opportunity to anticipate the news of devastating illness for the family. There
is, however, already a reasonable body of scientic evidence. DICKERSON et al., (2007) indicating
that the early diagnosis of AD creates the opportunity for faster initiation of treatment, in addition to
allowing the family and the patient to plan over time the best way to deal with the pathology and seek
health resources without despair. CAIXETA (2006).
The use of clinical (neuropsychological) evaluation for early diagnosis is fundamental, since
the patient effectively presents characteristics that signal a morbid process. To be able to map the
disease, it is necessary to focus on insights and better understand the complex phenomenon of passage
from the condition of normality to dysfunction, such a diagnosis brings together the complexity of
the following areas: neuropsychology, internal medicine, psychopathology, imaging, genetics, in
addition to multiple other variables that need to be properly gathered and systematized by the doctor.
(CAIXETA, 2012).
When one understands and studies the higher nervous activities, it is necessary to have the
necessary notion to be able to qualify the disorder and not simply verify it. Only a careful and well-
done evaluation will lead to a neuropsychological understanding and analysis. The factors resulting
from this qualitative examination contribute to improve the path of indication regarding reeducation
in the patient’s process. (CAIXETA, 2012).
THE PSYCHOLOGICAL IMPACTS OF ALZHEIMER’S DISEASE
When we think about presenting the impact of the psychological domains that AD alters on
patients, we start with communication difculties and neuro-psycholinguistic assessment to promote
a better quality of life for patients, caregivers and family members. The verbal or non-verbal way that
human beings communicate is the passport to their interpersonal relationships and the individual’s
social insertion in the world in which they live. How can we understand the complex and dynamic
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model of symbols which is used so that communication and thought can be emitted and understood
independently and effectively, whatever their mode of presentation. (ASHA, 1990). And the denition
that involves the whole of communication is not just an isolated process, but involves intelligibility of
speech and comprehension, reading, among others. CAIXETA, 2006).
In this sense, the focus becomes the efciency and independence of communication as an
appropriate response to the demands of everyday life (FRATALLI et al., 1995). The various mental
processes that involve the use of language include the use of linguistic information, the formation of
non-linguistic conceptual and perceptual systems. (ORTIZ; BERTOLUCCI, 2005).
Language impairment in AD accompanies the stages of the disease, which can progress with
variable speed. During the neurolinguistic assessment, the mnemic decits are clearly observed by
the rapid forgetting of verbal requests, stories and pictures (ORTIZ; BERTOLUCCI, 2005). Patients
usually remember past facts, and some confuse current events with those already experienced.
(KENSINGER; KRENDL; CORKIN, 2005).
The early stages of the disease are characterized by the presence of anomies (difculty in
nding words and naming objects), word substitution, and a tendency to use general terms, as in
the case of hypernyms (“animal” for “dog”) and emission of semantic paraphasias, when there is a
change for a similar semantic category (“pipe” for “cigarette”). The use of pleonasms is observed
in spontaneous language. At this stage, the epilinguistic function is still preserved, with frequent
correction and recognition of one’s own errors. (KOCH; TRAVAGLIA, 1990).
The language is elliptical, with the presence of circumlocutions, that is, the use of empty,
generalized expressions, such as: “catch that business”. Vocabulary becomes impoverished and there
is a reduction in verbal uency (MANSUR et al., 2005). The decit in episodic memory is usually
expressed by forgetting people’s names, places where objects were kept, and the presence of repetitions
(questions, statements) in conversation.
Discursive incoherence, when already manifest, shows the impairment of episodic memory
and executive functions. Verbal and visuospatial memory alterations are expressed by forgetting
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messages and by the frequency with which the patient can get lost in places he already knows.
(IZQUIERDO, 2002).
Chart 1 shows how the synthesis of language alterations occurs in Alzheimer’s disease.
Chart 1 - Synthesis of Language Disorders in Alzheimer’s Disease
SIGNS EA R LY STAGE INTERMEDIATE
STAGE
A D V A N C E D
STAGE
Memory difculties xXx Xxx
Presence of anomie and production
of paraphasias and neologisms
xXx Xxx
Presence of pragmatic changes x Xx Xxx
Syntactic changes xXx
Disregard for conversational laws
(pragmatic in nature
xXx
Conversation reduction x
Presence of echolalia x
Auditory impairment for oral
language
x
Source: Beilke and Pinho (2010)
With the characterization and understanding of how changes are occurring in the patient,
we can proceed to a better investigation of the cognitive and linguistic functions that lead to
neurolinguistic assessment to understand the importance of these roles played in the process of
language comprehension and production. (CAIXETA, 2012).
