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Cognitive & neurologic, delirium & dementia spring 2012 abridged
 

Cognitive & neurologic, delirium & dementia spring 2012 abridged

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  • Cognition is the intellectual ability to think. Cognitive functioning is one’s intellectual capacity to understand and respond to the world. In general, the word “cognition” refers to all of the mental activities involved in receiving information, comprehending it, storing it, retrieving it, and using it. Thus cognition includes: 1. The sensory and perceptual processes that enable us to receive information from the world (e.g., vision, hearing, smell, taste, and tactile sensation/perception); 2. All of the mental processes involved in attending to the information, recognizing it as something meaningful, making sense of the information, relating it to what is already known, organizing the information, deciding what is important and what is not important, storing the information for later retrieval, retrieving it when useful; 3. Using the information to make decisions about what to do, to solve problems, to communicate, and the like.
  • Changes in cognition related to aging vary greatly from person to person.
  • The perception of pain decreases with age, rather than increases. The slower perception of pain can lead to injuries.
  • Contrary to the stereotype of increasing rigidity and inflexibility with age, healthy older people maintain stable personalities and psychological adaptation throughout their lives. Late adulthood is no longer seen as a period of growth cessation and arrested cognitive development, but rather a continued period of growth & development with the opportunity for development of unique capacities. Normal, healthy aging is not characterized by cognitive and mental disorders. Most people over age 65 do not suffer from memory defects or dementia. The overwhelming majority of older people have no mental impairment. Normally, an older person’s mental health and cognition remain relatively stable. For those functions that do change, usually the change is not severe enough to cause significant impairment in daily life (functional ability) or social ability.
  • Cognitive skills such as remembering, solving complex problems, paying attention, and processing language are affected by age- and disease-related changes in the brain.
  • With age, loss of nerve cell mass causes some atrophy of the brain and spinal cord, and brain weight decreases. The number of nerve cells declines, each cell has fewer dendrites, and some demyelinization of the cells occurs. These changes slow nerve conduction. Response and reaction times are slower; reflexes become weaker.
  • Plaques, tangles, and atrophy occur in the brain to varying degrees; there is not always a relationship between these changes and cognitive function. Free radicals accumulate with age and may have a toxic effect on certain nerve cells. Cerebral blood flow decreases about 20% as fatty deposits gradually accumulate in the blood vessels, and decreases are even greater in persons with small-vessel cerebrovascular disease due to diabetes and hypertension; this contributes to an increased risk for strokes. The brain has a greater ability to compensate after injury than does the spinal cord, but this ability to compensate declines with age. Intellectual performance tends to be maintained until at least age 80, although a slowing in central processing delays the time required to perform tasks.
  • Verbal skills are well maintained until age 70, after which there is a gradual reduction in vocabulary, a tendency to make semantic errors, and abnormal rhythm and intonation. Other age-related changes in intellectual function are subtle but can be detected as difficulty learning, especially languages, and forgetfulness in noncritical areas. The general lack of replacement of neurons affects the sensory organs’ function, which becomes less acute with age. The number and sensitivity of sensory receptors, dermatomes, and neurons decrease, resulting in dulling of tactile sensation. There is also some decline in the function of cranial nerves mediating taste and smell. Increased levels of taste, sound, scents, touch, and lighting are required for perception by older persons as compared to younger adults.
  • Normally, cognition remains relatively stable – no significant impairment in intellectual function. The abilities for verbal comprehension and arithmetic operations are unchanged. Crystallized intelligence (acquired knowledge) usually increases with age. It arises from the dominant hemisphere of the brain. This type of intelligence reflects accumulated past experience and the effects of socialization. This cognitive characteristic is strongly associated with wisdom, judgment, and life experiences. Crystallized intelligence enables the individual to use past learning and experiences for problem-solving. Crystallized intelligence refers to cognitive skills, such as vocabulary, information, and verbal comprehension, that people acquire through culture, education, informal learning, and other life experiences. Wisdom and knowledge about the ways of the world are typical strengths of older people
  • Cognitive skills such as remembering, solving complex problems, paying attention, and processing language are affected by age and disease-related changes in the brain. Fluid intelligence (ability to learn new concepts) decreases with age. This type of intelligence denotes a capacity for abstract creativity. This is intelligence applied to new tasks or the ability to come up with novel or creative solutions to unforeseen problems. Fluid intelligence is the information processing system. It depends primarily on a person’s inherent abilities, such as memory, pattern recognition, and the central nervous system. Fluid intelligence is associated with integration, inductive reasoning, abstract thinking, and flexible and adaptive thinking. This cognitive characteristic enables people to identify and draw conclusions about complex relationships (executive function). Examples of abstract thinking are analogies and metaphors. Complex tasks that require taking in and analyzing new information – more difficult It is important to encourage activities that promote cognitive development in older clients such as reading, studying a new topic, solving word problems and doing puzzles.
  • Memory is defined as the ability to retain or store information and retrieve it when needed. Memory is a complex set of processes and storage systems. Two components characterize memory: short-term (recent) memory and remote or long-term memory. Memory can be short-term or long-term. In short-term memory , your mind stores information for a few seconds or a few minutes: the time it takes you to dial a phone number you just looked up or to compare the prices of several items in a store. Long-term memory involves the information you make an effort (conscious or unconscious) to retain, because it’s personally meaningful to you (for example, data about family and friends); you need it (such as job procedures or material you’re studying for a test); or it made an emotional impression (a movie that had you riveted, the first time you ever caught a fish, the day your uncle died). Information stored in the long-term or remote memory includes things that you stored in your memory years ago, such as memories of childhood. Short-term or recent memory (being asked to recall information after more than a few minutes) is most affected by normal aging. This is usually benign and is called the benign forgetfulness of aging. Long-term (remote) memory remains intact in most older adults. Normal healthy older persons who forget where they put the egg beater can be assured there is no significant memory problem. But if they forget what an egg beater is or how to use it, they should be referred for further evaluation and treatment.
  • A, B, D, F, G, I Cognitive functions NOT affected by normal aging: VOCABULARY, ARITHMETIC, WISDOM & JUDGMENT
  • A, B, D, E, F, G The nurse should: Provide shorter, more frequent sessions Present one idea at a time Make sure there is adequate lighting Provide concrete, not abstract information (basic facts)
  • D
  • Significant changes in mood, cognitive ability, and personality should never be dismissed as normal aging, but always aggressively assessed and referred for treatment. Decline in intellectual function is generally greater in older people who develop disease and disability than in those who remain healthy. Many decrements in cognitive capacity, mood, and performance that formerly were attributed to “normal aging” are now known to be associated with psychiatric illness or physical disease. Cognitive or neurologic symptoms that should be investigated and not written off as normal changes of aging include: Memory and intellectual difficulties – Cognitive changes due to underlying anxiety, depression, or other potentially treatable psychiatric disorders can masquerade as Alzheimer’s disease. Change in sleep patterns – Drastic changes in sleep patterns such as early morning awakening, declines in total sleep time, and increased sleep latency (longer time to fall asleep) may be signs of underlying anxiety of depression. Physical problems such as pain, respiratory disease, and cardiac disease can also interfere with sleep. Underlying psychiatric problems can exaggerate and intensify sleep disturbances in the older adult. Delusions – False beliefs that persist and exert a negative influence on behavior or attitude (e.g., the belief that all food is poison and eating food will cause death). Hallucinations – False perceptions and sensations such as hearing voices or seeing people who are not there. Disordered thinking – Characterized by lack of logical thought processes; failure to be able to "think straight." As a result, thoughts and communications become disorganized and fragmented. The person may not be able to concentrate on one thought for very long and may be easily distracted, unable to focus attention. Thoughts may come and go rapidly. The person may be unable to connect thoughts into logical sequences, with thoughts becoming disorganized and fragmented. This lack of logical continuity of thought, termed a "thought disorder," can make conversation very difficult and may contribute to social isolation. If people cannot make sense of what an individual is saying, they are likely to become uncomfortable and tend to leave that person alone. Serious problems such as legal situations from poor judgment and inability to communicate basic needs and safety concerns, may result. Problems with emotional expression – Sudden or prolonged gradual loss of emotional responsiveness and expression may indicate the presence of psychiatric illness in the older adult. Failure to show emotion, laugh, cry, or make eye contact, or withdrawal from opportunities for human interaction, may be signs of severe depression. This is sometimes called the flat affect.
