Dementia

NURSING MANAGEMENT OF DEMENTIA

“3dS” OF GERIATRICS 

COMMON IN OLDER ADULTS AND THEIR SIGNS AND SYMPTOMS OFTEN OVERLAP

DEMENTIA -

A general term that refers to progressive, degenerative brain dysfunction, including deterioration in memory, concentration, language skills, visuospatial skills, and reasoning that interferes with a person’s daily functioning.

DEMENTIA  -the

most common type of dementia is ALZHEIMER’S DISEASE named after Dr. Alois Alzheimer.

 -There

are no specific interventions for the prevention of AD

DEMENTIA  ALZHEIMER’S  -Although

DISEASE

the aging brain undergoes many developmental changes, these changes do not significantly interfere with the daily functioning of most older adults.

DEMENTIA  ALZHEIMER’S

DISEASE  -HALLMARKS OF AD:  1. Beta-Amyloid Plaques  2. Neurofibrillary tangles  -the

plaques and tangles interfere with normal nerve cell function and lead to neuronal death.

TYPES OF DEMENTIA  1.

ALZHEIMER’S DEMENTIAL

 -most

common type of dementia ; (50%70% of all cases)

 2.

VASCULAR DEMENTIA

 -2nd  3.

most common type

MIXED DEMENTIA

 -AD

plus Vascular Dementia

TYPES OF DEMENTIA  4.

Demential with Lewy bodies or Lewy body dementia (LBD)

 -with

a specific pathological finding in the bran (abnormal deposits of a protein, alpha-synuclein)

TYPES OF DEMENTIA  4.

Demential with Lewy bodies or Lewy body dementia (LBD)  Motor symptoms n the early stage of LBD (which occur in the late stage of AD) hallucinations in early LBD (which  Visual occur in the middle stage of AD, if at all)  Fluctuating mental status as a feature of LBD  (which usually occurs only due to delirium in AD

TYPES OF DEMENTIA  5.

Frontotemporal dementia or Frontal lobe dementia (FLD)

 -affects

the frontal and temporal lobes of the brain and is often characterized by early deficiencies in executive functioning

 -personality

changes & disinhibition

RISK FACTORS OF DEMENTIA  1.

AGE

 -doubles  2.

FAMILY HISTORY

 -first  3.

every 5 years after age 65 years

degree relative with AD

GENETICS

 -APOLIPOPROTEIN

E-e4 (APOE-e4)

RISK FACTORS OF DEMENTIA  4.

HISTORY OF HEAD INJURY

DIAGNOSTIC CRITERIA FOR ALZHEIMER’S DISEASE 

Multiple Cognitive Deficits/impairment



1. Impaired short-or long-term memory AND



2. At least one of the following: 

Impaired executive function (abstraction, planning, organizing, sequencing)



Aphasia (language disturbance)

DIAGNOSTIC CRITERIA FOR ALZHEIMER’S DISEASE 

Apraxia (impaired purposeful movements)



Agnosia (inability to recognize sensory stimuli)

3. The changes signifantly interfere with social and /or occupational function and represent a decline from previous level of function. 4. The course has been a gradual onset and continuing decline 5. The changes do not occur exclusively during delirium 6. The changes are not better accounted for by another condition

Medical diagnosis of Alzheimer’s Disease/Dementia 1.

Visit a primary care provider 

Goal: Identify and treat dementia in the early stage, before the symptoms are more apparent and when interventions tend to be more successful. 2. PCP will conduct a history and physical examination and medical history 3. Brain imaging-CT-scan/MRI -it will rule out other possible causes of cognitive decline

Medical diagnosis of Alzheimer’s Disease/Dementia 3. PCP will do simple ‘paper and pencil’ screening test -to determine the presence and degree of cognitive impairment -diagnosis is made by: physicians with experience in geriatrics -Geriatric internist, geriatric psychiatrist Ex. MINI MENTAL STATE EXAMINATION

Medical diagnosis of Alzheimer’s Disease/Dementia -Many persons with a new diagnosis of demention and /or their families may believe that the diagnosis is INCORRENT- DENIAL. Common psychological coping mechanism-- DENIAL

STAGES OF ALZHEIMER’S DISEASE 

3 STAGES



1. MILD Subtle, unnoticed, “just getting older”



2. MODERATE Behavioral and psychological symptoms of demential (BPSD)



3. SEVERE requires total care and will die because of complications

Pharmacological Intervention for Dementia 1.