Memory loss is a symptom that permeates all stages of the disease, but it is a way to understand
when it may be something more serious. Just as a subject is someone independent and unexpectedly
becomes dependent, because he has a devastating emotional illness. By losing memories and memory,
the individual is left without the subjective identity. (ANNUNCIATO, 2018).
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DEFICITS ASSOCIATED WITH ALZHEIMER’S DISEASE
Below, some of the signs that AD can relate according to the stage and advancement of the
pathology will be presented.
Caution
Considering several criteria, attention is the function or operationalization that can be
classied as: selective, divided, sustained or alternate. (CAIXETA, 2006). Alternating attention is
dened as the ability to switch attentional focus from one stimulus to another during the execution of
a task, as distinct from divided attention, because in the latter the intentional focus is maintained on
more than one stimulus simultaneously. (SISTO et al., 2006).
Focused attention refers to the ability to select a stimulus from several, while sustained
attention refers to the ability of the individual to keep their attention on a stimulus or a sequence of
stimuli for the time necessary to perform a task. (REUDA, SISTO, 2009).
In the evolution of AD, attentional decits appear relatively early. Usually, after the onset
of episodic memory decits, but in general, before the manifestations of language and visual-spatial
alterations. In AD patients, the level of sustained attention is relatively preserved, but the use of time
in the execution of the task tends to affect the quality of performance, especially in the more advanced
phases of the moderate stage and with discrimination tasks, which suggests changes in surveillance.
(CAIXETA, 2012).
Memory
Memory impairment is the clinical event of greatest magnitude for the diagnosis of AD
(DICKERSON; EICHENBAUM, 2012). Generally, in the early stages, there is impaired episodic
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memory and difculties in acquiring new information, with impaired learning (probably justiable,
because the hippocampal pathology in AD is earlier, selective, and universal), evolving gradually with
impairments in other cognitive functions. (GALLUCI NETO; TAMELINI; FORLENZA, 2005).
Patients with AD have difculties in acquiring and consolidating information due to coding
failures and, consequently, information is not transferred from short-term memory to long-term
memory (“amnesia”). Impairments in retention, exemplied by classical amnesia, are characterized
by difculties in retrieval and recognition tasks. (CAIXETA, 2012)
Because there is a fundamental inability to “download” information, the patient benets
little from closed-ended questions and multiple-choice alternatives to open-ended questions. There is
a loss of information, for example, of a short report, from an immediate recovery to a later recovery.
(DICKERSON; EICHENBAUM, 2010).
Language
Limitations involving language occur due to a primary rupture in the structural elements
of language-phonology, syntax, and semantics or as a consequence of non-linguistic factors, such as
short-term memory, motivation, prosody, strategic functioning, pragmatism, and social perception.
(JAKUBOVICZ; MEINBERG, 1992). The presence of grammatical errors or paraphasias of the
phonemic type, and of the semantic type, thus arising an aphasia associated with cortical dysfunctions,
affecting the classical areas of language.
When the standard tests of repetition of naming and linguistic comprehension are performed,
patients obtain poor results. A semantic disparity in which the patient has great difculty both
naming and understanding the meaning of individual words, despite grammatically uent speech,
demonstrates an association with circumscribed lesions, involving the temporal, inferior, and middle
gyri. (BAYLES, 1982).
The frontal lobe with dysfunction is associated with reduced speech production, leading the
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patient to progressively speak less and in order to answer questions in a brief format. Poor results in
linguistic tasks may occur due to the hurried way of responding, demonstrating a random nature of
errors and absence of positive evidence or grammatical disturbances. (SOUZA et al., 2008).
Subcortical lesions cause problems in word retrieval, and patients perform poorly on naming
tasks. Naming performance in a closed task is often superior to performance in open-ended tasks,
involving information generation, such as verbal inuence. Patients have no difculty in understanding
the meaning of individual words, but in naming them, as they make mistakes in comprehension,
due to the need to apply mental effort and mental manipulation of information. (COSTELLO;
WARRINGTON, 1989).
Perception
Problems in perception occur at the level of sensory discrimination, the acquisition of a
structured perception (perceptual agnosia) or attribution of meaning. The regions involved are the
occipital, parietal and temporal cortex respectively. (EFRON, 1968). Even with preserved visual
acuity, patients may present sensory discrimination disorders, causing impairment in the detection
of elementary forms and in combination tests. Perceptual disturbances as well as object recognition
are altered secondarily, as many elementary tasks of sensory discrimination are performed normally,
however, the patient has difculty in recognizing objects, especially when they are superimposed
on others, when the project is unnished or presented with an unusual orientation. (DE RENZI;
SCOTTI; SPINNLER, 1969).