  • Although arthritis, heart disease, and other physical diseases are not welcomed by older adults, these conditions tend to be dreaded less than the loss of normal cognition. With advancing years, there is increased risk for impaired cognition. Impaired cognition is not a normal consequence of aging, although the incident increases as one grows older. Impaired cognition is a term that describes a range of disturbances in cognitive functioning, including disturbances in memory, orientation, attention, concentration, judgment, learning ability, perception, problem solving, psychomotor ability, reaction time, and social ability. Impaired cognition threatens the ability to communicate, function independently, make decisions, and comprehend events. There are two main types of impaired cognition: delirium and dementia. Delirium is a reversible alteration in cognition caused by acute conditions. Dementia is an irreversible impairment in cognition caused by disease or injury to the brain. Knowledge about cognitive function in aging and appropriate assessment and evaluation are keys to differentiating these two syndromes.
  • Level of consciousness – Alert state, attentiveness. With delirium, can be lethargic, agitated, or hyper vigilant. PALS – alert, responsive to voice, responsive to pain, unresponsive Orientation status – Awareness with regard to person, place, time, and situation
  • True. Delirium is a reversible alteration in cognition that has a rapid onset and needs prompt diagnosis and treatment to prevent permanent damage. Knowledge of the differences between delirium and dementia is essential for an acute diagnosis.
  • Delirium is a state of mental confusion that develops quickly and usually fluctuates in intensity. It is a temporary disordered mental state, characterized by disturbed intellectual functions; disorientation of time and place but usually not of identity; altered attention span; worsened memory; labile mood; meaningless chatter; poor judgment; and altered level of consciousness. Delirium is given many labels: acute confusional state, acute brain syndrome, confusion, metabolic encephalopathy, and toxic psychosis. Delirium is a syndrome, or group of symptoms (not a disease process in itself), caused by a disturbance in the normal functioning of the brain. While it is not a specific disease itself, patients with delirium usually fare worse than those with the same illness who do not have delirium. Delirium alters level of consciousness, whereas dementia does not. Disturbance of consciousness (reduced clarity of awareness of the environment) with reduced ability to focus, sustain or shift attention . Acute onset and fluctuations – Confusion usually develops suddenly and progresses over the next few hours or days. The confusion fluctuates with periods of agitation and restlessness followed by periods of tiredness and indifference. Significant perceptual changes can occur (such as visual hallucinations or illusions), disturbances in sleep-wake cycle. Restlessness and sleep disturbances may be early clues. The patient may be suspicious, have personality changes. Physical signs, such as shortness of breath, fatigue, and slower psychomotor activities, may accompany behavioral changes. The onset of symptoms with delirium tends to be rapid. Acute change (hours to days) and fluctuation (during the course of the day). Delirium is always secondary to another condition. Caused by general medical condition, or substance-induced (drug of abuse, medication, or toxin exposure).
  • The delirious patient has a reduced awareness of and responsiveness to the environment, which may be manifested as disorientation, incoherence, and memory disturbance. Delirium is often marked by hallucinations, delusions, and a dream-like state. The patient has d ifficulty distinguishing between reality & misperceptions. What is the key aspect that suggests delirium? Attention (distractibility) Delirium is characterized primarily by difficulty focusing, maintaining, or shifting attention (inattention). Consciousness level fluctuates; patients are disoriented to time and sometimes place or person. They may have hallucinations. Confusion regarding day-to-day events and daily routines is common, as are changes in personality and affect. Thinking becomes disorganized, and speech is often disordered, with prominent slurring, rapidity, neologisms, aphasic errors, or chaotic patterns. Symptoms fluctuate over minutes to hours; they may lessen during the day and worsen at night. Symptoms may include inappropriate behavior, fearfulness, and paranoia. Patients may become irritable, agitated, hyperactive, and hyperalert, or they may become quiet, withdrawn, and lethargic. Very elderly people with delirium tend to become quiet and withdrawn—changes that may be mistaken for depression. Some patients alternate between the two. Usually, patterns of sleeping and eating are grossly distorted. Because of the many cognitive disturbances, insight is poor, and judgment is impaired. Other symptoms and signs depend on the cause.
  • Confusion usually develops suddenly and progresses over the next few hours or days. Confusion is not a consequence of normal aging, and any change in mental status of an older person needs thorough assessment. Failure to recognize delirium by assuming confusion to be normal contributes to the morbidity and mortality associated with this condition. Time limited Usually occurs within first 2 days, rarely after day 6 May resolve in a few hours to days or persist for weeks to months Usually lasts 1 to 7 days The confusion fluctuates with periods of agitation and restlessness followed by periods of tiredness and indifference. A fluctuating mental status is important to identify because it often signals a need for additional treatment. Delirium is reversible in most circumstances, and prompt care. E arly recognition and treatment is essential. As older adults have multiple health conditions, it is important to remember that several coexisting factors can be responsible for a delirium.
  • Delirium is a medical emergency. Delirium is associated with: Higher mortality rates! Increased cost and length of hospital stays Functional decline Predicts dementia and death Delirium during hospitalization is associated with increased rates of illness and death, nursing home placement, and readmission, as well as prolonged and costly hospitalizations. In fact, delirium may act as a prognostic indicator for death for up to 12 months after hospitalization. And it can cause significant stress in patients, spouses, and caregivers. Research has shown that early identification and treatment of delirium result in improved outcomes, including decreased mortality rates and shorter hospital stays
  • Delirium is more common in the elderly than in the general population and is a common part of many terminal illnesses. Factors predisposing older adults to delirium include normal age-related changes in the brain and nervous system, diminished eyesight and hearing, greater use of medications, and diseases that injure the brain and predispose to delirium such as dementia.
  • Delirium occurs in 10-40% of older hospitalized patients, and is associated with an increased risk of nursing home admission,increased costs, length of stay, mortality rates, functional decline, and increased use of chemical and physical restraints. Risk factors for delirium include older age, dementia, infection, severe illness, multiple co-morbidities, dehydration, psychotropic medication use, alcoholism, vision impairment, and fractures. Delirium is often unrecognized by clinicians. Therefore, patients should be assessed frequently using a standardized tool to facilitate prompt identification and management of delirium and underlying etiology. Delirium is found on general or specialty medical and surgical units, with the highest incidence seen in postoperative patients undergoing cardiac or orthopedic surgery, in the ICU, and during the last weeks of terminal illness.
  • The causes of delirium are potentially reversible so accurate assessment and diagnosis are critical. Early detection and treatment is essential because delirium is a sign of a serious underlying medical condition. In addition, older people with delirium are susceptible to injuries, falls, dehydration, pressure sores, and malnutrition. There are a large number of possible causes of delirium. It is most often a complication of a medical illness, a drug or substance effect on the brain, or a surgical procedure involving general anesthesia. Environmental factors such as noise, relocation, and the use of invasive devices and restraints influence the development and escalation of delirium. Metabolic disorders are the single most common cause, accounting for 20-40% of all cases. This type of delirium, termed "metabolic encephalopathy," may result from organ failure, including liver or kidney failure. Other metabolic causes include diabetes mellitus, hyperthyroidism and hypothyroidism, vitamin deficiencies, and imbalances of fluids and electrolytes in the blood. Severe dehydration can also cause delirium. Drug intoxication ("intoxication confusional state") is responsible for up to 20% of delirium cases, either from side effects, overdose, or deliberate ingestion of a mind-altering substance. Many factors usually contribute to its development, although patients with advanced age, severe illness, or dementia may develop delirium in response to a single factor. The condition usually occurs as a result of complex interactions among multiple causes and is more common in older adults. Almost any general medical condition and many medications can cause delirium. Delirium can occur at any time during hospitalization, often in response to a worsening illness or new insults, including urinary catheterization, use of physical restraints, malnutrition, any iatrogenic event, or administration of more than three new medications. Delirium is often reversible once its causes are identified and treated.
  • Urosepsis – can occur very rapidly; level of consciousness changes, falling BP
  • During the initial acute stage, establishing medical stability and minimizing stimulation are primary goals. Minimizing stimulation – Controlling environmental temperature, noise and traffic flow is important. Placing this patient in a quiet area away from the mainstream activity is beneficial. Bright lights should be avoided, but ample lighting is needed to enable the patient to adequately visualize the environment. Consistency in care is important; thus, the patient benefits from interaction with only a limited number of people. The nurse should ensure that the patient does not harm himself or herself or others and that physical care needs are met. Regardless of the level of intellectual function or consciousness, it is important to speak to the patient and offer explanations of activities or procedures being done. Families may need considerable support and realistic explanations to alleviate their anxieties. “No, he does not have Alzheimer’s. His confusion is because of a low level of sugar in his blood. He’ll be better as soon as the level is brought back to normal.”
  • P. 417 in book. Individuals with cognitive impairment may experience a nocturnal confusion, appropriately named “Sundowner syndrome,” due to its presentation “after the sun goes down.” Some of the factors that increase the risk of this condition include unfamiliar environment (e.g., recent admission to a facility), disturbed sleep patterns (e.g., from sleep apnea), use of restraints, excess sensory stimulation, sensory deprivation, or change in circadian rhythms.