Cholinesterase inhibitors (CEIs)

-blocks cholinesterase enzyme ; (DONEPEZIL, RIVASTIGMINE, GALANTAMINE) Acetylcholine -is a neurotransmitter in the brain, known to be important for memory. Medication/Disease that inhibit acetylcholine interfere with memory.

Pharmacological Intervention for Dementia 2. N-methyl-D-Aspartate (NMDA) Receptor antagonist -protect neurons from glutamate excitotoxicity without completely eliminating the glutamate necessary for normal neurological function.

DELIRIUM 

Is a syndrome that occurs acutely is and often called acute confusion, unlike dementia which is called chronic confusion.



Hours or days and is caused by some other underlying medical problem.

DELIRIUM CONFUSION ASSESSMENT METHOD 1.

Acute Onset or fluctuating course

2.

Inattention

3.

Disorganized thinking

4.

Altered Level of Consciousness

-Diagnosis: both 1,2 are present along with either features 3 or 4

DELIRIUM CONFUSION ASSESSMENT METHOD 1.

Acute Onset or fluctuating course

2.

Inattention

3.

Disorganized thinking

4.

Altered Level of Consciousness

-Diagnosis: both 1,2 are present along with either features 3 or 4

DELIRIUM 

The nurse plays a critical role in identifying whether an older adult has experienced an acute change in mental status



The primary treatment for delirium is to discover or treat the etiology or cause.



Report the changes to the HCP/physician



Identify medications that can cause confusion



Keep the patient comfortable



Hypoactive vs. Hyperactive delirum



Avoid physical restraints because they tend to cause more panic and agitation

DELIRIUM 

Move the patient to room near the nurse’s station



Implement ris for fall protocols



One to one care and supervision



Eliminate tethers as ordered (catheter, oxygen tubings)



Elimination of confusing external stimuli ( television)

DEPRESSION 

A disorder that includes changes in feelings or mood, described as feeling sad , hopeless, pessimistic or blue lasting most of the day, with loss of interest in pleasurable activities.

COMPARISON OF SIGNS AND SYMPTOMS OF DEMENTIA, DEPRESSION AND DELIRIUM DEMENTIA

DEPRESSION

DELIRIUM

ONSET

GRADUAL OVER MONTHS TO YEARS

USUALLY GRADUAL

ACUTE OVER HOURS TO DAYS

COURSE

SLOWLY PROGRESSIVE, IRREVERSIBLE, MINIMALLY TREATABLE

CHRONIC, SOMETIMES ABRUPT WITH PSYCHOSOCIAL STRESSORS, TREATABLE

FLUCTUATING. REVERSIBLE WITH IDENTIFICATION AND TREATMENT OF CAUSE

LEVEL OF CONSCIOUSNESS

ALERT

ALERT

ALTERED, CLOUDED, FLUCTUATING

MEMORY

IMPAIRED. SHORT-T. AND LONG T.

INTACT, MAY EXHIBIT POOR EFFORT IN MEMORY TESTS

SHORT-TERM MEMORY LOSS

ORIENTATION

IMPAIRED TO TIME, PLACE , PERSON THEN SELF

INTACT

IMPAIRED, FLUCTUATING

PSYCHOMOTOR SPEED

NORMAL. SLOWED IN ADVANCED STAGES

MAY BE NORMAL, HYPOACTIVE, HYPERACTIVE

HYPOACTIVE, HYPERACTIVE OR MIXED

LANGUAGE

WORD-FINDING DIFF. IMPAIRED INCREASES W/ DISEASE PROG.

NORMAL, MAY NOT INITIATE MUCH CONVERSATION

OFTEN INCOHERENT

HALLUCINATION

USUALLY VISUAL IF PRESENT.

NONE. UNLESS PSYCHOTIC

COMMON, TEND TO BE