The patient has difculty copying drawing lines, although in associative agnosia he can
discriminate between similar perceptual stimuli, nd identities and copy drawings of objects that he
does not recognize, indicating that the problem of recognition lies in the attribution of meaning, normal
perception. Object recognition failure, however, may not be total. The patient may be successful in
classifying gures, but may fail to identify more accurately. (DE RENZI; SCOTTI; SPINNLER,
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1969).
Spatial Orientation
The parietal lobes cause spatial orientation to occur, including the ability to locate and
appreciate the spatial relationships between objects. Visuospatial disturbances manifest themselves
in tasks such as linear orientation, point counting, spatial location combination, and cubic estimation.
When designing and performing block construction tasks, there is a loss of spatial conguration
as a whole and disorder between the elements (visual-constructive disturbance). The subject cannot
indicate, in a group of objects, the one that is farthest or closest, that is more to the right or to the left,
longer or shorter.
Often, spatial orientation may be compromised for reasons that are not primarily spatial, but
may be due to poor strategic and organizational skills associated with frontal lobe dysfunction. Thus,
inadequate performance is observed, resulting from organizational difculties instead of spatial ones,
which have different characteristics. (HEILMAN VALENSTEIN, 1979).
Motor Apraxias
It is the memory of the motor act. Failures in motor commands occur in patients who are
physically well (without motor decits or alterations in comprehension), may occur as a result of a
primary apraxia associated with damage to the parietal and/or frontal, premotor, or upper regions. At
the same time, in a secondary way, there is a spatial disorder related to parietal lobe dysfunction or
difculty in temporal sequencing associated with lesions of the frontal lobe and subcortical regions.
Apraxic patients have difculty conceptualizing the appropriate action (conceptual apraxia), in others,
the problem lies in converting the idea into action (ideomotor apraxia). Some patients even have
discernment and recognize the discrepancy between the intention and the response performed.
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Asymmetric apraxia occurs when altered motor responses correspond to spatial dysfunction
and are generally bilateral and symmetrical (HEILMAN VALENSTEIN, 1979). It can also be
distinguished from spatial dysfunction due to the preservation of performance in spatial tasks,
in which motor responses are minimized or eliminated, such as left and right orientation or point
counting. (WALDEMAR et al., 2007).
Patients with chronological sequential difculties secondary to frontal lobe dysfunction are
able to mimic hand postures correctly, but unable to reproduce them in sequence. There may be
preservation of responses from one motor sequence to the next. (LÚRIA, 1966).
Front Executive Functions
Several tasks that involve planning, organization, sequencing, abstraction, decision-making,
critical judgment, and strategy skills in activities aimed at an end goal are sensitive to frontal lobe
damage and to those subcortical structures that project from these regions. Such changes help to
distinguish the performance and characteristics of these functions. Mismatch in word generation and
verbal uency tasks demonstrate disproportionality in the naming pattern of things.
If the frontal lobe dysfunction is primary, it will lead to concrete answers, denoting the
inability to abstract concepts. Disability is also observed when there is a change in the mental setting.
Poor performance that occurs for non-frontal reasons often does not last, and patients may oscillate
from one task to another.
DIAGNOSIS OF ALZHEIMER’S DISEASE
According to the DSM-5 (2013), the diagnosis of AD begins with the nding of neurocognitive
disorder (CNT), from then on the central characteristics of major or mild CNT, due to Alzheimer’s
disease, include insidious onset and gradual progression of symptoms. The characteristic presentation
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is amnesiac, but there are also uncommon non-amnesic presentations, especially visual, spatial, and
aphasic ones.
In the mild phase of TNC, Alzheimer’s disease usually manifests itself with impairment
in memory and learning, sometimes accompanied by impairments in executive functions, such as
planning and organization. When CNT is moderate to severe, visual-constructive/perceptual motor
skills and language are usually also impaired; Social cognition tends to be preserved until later in the
course of the disease.
The diagnosis of mild or major neurocognitive disorder due to AD can be divided into
possible and probable, considering cases in which there is a family history or genetic test suggestive
of the presence of the disease; while cases in which the symptomatology and natural history of the
disease are compatible with Alzheimer’s disease are possible, without a family history or genetic test
suggestive of the disease.
Although biomarkers, such as the dosage of metabolites of tau protein (responsible for the
development of neurobrillary tangles) and amyloid B-peptide (responsible for the formation of
amyloid plaques) are being studied, the diagnosis of conrmation can currently only be given through
visualization of the nervous tissue, presenting the pathologies previously discussed, which rarely
occurs in vivo, given the risks involved in a brain biopsy and the accuracy of the clinical diagnosis.
(STAHL, 2014). Therefore, for the diagnosis to be as accurate as possible, a good anamnesis and a
good clinical history are necessary. (KUMAR et al., 2016).