  • P. 417 in book. Encourage exercise during the day and limit daytime napping, but make sure that the person gets adequate rest during the day because fatigue can increase the likelihood of late afternoon restlessness. Providing physical activity in the afternoon to help the person expend energy Try to schedule more physically demanding activities earlier in the day. For example: bathing could be earlier in the morning large family meals could be at midday Limit outings to the morning hours. Decrease the length and amount of stimulus: Even during the earlier part of the day, the individual with Alzheimer's can only tolerate so much stimulation and commotion. Take steps to eliminate over-stimulation such as T.V., children, any noise making item, quick movements and many things going on at one time. Set a quiet, peaceful tone in the evening to encourage sleep. Keep the lights dim, but keep a nightlight on throughout the night Eliminate loud noises – control noise and traffic flow in the evening Even play soothing music if the person seems to enjoy it. Identify and minimize physical discomfort. Physical discomfort may play a part in sundowning. Hunger, being wet or soiled, feeling cold/hot and other sources of discomfort can increase agitation, especially in the late afternoon and early evening. Ensuring the environmental temperature is within a comfortable range for the person Provide light snacks during the day to prevent hunger. Apples and other fruits can help replace lost energy from pacing or other activities. Try to keep bedtime at a similar time each evening. Developing a bedtime routine may help. Placing familiar objects in the person’s room Restrict access to caffeine late in the day. Use night-lights in the bedroom, hall, and bathroom if the darkness is frightening or disorienting. Adjust lighting in the environment to prevent the room from becoming too dark in the evening. Make sure that the person’s basic needs are met (e.g., adequate fluids, toileting, dry clothing) and all medical conditions are dealt with. Conditions such as urinary tract infections, flus/colds, asthma, allergies and other conditions can contribute to sundowning. When you notice the first signs of sundowning, consult the provider to make sure that there are no conditions that need medical attention. Having frequent contact with the person to offer reassurance and orientation Using touch to provide human contact and calm the person
  • “5 precious memories”
  • Dementia is an irreversible, progressive impairment in cognitive function affecting memory, orientation, judgment, reasoning, language and problem solving. It is caused by damage or injury to the brain. An estimated 5.3 million older adults have some form of dementia How is dementia different from depression and delirium? Slower in onset Progressive, not variable Irreversible Different causes Life delirium, dementia is considered a syndrome, not a diagnosis. The person with dementia has both a chronic illness and a terminal illness, first losing the ability to independently perform activities of daily living and finally becoming completely dependent in all aspects of self-care.
  • The person with dementia has both a chronic illness and a terminal illness, first losing the ability to independently perform activities of daily living and finally becoming completely dependent in all aspects of self-care. The hallmark of dementia is the cognitive symptom of memory loss. Short-term memory impairment is usually the first symptom of dementia. Deficits can be detected before other impairments becomes obvious. The best screening test for dementia is a short-term memory test (eg, registering 3 objects and recalling them after 5 min); patients with dementia forget simple information within 3 to 5 min. Another test assesses the ability to name objects within categories (eg, lists of animals, plants, or pieces of furniture). Patients with dementia struggle to name a few; those without dementia easily name many. As the dementia worsens, other deficits appear and symptoms develop, becoming progressively degenerative over time. In addition to disruptions in cognition, dementias are commonly associated with changes in function and behavior, which appear later in the course of the syndrome. Unlike delirium, attention is preserved in dementia (until late in the disease).
  • Scoring Give 1 point for each recalled word after the CDT distractor. Score 1–3. A score of O indicates positive screen for dementia. A score of 1 or 2 with an abnormal CDT indicates positive screen for dementia. A score of 1 or 2 with a normal CDT indicates negative screen for dementia. A score of 3 indicates negative screen for dementia. The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time.Source: Borson S, Scanlan J, Brush M, Vitaliano P, Dokmak A. The mini-cog: a cognitive “vital signs” measure for dementia screening in multi-lingual elderly. Int J Geriatr Psychiatry 2000; 15(11): 1021–1027.
  • Clinical diagnosis of dementia requires (1) loss of an intellectual ability with impairment severe enough to interfere with social or occupational functioning and (2) ruling out delirium. Assessment domains include cognitive, functional, behavioral, physical, caregiver, and environment. Delirium must be ruled out because cognitive impairment caused by delirium may be reversible. The development of delirium may indicate decreased reserve capacity of the brain and may signal an increased risk for dementia. Each cognitive deficit must substantially impair function and represent a significant decline from a previous level of functioning. Also, the deficits must not occur only during delirium.
  • Dementia, particularly, Alzheimer’s dementia, is a major age-related chronic condition since it affects the most rapidly growing segment of the population, persons over the age of 85. The prevalence of dementia increases with age, doubling every 5 years after age 65.
  • Alzheimer's is a brain disease that causes problems with memory, thinking and behavior. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks. The 7 th leading cause of death in the US. Between 4 and 5% of older adults are victims of Alzheimer’s disease, the most common form of dementia. Alzheimer’s disease accounts for 50 to 70 percent of dementia cases. Growing old is the biggest risk factor for developing Alzheimer’s disease (AD). Age is the biggest risk factor! In fact, the likelihood of developing Alzheimer’s disease doubles every 5 years after the age of 65. Scientists project a dramatic increase in prevalence unless new ways to prevent and treat the disease are discovered. By the year 2050, the prevalence of AD is expected to triple (increasing from 5.3 million at present to 16 million in 2050). By the year 2011, 13% of Americans will be over the age of 65 and one in 100 will be over age 85. AD is a major age-related chronic condition since it affects the most rapidly growing segment of the population, persons over the age of 85. About 47% of persons age 85 and older may get AD, and about 4.5 million Americans presently have AD. AD lasts from 2 to 20 years, with an average duration of 8 years. Thus, in the next 50 years, millions of persons will suffer from AD, develop related complications, require care for long-standing or age-related chronic problems, and require nursing care. Typical life expectancy is 8 to 9 years after symptom onset, with death usually occurring as a result of pulmonary infections, urinary tract infections, pressure ulcers, or other iatrogenic disorders.
  • Alzheimer's is a brain disease that causes problems with memory, thinking and behavior. Symptoms usually develop slowly and get worse over time, becoming severe enough to interfere with daily tasks. The 5 th leading cause of death in the US. 1 in 8 older Americans has AD. Every 69 seconds, someone in America develops AD. An estimated 5.4 million Americans of all ages have Alzheimer’s disease in 2011. This figure includes 5.2 million people aged 65 and older(41), A1 and 200,000 individuals under age 65 who have younger-onset Alzheimer’s.(42) Between 4 and 5% of older adults are victims of Alzheimer’s disease, the most common form of dementia. Alzheimer’s disease accounts for 50 to 70 percent of dementia cases. Growing old is the biggest risk factor for developing Alzheimer’s disease (AD). Age is the biggest risk factor! In fact, the likelihood of developing Alzheimer’s disease doubles every 5 years after the age of 65. Scientists project a dramatic increase in prevalence unless new ways to prevent and treat the disease are discovered. By the year 2050, the prevalence of AD is expected to triple (increasing from 5.3 million at present to 16 million in 2050). By the year 2011, 13% of Americans will be over the age of 65 and one in 100 will be over age 85. AD is a major age-related chronic condition since it affects the most rapidly growing segment of the population, persons over the age of 85. About 47% of persons age 85 and older may get AD, and about 4.5 million Americans presently have AD. AD lasts from 2 to 20 years, with an average duration of 8 years. Thus, in the next 50 years, millions of persons will suffer from AD, develop related complications, require care for long-standing or age-related chronic problems, and require nursing care. Typical life expectancy is 8 to 9 years after symptom onset, with death usually occurring as a result of pulmonary infections, urinary tract infections, pressure ulcers, or other iatrogenic disorders.
  • Alzheimer's disease is a progressive, degenerative disorder that attacks the brain's nerve cells, or neurons, resulting in loss of memory, thinking and language skills, and behavioral changes. Alzheimer’s disease is characterized by three changes in the brain. Two types of abnormal lesions clog the brains of individuals with Alzheimer's disease: Beta-amyloid plaques—freckles of barnacle-like piles of a toxic protein fragment called beta-amyloid. These protein fragments and cellular debris form sticky clumps that form outside and around neurons. The amyloid accumulations are called plaque. Neurofibrillary tangles—insoluble twisted fibers composed largely of the protein tau that build up inside nerve cells. Although these structures are hallmarks of the disease, scientists are unclear whether they cause it or a byproduct of it. The tau “clogs” the insides of brain cells and their connections. In Alzheimer’s disease, tau is changed and begins to pair with other threads of tau that become tangled. This causes the microtubules to disintegrate and collapse the neuron’s transport system. A third main feature of AD is the loss of connections between nerve cells (neurons) in the brain. Tangles begin to develop deep in the brain, in an area called the entorhinal cortex, and plaques form in other areas. As more and more plaques and tangles form in particular brain areas, healthy neurons begin to work less efficiently. Then, they lose their ability to function and communicate with each other, and eventually they die. This damaging process spreads to a nearby structure, called the hippocampus, which is essential in forming memories. The plaques and tangles represent the death of nerve cells throughout the brain. Eventually, the brain shrinks to about one-third its normal weight.