Treatment
In the treatment of AD, in addition to medications, non-pharmacological interventions are
necessary, which are often as effective or more effective in managing behavioral and psychological
symptoms. These interventions include cognitive/neuropsychological rehabilitation, occupational
therapy, physiotherapy, psychotherapy, music therapy, among others. (CARVALHO et al., 2016).
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Currently, the pharmacological treatment of AD has four drugs: donepezil, galantamine,
rivastigmine and memantine. Donepezil, galantamine and rivastigmine are acetylcholinesterase
inhibitors, that is, they act by inhibiting the enzyme that destroys acetylcholine, thus increasing the
availability of this neurotransmitter. Memantine, in turn, is a non-competitive receptor antagonist,
reducing the effects of excessive release of this neurotransmitter that occurs in AD (STAHL, 2014;
STAHL, 2017).
These drugs act on the symptoms of the disease, but cannot prevent its progression. However,
numerous clinical trials are being carried out, researching how to attack the disease in different ways,
such as immunotherapy to reduce the deposition of B-amyloid and tau protein, or even to try to reverse
the degeneration caused by the disease in the brain. (STAHL, 2014; KANDEL, 2014). In Brazil, these
drugs can be obtained free of charge through the SUS High-Cost Medication Program. Medications
are also used to treat symptoms of depression, anxiety, and psychotic symptoms.
POSSIBILITY OF REHABILITATION OF PEOPLE WITH ALZHEIMER’S
The ideal of eternal youth is not just an allegory of fantastic stories. It is, more than that, an
ideal that continues to be pursued, even if disguised. With the development of industrial civilization,
aging has become a great fear, as we currently live with the terror embedded in the idea of becoming
old. In the age of information and technology, aging incorporates another meaning, the possibility of
developing a disease that takes away what is most precious – memory, criticism, one’s own self, loves.
It is the disease of Alzheimer ‘s. (ANNUNCIATO, 2018).
A new lease of life has been given to a relatively new area in the eld of AD studies and its
prevention. Results from several observational studies published during the last decade suggest that
some factors associated with the disease can be modied. But a little distant, but possible.
By adequately understanding the factors involved in the genesis of the pathological process,
the probability of reaching knowledge regarding the prophylaxis of this disease process obviously
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increases. A good investigation of the potential causes of AD is based on identifying, in a simple way,
the association between certain factors or events (exposures) and dementia (ALMEIDA, 2006).
METHOD
This study proposes a review of the scientic literature, which presents as a method the
search, selection, analysis and description of the scientic production of a given theme or area, in
an integrated and critical way, as well as the presentation of gaps and possibilities for new research.
(ALVES; ROSE; SILVA; SARDINHA, 2016). This type of study can be carried out in the form of
categorization or in the form of critical analysis and the procedures adopted in this review were: (a)
identication of the theme and the guiding question; (b) choice of descriptors to be used in the research;
(c) establishment of inclusion and exclusion criteria; (c) categorization of studies; (d) evaluation of the
research; (e) interpretation of the results; (f) synthesis of knowledge.
According to Fonseca (2002, p. 32), bibliographic research is done from the survey of
theoretical references already analyzed, and published by written and electronic means, such as books,
scientic articles, web site pages. Therefore, any scientic work must begin with a bibliographic
search. This initial step allows the researcher to know what has already been studied on the subject.
However, there are scientic researches that are based solely on bibliographic research, looking for
published theoretical references with the objective of collecting information or previous knowledge
about the problem to which the answer is sought. (FONSECA, 2002, p. 32).
In this research, a search was carried out in the electronic databases: Scientic Electronic
Library Online - SciELO and Electronic Journals in Psychology - PePSIC with the keywords
Alzheimer’s, rehabilitation, as they cover more publications than other terms. These databases were
chosen because they are electronic databases of Brazilian journals.
The inclusion criteria established for this study were: (a) indexed articles; (b) national
publications; (c) published in the period from 2010 to 2020; (d) empirical studies. The exclusion criteria
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were: (a) central theme that did not contemplate the objective of the research; (b) articles published in
the period before 2010 and after 2020; (c) articles with double indexing and (d) theoretical studies or
studies that focused on themes unrelated to Alzheimer’s and Rehabilitation.
The two databases were consulted between April and September 2021, and 10 articles were
located in the PePSIC database and 03 in the SciElo database.
Based on the inclusion and exclusion criteria of the articles initially located, 01 was excluded,
which was outside the period established for the research (1 previous publication).
An increase in scientic production was observed in the last decade in Brazil, which justies
the present review. 02 articles that studied AD from the perspective of other areas, or did not deal
with empirical research (theoretical, reviews and historical surveys) were also excluded, most of the
research was empirical. By considering only the articles that used Alzheimer’s and Rehabilitation,
in empirical research, 10 articles were selected, which were analyzed according to the theme cited,
their objectives and the samples used t the requested criteria. Thus, there is a trend of increasing
production, but with a certain irregularity.
DATA ANALYSIS
This work proposes to present AD and its psychological impacts, the possibilities of
psychological rehabilitation as an individualized process, with unique and distinct potentialities,
making a distinction between normal and pathological old age. Alzheimer’s is a disease in which
brain cells and their connections degenerate and die.
Memory loss is the most evident and well-known sign. However, the individual may also
present mental confusion, emotional instability and regression in motor capacity. AD is the most
common cause of dementia, accounting for 70% of all cases worldwide. Dementia can be characterized
as a persistent state of cognitive deterioration, including memory loss, difculty in communication
and comprehension, decreased attention span; functional deterioration, including coordination and
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visual perception problems; and emotional deterioration, including depressive symptoms, anxiety,
delusions, hallucinations, and aggressiveness. (APOSTOLOVA et al., 2012).
Between 2012 and 2015, the disease registered a 75% increase in cases of hospitalization in
Brazilian hospitals. Currently, it is estimated that there are about 35.6 million people with this type
of dementia in the world. This number will practically double by 2030 and triple by 2050, according
to data from the World Health Organization (WHO), 2020. In Brazil, the possibility is that there are
about 1.2 million people with AD. It should be noted that most people with the disease have not yet
received the medical diagnosis and the necessary treatment.
The cognitive problem was rst described in 1906 by the German psychiatrist and neurologist
Alois Alzheimer. On September 21, 1994, in Edinburgh, the capital of Scotland, the 10th annual
conference of Alzheimer’s Disease International was opened, at which time the World Alzheimer’s
Day campaign was launched. The conference was chaired by Princess Yasmin Aga Khan, daughter
of actress Rita Hayworth diagnosed with Alzheimer’s in the early 80s, died of the disease in 1987.
(INFORMA SUS).
The campaign was created through the signing of a document in conjunction with the World
Health Organization (WHO), with the participation of Brazilian doctor José Manuel Bertolone, a
WHO employee at the time. The campaign, then, originated as a way to raise awareness and inform
leaders, politicians and the population around the world about Alzheimer’s Disease. The document
encouraged the creation, at a global level, of local organizations to support patients and their families.
Currently, there are numerous Alzheimer’s institutions around the world. In Brazil, we have the
Brazilian Alzheimer’s Association (ABRAZ).
But more than a century has passed and with the increase in the population’s life expectancy,
more families have begun to live with people who “disappear”, lose their identities, regress in their
emotional and motor behaviors, needing specic care 24 hours a day, seven days a week.
Even though the accumulation of cases shows that the disease has an important genetic slant,
the evidence about what was happening in the brains of people diagnosed with Alzheimer’s was still
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unclear. Until recently, there was a lack of indicators on what increased risk during the development of
the entire process. And without knowing the cause, it was extremely delicate to talk about something
primordial, but totally unknown: prevention and rehabilitation.
Analyzing it as follows: if we do not know the cause, we cannot prevent the result. Over the
years, with studies, case analysis and the growing concern of not letting a loved one be devastated by
the lack of memories, many specialists are nding strong answers so that prevention can already be
applied, and that the regression of the disease is something concrete and possible (ANNUNCIATO,
2018).
Researchers in the area, together with Dr. BREDSEN (2018) have already identied that in
the brain, of those with Alzheimer’s, there is a higher concentration of a protein called beta-amyloid,
which is one of the responsible for the distribution of the ability to remember. This protein has always
been considered the great villain of the problem, a lot of money and has already been spent in an
attempt to “break the plates”. But the big surprise for the researchers was the discovery that these
plaques arise in an attempt to help protect our neurons when the brain feels threatened.
More advanced studies BREDESEN (2018) found that this beta-amyloid protein has a very
important link between Alzheimer’s and diabetes. The latest research indicates that glucose and,
consequently, elevated insulin in the blood (insulinemia) can rapidly increase beta-amyloid levels,
paving the way for all brain phenomena that result in the loss of memory and cognitive functions.
In addition, the scientic trials of ANNUNCIATO (2018) show connections between other
diseases. Toxic particles typical of AD (the ADDLs) make neurons resistant to insulin and this impairs
the transmission of data between them.
These trials allowed for a unique understanding of the causes of the disease, not just having
to accept the consequences. Once the theoretical approaches of the work are presented, the titles and
how the evolution of this literature review work took place will be chronologically arranged.
In the table below are the articles selected in the literature review and their descriptors.