  • T hese neurons, which produce the brain chemical, or neurotransmitter, acetylcholine, break connections with other nerve cells and ultimately die. For example, short-term memory fails when Alzheimer's disease first destroys nerve cells in the hippocampus, and language skills and judgment decline when neurons die in the cerebral cortex There are also changes in neurotransmitter systems associated with Alzheimer’s disease, including reductions in serotonin receptors, serotonin uptake into platelets, production of acetylcholine in the areas of the brain in which plaque and tangles are found, acetylcholinesterase (which breaks down acetylcholine), and choline acetyltranserase. AD disrupts the three processes that keep neurons healthy: 1) communication, 2) metabolism, and 3) repair. As a result, many nerve cells are destroyed or die, causing memory failure, personality changes, problems carrying out activities of daily living, and other deficits.
  • Attacks where we are vulnerable – at the synapse (Where one nerve cell connects to the next) Chemicals passing across synapse (messengers) are diminished Some treatments maintain/heighten remaining acetylcholine Plaques, abnormal clusters of protein fragments, build up between nerve cells. Dead and dying nerve cells contain tangles, which are made up of twisted strands of another protein. Plaques form when protein pieces called beta-amyloid (BAY-tuh AM-uh-loyd) clump together. Beta-amyloid comes from a larger protein found in the fatty membrane surrounding nerve cells. Beta-amyloid is chemically "sticky" and gradually builds up into plaques. The most damaging form of beta-amyloid may be groups of a few pieces rather than the plaques themselves. The small clumps may block cell-to-cell signaling at synapses. They may also activate immune system cells that trigger inflammation and devour disabled cells. Now think about the brain: imagine that each cell within the brain is a light bulb and the entire brain is a brightly-lit city at night. Each neuron helps carry out the functions of the brain. During normal function, each neuron and all parts of the brain work together to carry out tasks such as remembering a relative's name, washing the dishes, or controlling one's temper. Alzheimer's disease gradually "turns off" each neuron in the brain, just like the lights in the city. As the individual neurons stop working, the brain does not function as well and the person has problems thinking, remembering, and carrying on with daily living. However, unlike an electrical circuit that can be repaired, damage in the brain caused by Alzheimer's disease and dementia are permanent and cannot be repaired.
  • Alzheimer’s disease leads to nerve cell death and tissue loss throughout the brain. Over time, the brain shrinks dramatically, affecting nearly all its functions. Areas most impacted are deep in the brain Affecting sites where activities are organized and integrated Functions of memory, attention and association (Putting a time and place to past events)
  • The greatest known risk factor for Alzheimer’s is advancing age . Most individuals with the disease are age 65 or older. Alzheimer's usually affects people older than 65, but can, rarely, affect those younger than 40. Less than 5 percent of people between 65 and 74 have Alzheimer's.   For people 85 and older, that number jumps to nearly 50 percent. One of the greatest mysteries of Alzheimer's disease is why risk rises so dramatically as we grow older. Sex. Women are more likely than men are to develop the disease, in part because they live longer. Another strong risk factor is family history. Those who have a parent, brother, sister or child with Alzheimer’s are more likely to develop the disease. The risk increases if more than one family member has the illness. When diseases tend to run in families, either heredity (genetics) or environmental factors, or both, may play a role. Scientists know genes are involved in Alzheimer’s. There are two types of genes that can play a role in affecting whether a person develops a disease— risk genes and deterministic genes . Alzheimer genes have been found in both categories. Head trauma: There may be a strong link between serious head injury and future risk of Alzheimer’s, especially when trauma occurs repeatedly or involves loss of consciousness. The observation that some ex-boxers eventually develop dementia suggests that serious traumatic injury to the head (for example, a concussion with a prolonged loss of consciousness) may be a risk factor for Alzheimer's. Protect your brain by buckling your seat belt, wearing your helmet when participating in sports, and “fall-proofing” your home. Heart-head connection: Growing evidence links brain health to heart health. The risk of developing Alzheimer’s or vascular dementia appears to be increased by many conditions that damage the heart or blood vessels. These include high blood pressure, heart disease, stroke, diabetes and high cholesterol Latinos & African Americans : Because Latinos and African-Americans in the United States have higher rates of vascular disease, they also may be at greater risk for developing Alzheimer’s. According to a growing body of evidence, risk factors for vascular disease — including diabetes , high blood pressure and high cholesterol — may also be risk factors for Alzheimer’s and stroke-related dementia. Lifestyle/ healthy aging: Other lines of evidence suggest that strategies for overall healthy aging may help keep your brain as well as your body fit. These strategies may even offer some protection against developing Alzheimer’s or related disorders. Try to keep your weight within recommended guidelines, avoid tobacco and excess alcohol, stay socially connected, and exercise both your body and mind. Education levels. Studies have found an association between less education and the risk of Alzheimer's. Some researchers theorize that the more you use your brain, the more synapses you create, which provides a greater reserve as you age. It remains unclear, however, whether less education and less mental activity create a risk of Alzheimer's or if it's simply harder to detect Alzheimer's in people who exercise their minds frequently or who have more education.
  • The majority of cases of AD result from complex interactions between genetic and environmental factors. Although environmental factors play a role, genetic factors do increase the risk for Alzheimer’s disease. Genetic factors. Studies have revealed several generations of Alzheimer’s disease patients occurring in the same family. Chromosomal abnormalities have been identified. Three genetic mutations are known to cause early-onset Alzheimer's. In addition, one form of the apolipoprotein E (APOE) gene increases one’s chance of developing late-onset Alzheimer's. A strong argument for the genetic formulation of the disease stems from its connection with Down syndrome. An extra chromosome 21 exists in persons with Down syndrome; not only do people with Down syndrome begin to develop symptoms of dementia after age 35, but also the prevalence of Alzheimer’s disease is higher in families with Down syndrome, and vice versa. An altered chromosome 21 in people with Alzheimer’s disease causes production of an abnormal amyloid precursor protein. Chromosomes 14 and 1 have also been found to have mutations within families who have a high prevalence of Alzheimer’s disease; these mutations cause abnormal proteins to be produced. If only one of these mutated genes is inherited from a parent with Alzheimer’s disease, a person has a 50/50 chance of developing the disease. Insulin-resistant neurons in brain. A drop in insulin production in your brain contributes to the degeneration of your brain cells, and studies have found that people with lower levels of insulin and insulin receptors in their brain often have Alzheimer’s disease. Another noteworthy connection between Alzheimer’s disease and diabetes came out in 2004, when it was revealed that people with diabetes might have a 65 percent higher risk of developing Alzheimer’s disease. Environmental factors . There is some investigation into the role of free radicals in the development of Alzheimer’s disease. Free radicals are molecules that can build up in neurons, resulting in damage (called oxidative damage). The damage blocks substances from flowing in and out of the cell, leading to brain damage. Some studies suggest that a diet rich in antioxidants may offer protection. One long-standing theory is that overexposure to certain trace metals or chemicals may cause Alzheimer's. Higher than normal levels of aluminum and mercury have been found in the brain cells of Alzheimer’s disease patients, causing some speculation regarding the role of environmental toxins in the disease. This suspicion led to concerns about everyday exposure to aluminum through sources such as cooking pots, foil, beverage cans, antacids and antiperspirants. Since then, studies have failed to confirm any role for aluminum in causing Alzheimer’s. Almost all scientists today focus on other areas of research, and few experts believe that everyday sources of aluminum pose any threat. Low zinc levels are present in persons with Alzheimer’s disease, although it is not certain if this is a cause or result of the disease.