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Chart 02 - Evolution of research on Alzheimer’s disease
Author Article Title Year
Olive tree Aging, Alzheimer’s disease and the contributions of the instrumental
enrichment program (IEP)
2010
Da- Silva et
al.
Neuropsychological rehabilitation program of memory applied to dementia:
an uncontrolled intrasubject study.
2011
Vale et al. Treatment of Alzheimer’s disease in Brazil: I. Cognitive disorders. 2011
Gutierrez et
al.
Economic impact of Alzheimer’s disease in Brazil: is it possible to improve
care and reduce costs?
2013
O a k ;
M a g e l l a n ;
Pedroso
Non-pharmacological treatments that improve the quality of life of older
adults with Alzheimer’s disease: a systematic review.
2016
Andrade et
al.
Transcranial continuous current stimulation in the adjuvant treatment of
Alzheimer’s disease.
2016
Morello; File;
Brandão
Language and communication interventions in Alzheimer’s disease: a
systematic review. communication intervention in Alzheimer’s
2017
Vilela et al. What Cochrane systematic reviews say about non-social interventions.
Pharmacological Disorders for the Treatment of Cognitive Decline and
Dementia?
2017
Madureira et
al.
Effects of multidisciplinary rehabilitation programs in the treatment of
patients with Alzheimer’s disease: a systematic review.
2018
Sá et al. Efcacy of cognitive rehabilitation in improving and maintaining activities
of daily living in patients with Alzheimer’s disease: a systematic review of
the literature.
2019
Source: the authors (2021).
As the table has shown, we can understand how studies have been happening and research
has advanced in search of rehabilitation possibilities in the context of the last decade. The expansion
of research contributes to changes in paradigms related to aging and maximization of knowledge and
possible rehabilitation of AD.
The 2010 article, AGING, ALZHEIMER’S DISEASE AND THE CONTRIBUTIONS OF
THE INSTRUMENTAL ENRICHMENT PROGRAM (PEI), demonstrates how successful aging
depends largely on disease prevention. With an adequacy of physical conditioning and preservation
of cognitive functions, because studies show that elderly people who have mild cognitive alterations
tend to have a higher risk of developing AD. (OLIVEIRA, 2010).
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Considering that an affected brain causes loss of memories and various cognitive
impairments, alternative treatment alternatives have been proposed in addition to pharmacological
therapy characterizing neuropsychological rehabilitation. In this work, in particular, the use of the
Instrumental Enrichment Program and the Mediated Learning Experience was addressed, aiming to
favor the optimization of residual capacities and the reduction of negative impacts on people’s quality
of life.
In the March 2011 study, NEUROPSYCHOLOGICAL REHABILITATION PROGRAM OF
MEMORY APPLIED TO DEMENTIA: AN INTRA-SUBJECT UNCONTROLLED STUDY, reports
the participation of elderly people with AD and other dementias who participated in rehabilitation
workshops, with gardening and colored tracks, and at the end of the program there was an increase in
the scores of the learning and memory tests. At the same time, a reduction in Depression scores was
observed and these reductions were associated with treatment with anticholinesterases.
In another article from September 2011, TREATMENT OF ALZHEIMER’S DISEASE IN
BRAZIL: I. COGNITIVE DISORDERS, this study was recommended by the Brazilian Academy
of Neurology, through its Scientic Department of Cognitive Neurology and Aging, the consensus
involves researchers in the medical eld and other professionals. Seeking guidance for pharmacological
and alternative treatment of cognitive disorders of AD. The inclusion of drugs in therapeutic
recovery includes: acetylcholinesterase inhibitors, memantine and other drugs and substances. As
for non-pharmacological recommendations, they include cognitive rehabilitation, physical activity,
occupational therapy and music therapy, and psychological follow-up for the behavioral symptoms of
dementia.
The 2013 study, ECONOMIC IMPACT OF ALZHEIMER’S DISEASE IN BRAZIL: is it
possible to improve care and reduce costs? With the objective of reducing costs related to AD in terms
of assistance and assistance to families and caregivers in the management of AD. When the disease
is in the mild stage, it is the cost of time for the unpaid caregiver, while those in which the disease is
more advanced, it is the care in relation to institutionalization. The literature indicates GUTIERREZ
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et al., (2013), in view of this scenario, care models that make it possible to maximize the functional
independence of the elderly and the maintenance of their abilities, but it is something that needs to be
discussed, structured and implemented in the Brazilian reality.
In 2016, this study NON-PHARMACOLOGICAL TREATMENTS THAT IMPROVE THE
QUALITY OF LIFE OF ELDERLY PEOPLE WITH ALZHEIMER’S DISEASE: A SYSTEMATIC
REVIEW, seeking to review the literature in the last ten years and the studies that adapted to the
objectives of the theme showed that the most described treatments indicated both cognitive and
multidisciplinary rehabilitation. These techniques have been shown to improve the quality of life in
elderly people with mild disease.