  • AD is a progressive and fatal brain disease.   The symptoms of this progressive, degenerative disease develop gradually and insidiously. They progress at different rates among affected individuals. The Global Deterioration Scale/ Functional Assessment Staging (GDS/ FAST) offers a means of staging Alzheimer’s disease. Stages range from 1 (normal adult) through 7 (severe AD). Although staging of the disease can help predict its general course and anticipate plans for care, it must be appreciated that many factors affect the progression of the disease and that there will be individual variation. Early in the disease, the patient may be aware of changes in intellectual ability and become depressed or anxious or attempt to compensate by writing down information, structuring routines, and simplifying responsibilities. It may take some time for symptoms to be detected, even by those close to the patient. The greatest risk for suicide for a person with dementia is in the early stage of the disease, when the individual is aware of the changes experienced. In addition to the history of symptoms from the patient and family members or significant others, diagnosis is aided by brain scans that can reveal changes in the brain’s structure that are consistent with the disease, neuropyschological testing that evaluates cognitive functioning, and laboratory tests and neurological evaluations. There is no single test that proves a person has Alzheimer’s. The medical workup is designed to evaluate overall health and identify any conditions that could affect how well the mind works. Experts estimate a skilled physician can diagnose Alzheimer’s with more than 90 percent accuracy. Doctors can almost always determine that a person has dementia, but it may sometimes be difficult to pin down the exact cause. Currently, a standard medical workup for Alzheimer’s disease often includes structural imaging with MRI or, less frequently, CT. These images are used primarily to detect tumors, evidence of small or large strokes, damage from severe head trauma or a buildup of fluid. Another promising area of functional imaging research focuses on developing tracer compounds that will attach to key abnormal brain deposits implicated in Alzheimer’s. For example, preliminary data suggests that one such tracer, called Pittsburgh compound B, may attach to beta-amyloid and “light up” in a PET scan. It may be hard to know the difference between age-related changes and the first signs of Alzheimer’s disease. Ask yourself: Is this something new? For example, if the person was never good at balancing a checkbook, struggling with this task is probably not a warning sign. But if their ability to balance a checkbook has changed a lot, it is something to investigate further by sharing with a healthcare professional. To help, the Alzheimer’s Association has created this list of warning signs for Alzheimer’s disease: Memory changes that disrupt daily life Challenges in planning or solving problems Difficulty completing familiar tasks Confusion with time or place Trouble understanding visual images and spatial relationships New problems with words in speaking or writing Misplacing things and losing the ability to retrace steps Decreased or poor judgment Withdrawal from work or social activities Changes in mood and personality
  • A
  • B
  • True
  • Stage 1:No impairment (normal function)  Unimpaired individuals experience no memory problems and none are evident to a health care professional during a medical interview. Stage 2:Very mild cognitive decline (may be normal age-related changes or earliest signs of Alzheimer's disease)  Individuals may feel as if they have memory lapses, especially in forgetting familiar words or names or the location of keys, eyeglasses or other everyday objects. But these problems are not evident during a medical examination or apparent to friends, family or co-workers.
  • Early-stage Alzheimer's can be diagnosed in some, but not all, individuals with these symptoms In his stage, ability to perform complex occupational and social tasks is compromised and may be noticeable by colleagues.  Family notice changes in memory. The person is easily “flustered” in social situations. This is a 'border stage' which does not necessarily progress.  When progression does occur, the true (potential) duration of this stage is probably 7 years; however, symptoms are commonly not observed until this stage has progressed at least midway through its temporal course. Early: Patients are alert and sociable, but forgetfulness begins to interfere with daily living. Memory loss. Forgetting recently learned information is one of the most common early signs of dementia. A person begins to forget more often and is unable to recall the information later. The affected person and friends, family or co-workers begin to notice deficiencies. Problems with memory or concentration may be measurable in clinical testing or discernible during a detailed medical interview. Cognitive impairment recognized by others. Common difficulties include: Word- or name-finding problems noticeable to family or close associates Decreased ability to remember names when introduced to new people Performance issues in demanding work or social settings noticeable to family, friends or co- workers Reading a passage and retaining little material Losing or misplacing a valuable object Decline in ability to plan or organize Anxiety
  • The diagnosis of Alzheimer's disease can be made with considerable accuracy in this stage. The most common functioning deficit in these patients is a decreased ability to manage instrumental (complex) activities of daily life.   Examples of common deficits include decreased ability to manage finances, to prepare meals for guests, and to market for oneself and one's family. The stage 4 patient shown has difficulty writing the correct date and the correct amount on the check.  Consequently, her husband has to supervise this activity.  The mean duration of this stage is 2 years. At this stage, a careful medical interview detects clear-cut deficiencies in the following areas: The affected individual may seem subdued and withdrawn, especially in socially or mentally challenging situations Decreased knowledge of recent occasions or current events Impaired ability to perform challenging mental arithmetic-for example, to count backward from 75 by 7s Decreased capacity to perform complex tasks, such as planning dinner for guests, paying bills and managing finances Reduced memory of personal history
  • In this stage, deficits are of sufficient magnitude as to prevent catastrophe-free, independent community survival.  The characteristic functional change in this stage is incipient deficits in basic activities of daily life. This is manifest in a decrement in the ability to choose proper clothing to wear for the weather conditions and/or for the daily circumstances (occasions).   Some patients begin to wear the same clothing day after day unless reminded to change.  The spouse or other caregiver begins to counsel regarding the choice of clothing. Moderate: This is often the longest stage of the disease with deterioration of intellect, logic, behavior, and function. The mean duration of this stage is 1.5 years. Major gaps in memory and deficits in cognitive function emerge. Disorientation to time and place. Become confused about where they are or about the date, day of the week or season. May become lost in unfamiliar situations. People with Alzheimer’s disease can become lost in their own neighborhood, forget where they are and how they got there, and not know how to get back home. Still remember their name. Some assistance with instrumental day-to-day activities becomes essential. Need help choosing proper clothing for the season or the occasion At this stage, individuals may: Be unable during a medical interview to recall such important details as their current address, their telephone number or the name of the college or high school from which they graduated Have trouble with less challenging mental arithmetic; for example, counting backward from 40 by 4s or from 20 by 2s Usually retain substantial knowledge about themselves and know their own name and the names of their spouse or children Usually require no assistance with eating or using the toilet.
  • Some assistance with instrumental day-to-day activities becomes essential. Poor or decreased judgment. Those with Alzheimer’s may dress inappropriately, wearing several layers on a warm day or little clothing in the cold. They may show poor judgment, like giving away large sums of money to telemarketers.
  • Memory difficulties continue to worsen, significant personality changes may emerge and affected individuals need extensive help with customary daily activities. At this stage, individuals may: Lose most awareness of recent experiences and events as well as of their surroundings Recollect their personal history imperfectly, although they generally recall their own name Occasionally forget the name of their spouse or primary caregiver but generally can distinguish familiar from unfamiliar faces Need help getting dressed properly; without supervision, may make such errors as putting pajamas over daytime clothes or shoes on wrong feet Need help with handling details of toileting (flushing toilet, wiping and disposing of tissue properly) Have increasing episodes of urinary or fecal incontinence Experience significant personality changes and behavioral symptoms, including suspiciousness and delusions (for example, believing that their caregiver is an impostor); hallucinations (seeing or hearing things that are not really there); or compulsive, repetitive behaviors such as hand-wringing or tissue shredding Resistiveness to care; many institutionalized at this stage Experience disruption of their normal sleep/waking cycle Tend to wander and become lost
  • At this stage, the ability to perform basic activities of daily life becomes compromised. Functionally, five successive substages are identifiable.  Unless supervised, patients may put their clothing on backward, they may have difficulty putting their arm in the correct sleeve, or they may dress themselves in the wrong sequence
  • Requires assistance adjusting the temperature of the bath water.  At approximately the same time as Alzheimer's patients begin to lose the ability to put on their clothing properly without assistance, but generally just a little bit later in the disease course, patients begin to require assistance in handling the mechanics of bathing. Difficulty adjusting the temperature of the bath water is the classical earliest deficit in bathing capacity in Alzheimer's disease. Requires assistance with cleanliness in toileting. After Alzheimer's patients lose the ability to dress and bathe without assistance, they lose the ability to independently maintain cleanliness in toileting. Requires assistance to maintain continence. After Alzheimer's patients lose the ability to dress, bathe and toilet without assistance, they develop incontinence. Generally, urinary incontinence precedes fecal incontinence. Strategies to prevent episodes of incontinence include taking the patient to the restroom and supervision of toileting. In this stage the patient's cognitive deficits are generally of such magnitude that the patient may at times confuse their wife with their mother or otherwise misidentify or be uncertain of the identity of close family members. At the end of this stage, speech ability overtly breaks down.
  • Severe: Loss of long-term memory and language skills. Memory difficulties continue to worsen, significant personality changes may emerge and affected individuals need extensive help with customary daily activities. Changes in mood or behavior. Someone with Alzheimer’s disease may show rapid mood swings – from calm to tears to anger – for no apparent reason. Confusion & memory loss is so severe that many patients have a drive to go somewhere, without knowing where (wandering behavior).
  • This is the final stage of the disease when individuals lose the ability to respond to their environment, the ability to speak and, ultimately, the ability to control movement. Patients require 24-hour care and can no longer complete basic self-care tasks including washing, eating, and using the bathroom. Frequently individuals lose their capacity for recognizable speech, although words or phrases may occasionally be uttered Individuals need help with eating and toileting and there is general incontinence of urine Individuals lose the ability to walk without assistance, then the ability to sit without support, the ability to smile, and the ability to hold their head up. Reflexes become abnormal and muscles grow rigid. Swallowing is impaired.