In the 2016 research, TRANSCRANIAL CONTINUOUS CURRENT STIMULATION IN
THE ADJUVANT TREATMENT OF ALZHEIMER’S DISEASE: A CASE STUDY. This is a case
report of a 73-year-old patient diagnosed with Alzheimer’s disease who underwent 10 daily sessions
of transcranial direct current stimulation (tDCS).
tDCS was applied to the left dorsolateral cortex as an adjuvant therapy to the traditional
treatment that the patient received (anticholinergic medication and cognitive training). The results
obtained demonstrated that tDCS had a stabilizing effect on the patient’s general cognitive function
and led to increased performance in all tests. Preliminary results indicate that tDCS has adjunctive
therapeutic potential for cognitive rehabilitation in Alzheimer’s disease.
In September 2017, the LANGUAGE AND COMMUNICATION INTERVENTIONS IN
ALZHEIMER’S DISEASE: A SYSTEMATIC REVIEW. COMMUNICATION INTERVENTION
IN ALZHEIMER’S. Alzheimer’s disease (AD) considerably compromises communication skills. As
the disease progresses, language and cognition deteriorate, reducing the ability to hold conversations,
which has a negative impact on social interaction. Interventions focused on language found that in
most interventions there were benets for at least one language or communicative skill, pointing
to higher levels of evidence and are recommended in the investigation of interventions focused on
language and communication skills of patients with dementia.
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In the 2017 study, WHAT DO COCHRANE SYSTEMATIC REVIEWS SAY ABOUT
NON-PHARMACOLOGICAL INTERVENTIONS FOR THE TREATMENT OF COGNITIVE
DECLINE AND DEMENTIA? Dementia is a condition with a high prevalence and global incidence.
Its chronic and progressive characteristic has an impact on physical, psychosocial and public health
aspects. Cochrane reviews on non-pharmacological interventions for cognitive dysfunction and/or
any type of dementia were included, following independent assessment by two authors.
Reviews have shown that carbohydrate intake and validation therapy may be benecial
for cognitive disorders. For dementia, there is a potential benet of physical activity programs,
cognitive training, psychological treatments, aromatherapy, light therapy, cognitive rehabilitation,
cognitive stimulation, hyperbaric oxygen therapy associated with donepezil, functional analysis,
reminiscence therapy, transcutaneous electrical stimulation, structured decision in feeding options,
case management approach, and interventions applied by non-specialist health workers and health
care units. specialized care. Several non-pharmacological interventions for patients with cognitive
impairment and dementia have been studied, showing potential benets.
In the 2018 article, EFFECTS OF MULTIDISCIPLINARY REHABILITATION PROGRAMS
IN THE TREATMENT OF PATIENTS WITH ALZHEIMER’S DISEASE: A SYSTEMATIC
REVIEW. Multidisciplinary actions with AD patients aim to interfere directly in the health/disease
process, with a comprehensive approach to individuals and family members, appropriate to their
realities. The studies showed the efciency of this treatment option with AD patients, signicant
improvements in neuropsychiatric symptoms and quality of life. However, as for cognition, the results
were not signicant or conicting.
In 2018, the book “THE END OF ALZHEIMER’S: THE FIRST PROGRAM TO PREVENT
AND REVERSE COGNITIVE DECLINE” arrived in Brazil by the author Dr. Dale E. Bredesen,
who is internationally known as a specialist in the mechanisms of degenerative diseases and presides
over renowned institutions in his eld.
In the 2019 Literature review, COGNITIVE EFFICACY IN IMPROVING AND
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MAINTAINING ACTIVITIES OF DAILY LIVING IN PATIENTS WITH ALZHEIMER’S
DISEASE: A SYSTEMATIC REVIEW OF THE LITERATURE. In order to validate the efcacy
of cognitive rehabilitation in patients with mild to moderate AD, the study presented cognitive
rehabilitation with non-pharmacological interventions. The studies demonstrated an improvement in
the performance of patients in the assessment instruments, especially with regard to the performance
of activities of daily living, demonstrating how much the patient’s independence is a consequence of
rehabilitation in daily activities, generating functional and structural changes. However, more studies
are needed to prove and apply this practice.
Thinking about ways and possibilities of how to put all this knowledge into practice, it
was decided to make the connection between the knowledge already demonstrated previously with
Psychology through Psychoeducation: which is a technique of Cognitive Behavioral Therapy (CBT),
recognized for helping new patterns of thought and behavior (LEAHY, 2004). In this approach,
collaboration and psychoeducation aim to develop strategies so that clients learn to recognize their
thoughts, emotions and behaviors and to be able to modify them (KENDALL & BEMIS, 1983).