  • National Institute on Aging and the Alzheimer’s Association – Published for first time in 27 years. The new guidelines include criteria for three stages of the disease: preclinical disease, mild cognitive impairment due to Alzheimer’s disease and, lastly, Alzheimer’s dementia. Under the new guidelines, for the first time, diagnoses will aim to identify the disease as it is developing by using results from so-called biomarkers — tests like PET brain scans, M.R.I. scans and spinal taps that reveal telltale brain changes. The evidence for preclinical AD is based almost entirely on AD biomarkers. Clinicians will not diagnose the new presymptomatic phase of Alzheimer’s until further research identifies the most reliable biomarkers indicating that Alzheimer’s is beginning to develop. Once reliable biomarkers are confirmed, they will also be used to more accurately distinguish “MCI due to Alzheimer’s disease” from MCI due to other causes. They will also be used to increase the accuracy of diagnosing dementia due to Alzheimer’s. Criteria for the earliest symptomatic manifestations, the MCI stage, represent a sharpening of previous efforts to define MCI. People with MCI experience a decline in memory, reasoning or visual perception that’s measurable and noticeable to themselves or to others, but not severe enough to be diagnosed as Alzheimer’s or another dementia. Finally, a revision of the 1984 criteria for dementia because of AD is provided. The criteria for probable AD dementia expand the breadth of the 1984 criteria and include biomarker enhancements to the diagnosis of AD dementia. The guidelines should make diagnosing the final stage of the disease in people who have dementia more definitive. But, the guidelines also say that the earlier a diagnosis is made the less certain it is. And so the new effort to diagnose the disease earlier could, at least initially, lead to more mistaken diagnoses. The core clinical criteria of the recommendations regarding AD dementia and MCI due to AD are intended to guide diagnosis in the clinical setting. However, the recommendations of the preclinical AD workgroup are intended purely for research purposes. Ultimately, it is hoped that the scientific knowledge gained over the past quarter of a century, leading to the reconceptualization of “Alzheimer’s disease” proposed by the NIA-Alzheimer's Association workgroup, will result in improved diagnosis and ultimately in effective disease-modifying therapy.
  • The biomarkers were developed and tested only recently and none have been formally approved for Alzheimer’s diagnosis. One of the newest, a PET scan, shows plaque in the brain — a unique sign of Alzheimer’s brain pathology. The others provide strong indications that Alzheimer’s is present, even when patients do not yet have dementia or even much memory loss. Dr. Aisen says he foresees a day when people in their 50s routinely have biomarker tests for Alzheimer’s and, if the tests indicate the disease is brewing, take drugs to halt it. That is a ways off but, he said, but “it’s where we are heading.” Under the new guidelines, for the first time, diagnoses will aim to identify the disease as it is developing by using results from so-called biomarkers — tests like brain scans, M.R.I. scans and spinal taps that reveal telltale brain changes.
  • AD requires a variety of nursing interventions and an interdisciplinary approach. Therapies helpful in mild to moderate stages. There are no treatments currently available that reverse or stop the advancement of the pathological processes of any progressive dementia, but some drugs may temporarily reverse or slow the progression of clinical symptoms. Because acetylcholine falls sharply in people with Alzheimer’s disease, medications that stop or slow the enzyme (acetylcholinesterase) that breaks down acetylcholine have been developed to help people with Alzheimer’s disease; these drugs include donepezil (Aricept), rivastigmine (Exelon), and galanthamine (Reminyl). Health professionals often divide the symptoms of Alzheimer's disease into "cognitive" and "behavioral and psychiatric" categories. Cognitive symptoms affect memory, language, judgment, planning, ability to pay attention and other thought processes. Behavioral and psychiatric symptoms affect the way we feel and act. Although currently there is no treatment to prevent or cure Alzheimer’s disease, clinical trials are being conducted by the National Institutes of Health and private industry in hopes of finding a means to improve function and slow the progress of the disease. Antioxidants; anti-inflammatory agents; supplements (folic acid and vitamins B6 and B12); gene therapy that adds a nerve growth factor to the aging brain; and the development of a vaccine are among the areas being investigated in clinical trials.
  • BE ABLE TO DISTINGUISH CHOLINESTERACE INHIBITORS FROM GLUTAMINE REGULATORS. Because acetylcholine falls sharply in people with Alzheimer’s disease, medications that stop or slow the enzyme (acetylcholinesterase) that breaks down acetylcholine have been developed to help people with Alzheimer’s disease; these drugs include donepezil (Aricept), rivastigmine (Exelon), and galanthamine (Razadyne). 1. Cholinesterase (KOH-luh-NES-ter-ays) inhibitors prevent the breakdown of acetylcholine (a-SEA-til-KOH-lean), a chemical messenger important for learning and memory. These drugs: Support communication among nerve cells by keeping acetylcholine levels high. On average, delay worsening of symptoms for 6 to 12 months for about half the people who take them. On average, the five approved Alzheimer's drugs are effective for about six to 12 months for about half of the individuals who take them. Some experts believe a small percentage of people may benefit more dramatically. Donepezil (Aricept), approved to treat all stages of Alzheimer's disease. Rivastigmine (Exelon), approved to treat mild to moderate Alzheimer's. Galantamine (Razadyne), approved to treat mild to moderate Alzheimer's. Slow progression of AD symptoms Titrate dose slowly, to highest level tolerated 2. Memantine (Namenda) works by regulating the activity of glutamate, a different messenger chemical involved in learning and memory. Glutamate is the main excitatory neurotransmitter in the brain. It is believed that too much stimulation of nerve cells by glutamate may be responsible for the degeneration of nerves that occurs in some neurological diseases such as Alzheimer's disease. Memantine blocks the receptor and thereby decreases the effects of glutamate. It is thought that by blocking the NMDA receptor and the effects of glutamate, memantine may protect nerve cells from excess stimulation by glutamate. Attachment of glutamate to cell surface "docking sites" called NMDA receptors permits calcium to flow freely into the cell. Over time, this leads to chronic overexposure to calcium, which can speed up cell damage. Memantine prevents this destructive chain of events by partially blocking the NMDA receptors. Memantine: Was approved in 2003 for treatment of moderate to severe Alzheimer's disease. Is currently the only drug of its type approved to treat Alzheimer's. Temporarily delays worsening of symptoms for some people. Many experts consider its degree of benefit is similar to the cholinesterase inhibitors. Temporarily delays worsening of symptoms for some people Side effects - Headache, constipation, confusion and dizziness.
  • Increase levels of acetylcholine in brain Treat symptoms of AD Slow progress AD Don’t cure disease
  • For many individuals, Alzheimer's disease affects the way they feel and act in addition to its impact on memory and other thought processes. As with cognitive symptoms, the chief underlying cause is progressive destruction of brain cells. In different stages of Alzheimer's, people may experience: Physical or verbal outbursts General emotional distress Restlessness, pacing, shredding paper or tissues and yelling Hallucinations (seeing, hearing or feeling things that are not really there) Delusions (firmly held belief in things that are not real) Many diagnosed individuals and their families find these symptoms the most challenging and distressing effects of the disease. There are two approaches to managing behavioral symptoms: using medications specifically to control the symptoms or non-drug strategies. Non-drug approaches should always be tried first. Potential solutions Monitor personal comfort. Check for pain, hunger, thirst, constipation, full bladder, fatigue, infections and skin irritation. Maintain a comfortable room temperature. Avoid being confrontational or arguing about facts; instead, respond to the feeling behind what is being expressed. For example, if a person expresses a wish to go visit a parent who died years ago, don't point out that the parent is dead. Instead, say, "Your mother is a wonderful person. I would like to see her too." Redirect the person's attention. Try to remain flexible, patient and supportive. Create a calm environment. Avoid noise, glare, insecure space, and too much background distraction, including television. Simplify the environment, tasks and solutions. Allow adequate rest between stimulating events. Provide a security object or privacy. Equip doors and gates with safety locks. Remove guns.
  • If non-drug approaches fail after they have been applied consistently, introducing medications may be appropriate when individuals have severe symptoms or have the potential to harm themselves or others. Medications can be effective in some situations, but they must be used carefully and are most effective when combined with non-drug approaches. The decision to use an antipsychotic drug needs to be considered with extreme caution. A recent analysis shows that atypical antipsychotics are associated with an increased risk of stroke and death in older adults with dementia. The FDA has asked manufacturers to include a “black box” warning about the risks and a reminder that they are not approved to treat dementia symptoms. The warning states: “Elderly patients with dementia-related psychosis treated with atypical antipsychotic drugs are at an increased risk of death compared to placebo.” Risks and potential benefits of a drug should be carefully analyzed for any individual. Examples of medications commonly used to treat behavioral and psychiatric symptoms of Alzheimer's disease, listed in alphabetical order, include the following: Antidepressant medications for low mood and irritability: citalopram (Celexa) fluoxetine (Prozac) paroxeine (Paxil) sertraline (Zoloft) trazodone (Desyrel) Anxiolytics for anxiety, restlessness, verbally disruptive behavior and resistance: lorazepam (Ativan) oxazepam (Serax) Antipsychotic medications for hallucinations, delusions, aggression, agitation, hostility and uncooperativeness: aripiprazole (Abilify) clozapine (Clozaril) haloperidol (Haldol) olanzapine (Zyprexa) quetiapine (Seroquel) risperidone (Risperdal) ziprasidone (Geodon)
  • Video Series The irreversible nature of dementia and its progressive deteriorating course can have devastating effects on affected individuals and their families. A majority of the care required by persons with dementia falls within the scope of nursing practice. Ensuring patient safety – One of the foremost care considerations is the safety of patients with dementia. Environmental safety must be ensured. Cleaning solutions, pesticides, medications, and inedible items that could be ingested accidentally must be stored in locked cabinets. Coverings should be applied to unused sockets, electrical outlets, fans, motors, and other items into which fingers may be poked. Matches and lighters should not be accessible; if the patient smokes, it must be under close supervision. Windows and doors can be protected with Plexiglas, and non-removable screens can be installed to avoid falls from windows. Poor judgment – Their poor judgment and misperceptions can lead to serious behavioral problems and mishaps. Consistent, controlled environment – A safe, structured environment is essential. The persons and components of the environment should be consistent. Familiar objects, a stable environment, and consistency of caregivers can reduce some of the safety risks and behavioral problems associated with dementia. Noise, activity, and lighting levels can overstimulate the patient and further decrease function; thus, they need to be controlled. This is particularly useful in preventing and managing sundowner’s syndrome. Items to trigger memory – Useful to include, such as photographs of the patient or a consistently used symbol (e.g., flower or triangle) on the bedroom door or personal possessions. Wandering behavior - Wandering is common among patients with dementia; rather than restrain or restrict them, it is more advantageous to provide a safe area in which they can wander. Protective gates can be installed to prevent patients from wandering away; alarms and bells on doors can signal when they are attempting to exit. With the great risk of patients wandering away and not being able to give their names or residence when found, it is beneficial for them to wear identification bracelets at all times and to have a recent photograph available.
  • The physical care needs of patients with dementia must not be overlooked. These individuals may not complain that they are hungry, so no one may notice that they have consumed less than one quarter of the food served; they may not remember to drink water, so they can become dehydrated; they may fight their bath so strongly that they are left unbathed; and pressure ulcers on their buttocks may go unnoticed. These patients need close observation and careful attention to their physical needs. Consideration must be given to their potential inability to communicate their needs and discomforts; a subtle change in behavior or function, a facial grimace, or repeated touching of a body part may give clues that a problem exists. Consistency in caregivers allows the caregivers to become familiar with a patient’s unique behaviors and more quickly recognize a deviation from that individual’s norm.
  • Monitor personal comfort. Check for pain, hunger, thirst, constipation, full bladder, fatigue, infections and skin irritation. Maintain a comfortable room temperature. Avoid being confrontational or arguing about facts; instead, respond to the feeling behind what is being expressed. For example, if a person expresses a wish to go visit a parent who died years ago, don't point out that the parent is dead. Instead, say, "Your mother is a wonderful person. I would like to see her too." Redirect the person's attention. Try to remain flexible, patient and supportive. Create a calm environment. Avoid noise, glare, insecure space, and too much background distraction, including television. Simplify the environment, tasks and solutions. Allow adequate rest between stimulating events.
  • As patients regress, their dignity, personal worth, freedom, and individuality may be jeopardized. Loved ones may view the demented family member as a stranger living inside the body that once housed the person they knew. Staff may see another dependent or total-care patient and have no sense of that person’s worth or unique life history. Viewed less and less as a normal human being or as the same person that has been known, the person with dementia may be treated in a dehumanizing manner. Special attention must be paid to maintaining and promoting the following qualities: Individuality – The nurse should learn the personal history and uniqueness of the patient and incorporate this into caregiving activities. Independence – Even if it take three times longer to guide patients through dressing than it would take to dress them, they should be afforded every opportunity for self-care. Freedom – As major freedoms become limited, minor choices and control become especially important. Nurses must be careful that, in the name of efficiency and safety, such severe restrictions to freedom are not imposed that the quality of life becomes minimal. Dignity – To become angry or laugh at the behaviors of a demented person is no less cruel than reacting in a similar fashion to a stroke victim who falls during ambulation. These patients should be afforded the respect given to any adult, including attractive clothing, good grooming, adult hairstyles, use of their names, privacy, and confidentiality. Connection – Persons with dementia continue to valued human beings who are members of families, communities, and the human race. Interaction and connection with other people and nature show recognition and respect for the spiritual beings that live within the altered bodies and minds.
  • *Ask about CASE STUDY* Assistance and support to the families of patients are integral parts of nursing care for persons with dementia. The physical, emotional, and socioeconomic burden of caring for a cognitively impaired relative can be immense. It should not be assumed that family members understand basic care techniques. The nurse needs to review basic, specific care techniques, including lifting, bathing, and managing inappropriate behaviors. The nurse can also help prepare families for the guilt, frustration, anger, depression, and other feelings that normally accompany this responsibility. Helping families plan respite, network with support groups, and obtain counseling may be beneficial. Most states now have chapters of the Alzheimer’s Association to which nurses can refer families. Key Concept – It cannot be assumed that family members understand feeding, bathing, lifting, and other basic caregiving skills.
  • Create a calm environment. Avoid noise, glare, insecure space, and too much background distraction, including television. Simplify the environment, tasks and solutions. Allow adequate rest between stimulating events. Provide a security object or privacy. Equip doors and gates with safety locks. Remove guns. Situations affecting behavior may include: Moving to a new residence or nursing home Changes in the environment or caregiver arrangements Misperceived threats Admission to a hospital Being asked to bathe or change clothes Fear and fatigue resulting from trying to make sense out of an increasingly confusing world

Cognitive & neurologic, delirium & dementia spring 2012 abridged Cognitive & neurologic, delirium & dementia spring 2012 abridged Presentation Transcript

  • Cognitive & Neurologic Delirium & Dementia NURS 4100 Care of the Older Adult Spring 2012 Joy Shepard, PhD(c), MSN, RN, CNE, BC
  • Objectives
    • Describe the cognitive and neurologic effects of aging
    • Identify signs and symptoms of cognitive and neurologic disorders in older adults
    • Differentiate delirium from dementia
    • Identify factors that cause delirium in older adults
    • Lists causes of dementia in older adults
    • Describe the symptoms, unique features, and related nursing care for Alzheimer’s Dementia
  • Key Terms
    • Intelligence – Ability to think & learn new things
    • Level of consciousness – Degree of cognitive function involving arousal mechanisms
      • Alert, responsive to voice, responsive to pain, or unresponsive
      • Most sensitive indicator of deterioration of neurological status
    • Memory – Ability to retain or store information and retrieve it when needed
  • Key Terms
    • Orientation – A wareness with regard to person, place, time, and situation
    • Perception – Ability to experience, recognize, organize and interpret sensory stimuli
    • Sensation – Ability to receive and process stimuli received through sensory organs
  • Cognition – Mental Process of Knowing
    • Mental activities: information
      • Receiving