Psychoeducation can use resources such as videos, audios, pamphlets, campaigns, etc. In
these psychoeducational plannings, they can be involved by professionals from different areas of
health, providing an interdisciplinary work that provides the client with a care whose integrality is
present. (LEMES & ONDERE NETO, 2017, p. 26)
One of the most impactful studies regarding the natural treatment for Alzheimer’s is the
“Reversal of cognitive decline: A noveltherapeutic program”, by Dr. Dale E. Bredesen, from the
University of California at Los Angeles (UCLA) and published in the scientic journal Aging in
2014. In this study, Dr. Bredesen gathered 10 patients with progressive memory loss in recent years
and diagnosed with Alzheimer’s. For each of the patients, Dr. Bredesen put together a protocol that
considered, as key elements, the use of supplements, combined with specic nutrition and physical
activities. After the change in the lifestyle of these patients, there was regression of Alzheimer’s
symptoms in 09 out of 10 patients. (BREDESEN, 2018).
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Also in 2018, neuroscientist Dr. Nelson Annunciato released his book “SUPERBRAIN
WITHOUT ALZHEIMER’S”, which contains information and directing studies to an area that has
been largely neglected, because according to him, we can have “SUPERBRAINS”.
The articles demonstrate that the implementation of policies that favor prevention and awareness
about care and possibilities for improvement for AD patients and their families, dealing with the
reduction of suffering and the psychological impacts on patients and their families. The aforementioned
articles from 2018/2019 report the possibilities of rehabilitation through multidisciplinary teams and
with the effectiveness of neurocognitive plasticity, but regarding Psychology few contributions related
to the subject addressed.
FINAL CONSIDERATIONS
The information from this research shows that the degenerative process of AD is permeated
by issues that cannot yet be dribbled, in addition to being understood and experienced differently by
the various subjects who participate in it. It is through this context that strategies can be constituted
for each patient to face and prevent illness and, although they belong to a group of people, they
transcend each one individually.
Thus, inuenced by the literature and recent research, facing the disease from another
perspective should be a goal to be pursued by health professionals. Therefore, Psychology aims to
make preventive health psychoeducation add this new perspective through a sharing of knowledge.
From this context, the present study nds that elements such as family, social relationships
and culture have an impact on the way the experience of AD is lived. After all, alongside a person with
the disease, professionals put into practice a wide range of knowledge, beliefs, values and attitudes
that surround the health, disease and care process.
In addition, this study also demonstrates that knowledge determines and provides care to
sick patients, and must be the common denominator of many of the actions and strategies adopted
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by professionals. And so it becomes difcult without communication skills, interpersonal and
multiprofessional theoretical framework.
To establish a care plan appropriate to the individual needs of the patient with Alzheimer’s, for
this complex process to be effective, one type of treatment is not enough, but the set of multidisciplinary
knowledge. Thus, this study reveals that understanding the disease is capable of providing security and
new possibilities of treatment and prevention for professionals and researchers, who tend to feel more
self-condent in the face of issues related to AD from the moment they receive a logical explanation
for the manifestations presented by the patient. This is a way to allow the professional to realize, for
example, that the behavioral symptoms of dementia are not directed on purpose, but a consequence
of the symptoms.
It is possible to verify that psychological mechanisms (stigma, denial and negative view of
the disease) and ideas about the manifestations of the disease associated with stereotypes about aging
can compromise the achievement of a more secure knowledge about this type of dementia. Although
professionals report being aware of the biological nature of the disease, interpretations of causality
between the patient’s life history and this type of dementia exist, which leads to the idea that changes
that emotionally impact the subject can inuence the development of the disease.
The physiological, genetic, and hereditary dimensions were addressed in this study to explain
the causes of AD, but psychosocial and sociocultural dimensions also occur when we question the
etiology of this type of dementia. These different interpretations have repercussions on the acquisition
of awareness of the disease and, consequently, on attitudes towards a person with AD.
In view of these ndings, it is considered that knowing these representations in health
practices means overcoming the scientistic view and advancing towards the understanding of the
complexity inherent to psychoeducation in preventive health of AD.
Thus, the present research contributes to stimulate the creation of training programs and
research in Psychology, through Psychoeducation aimed at prevention and possible reversal in AD.
Thus, professionals would have support to deal with the behavioral manifestations of the disease and
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would receive clarication regarding basic and preventive care, such as feeding and sleep hygiene,
which contributes to alleviating difculties that arise during the illness process. The research showed
that enough is already known to achieve psychological and functional health rehabilitation for people
affected by AD, but there is still little work that connects the areas of health in order to obtain better
results.
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