      • Comprehending
      • Storing
      • Retrieving
      • Using
    • Includes
      • Sensation & perception
      • Attention
      • Memory
      • Problem-solving
  • Age-Related Changes Affecting Cognitive & Neurologic Functioning
  • Normal Changes of Aging – Cognitive & Neurologic
  • Question
    • Normal age-related changes in the nervous system can include all of the following EXCEPT:
    • (A) Changes in sleep patterns
    • (B) Delayed reaction time
    • (C) Increased perception of pain
    • (D) Reduced blood flow to the brain
    • (E) Slower reflexes
  • Aging & Cognitive Function
    • Not characterized by cognitive & mental disorders
    • Mental health & cognition remain stable
    • Functional changes: usually no significant impairment
  • Aging & Cognitive Function
    • Cognitive skills negatively affected by age
      • Remembering
      • Solving complex problems
      • Paying attention
      • Reaction time
      • Information processing
  • Effects of Aging on the Neurologic System
    • Loss of nerve cell mass
      • Atrophy: brain & spinal cord
    • Number of nerve cells declines
      • Nerve conduction: slower
      • Response & reaction times: slower
      • Reflexes: weaker
  • Effects of Aging on the Neurologic System
    • Some plaques, tangles, & atrophy of brain
    • Free radicals accumulate
    • Decrease in cerebral blood flow
    • Intellectual performance unchanged
    • Slowing in central processing
      • Delay in time required to perform tasks
  • Effects of Aging on the Neurologic System
    • Verbal skills maintained
    • Number and sensitivity of sensory receptors, dermatomes, and neurons decrease
      • Dulling of tactile sensation
    • Decline in function of cranial nerves affecting taste and smell
  • Aging & Cognitive Function: Intellectual Function
    • Basic intelligence maintained
      • Verbal comprehension & arithmetic
    • Crystallized intelligence (wisdom) – improves with age
      • Accumulation of knowledge over lifespan
      • Application of skills/ knowledge to solving problems
      • Wisdom, practical knowledge
      • Tasks using well-practiced skills or familiar information not affected by age
    • Wisdom, knowledge of ways of world, accumulation of practical expertise = strength
  • Aging & Cognitive Function: Intellectual Function
    • Fluid intelligence (creativity) – declines with age
      • Information processing system (speed with which information can be analyzed)
      • Ability to plan, organize, or think abstractly (executive function)
      • Ability to learn new concepts
      • Attention, memory capacity
      • Complex tasks
  • Aging & Cognitive Function: Memory
    • Short-term (recent) memory – reduced (mild forgetfulness)
      • New information forgotten more rapidly
      • More difficulty retaining information in the presence of interference or shifting attention
      • Memory aids, cues, or reminders can assist
    • Long-term (remote) memory – remains intact
  • Question
    • Cognitive functions that are negatively affected by normal aging include (Select all that apply):
    • A. Remembering
    • B. Solving complex problems
    • C. Vocabulary
    • D. Paying attention
    • E. Arithmetic
    • F. Reaction time
    • G. Speed of information processing
    • H. Wisdom, judgment
  • Question
    • When teaching older adults, the nurse should (Select all that apply):
    • A. Allow more time for processing information
    • B. Include shorter, more frequent sessions
    • C. Provide a dim environment to reduce stimuli
    • D. Limit background noise
    • E. Provide information that is concrete rather than abstract
    • F. Make sure there are as few distractions as possible
    • G. Present one idea at a time
    • H. Provide instructor-paced, rather than learner-paced sessions
  • Question
    • The mental process most sensitive to deterioration with aging is:
      • A. Creativity
      • B. Judgment
      • C. Intelligence
      • D. Short-term memory 
  • Symptoms That Should Be Investigated
    • Memory & intellectual difficulties
    • Change in sleep patterns
    • Delusions, hallucinations, disordered thinking
    • Loss of emotional responsiveness (flat affect)
  • Impaired Cognition
  • Impaired Cognition
    • Fear of loss of cognitive function
    • Losses that result from impaired cognition
    • Aging increases the risk for:
      • Delirium: acute and reversible
      • Dementia: chronic and irreversible
    • Differences between delirium & dementia
  • How Does Delirium Differ from Dementia?
    • Delirium
    • Rapid onset
    • Fluctuates; worse at night
    • Altered LOC
    • Easily distracted; attention impaired
    • Dementia
    • Chronic, insidious
    • Symptoms progressive but stable
    • LOC usually not affected
    • Tries hard to do task; great effort to recall
  • Question
    • Is the following statement true or false?
    • A major difference between delirium and dementia is that delirium alters a person’s level of consciousness whereas dementia does not
  • Delirium
  • Definition of Delirium
    • Reduced level of consciousness
      • Difficulty focusing, shifting or sustaining attention
    • Cognitive change
      • Deficit of language, memory, orientation, perception; not attributed to dementia
    • Develops rapidly (hrs to days)
    • Varies (fluctuates) during the day
    • Disturbances: attention, perception, thinking, memory, psychomotor behavior, sleep-wake
    • General medical condition directly causes it
  • Recognition of Delirium
    • Impaired attention, distractibility
    • Prominent disorientation
      • Disorganized & distorted thinking (fearfulness, paranoia)
      • Inability to recall recent events
      • Incoherent speech
    • Inability to sleep
    • Disorders of perception
      • Terrifying hallucinations, vivid dreams
      • Intense emotional disturbances
      • Strange, absurd fantasies & delusions
    • Psychomotor behavior: lethargic, agitated, or mixed
  • Confusion Assessment Method (CAM) DELIRIUM
  • Delirium = Acute Confusion
    • Delirium begins with confusion , can proceed to stupor or excessive activity
    • Time limited (hrs to days)
    • Fluctuates over the course of day
    • Reversible…
      • … With prompt treatment
    • Treat underlying cause(s), coexisting factors
    • Variable outcome
      • Can range from full recovery to death
  • Delirium: Acute State of Confusion
    • A medical emergency
    • High morbidity & mortality rate (20-30%), longer hospital stay, increased risk nursing home placement
      • Delirium has a fatality rate as high as Acute MI or Sepsis (Cleveland Journal of Medicine, Nov 2004)
    • Reversible if Dx and Tx in time!!!
  • Delirium – Risk Ractors
    • Advanced age higher risk!!!
    • Cognitive impairment or dementia (older people with dementia are especially susceptible to delirium)
    • Hx of previous episodes of delirium
    • Multiple medical conditions
    • Multiple medications
    • Severe stress (from events like a move to a new environment, recent surgery or recent injury)
  • Delirium: One of the Most Commonly Encountered Medical Disorders in Medical Practice!!!
    • 10-40% of elderly general medical patients will experience a LIFE THREATENING CONFUSIONAL STATE
    • Up to 40% of long-term care residents
    • 40-60% of surgical patients
    • Up to 80% of patients in ICUs (“ICU Psychosis”)
    • Do not accept symptoms as “normal”
    • REQUIRES CONTINUOUS NURSING CARE
  • Delirium - Causes Heart attack, pneumonia, or other condition causing lack of oxygen in the blood and the brain M yocardial (heart) and lungs Such as inability to empty bladder or bowel U rinary or fecal problems Such as from a stroke I ntracranial Such as poor or uncorrected vision and hearing R educed sensory input Particularly urinary or respiratory tract infections (UTI or pneumonia); blood or wound infection after an injury or surgery I nfection Stopping certain medications, alcohol withdrawal L ack of drugs Especially from dehydration; Na+, K+ E lectrolyte imbalance Particularly anticholinergics, sedative-hypnotics, benzodiazepines, barbiturates, opioids; many medications (polypharmacy) D rugs
  • UTI & Pneumonia
    • UTI
      • Positive leukoesterace on urinalysis
      • Positive nitrites
      • WBCs in urine
      • Danger of evolving into urosepsis (can occur very rapidly)
      • Confusion
    • Pneumonia – Anorexic, LOC changes
  • Delirium: Nursing Care During Acute State
    • Establishing medical stability
    • Minimizing stimulation (cluster care)
    • Consistency in care
    • Prevention of harm
    • Teaching and support
  • Sundowner Syndrome
    • Nocturnal confusion
    • Confusion “as the sun goes down”
    • Increased with unfamiliar surrounding
    • Often disturbed sleep patterns
    • May result from excess sensory stimulation or deprivation
  • Prevention/Management of Sundowner’s
    • Keep familiar objects in view
    • Provide physical activity during the day
    • Avoid napping during day
    • Use a nightlight in room
    • Provide human contact and touch for reassurance
    • Control noise and visitors in evening
    • Meet basic needs for fluids, food, toileting
  • Question
    • An 84-year-old patient with a diagnosis of delirium is admitted to the hospital. In addition to being acutely confused, the patient is vomiting and jaundiced, and has bruises and petechiae on his trunk.
    • To evaluate the cause of the patient’s delirium, laboratory analyses of blood are ordered. The results are as follows: serum creatinine 1.0, blood urea nitrogen 10, potassium 3.21, sodium 138, glucose 80, INR 5.3, Hgb 7.0, Hct 21, serum albumin 2.1, elevated ALT / AST, and elevated bilirubin.
    • Based on these laboratory results, the nurse should record which of the following nursing diagnoses on the patient’s care plan?
    • A. Acute Confusion r/t Hyperkalemia
    • B. Deficient Fluid Volume r/t Vomiting
    • C. Disturbed Sensory Perception r/t Hepatic encephalopathy
    • D. Ineffective Cerebral Tissue Perfusion r/t Hypoglycemia
  • Dementia
  • Dementia – Impaired Cognitive Function
    • Progressive , irreversible deterioration in the following areas:
      • Memory, orientation, reasoning, language, problem-solving, sociability, mood, personality, & functionality
    • Deterioration of cognitive function eventually becomes extreme enough to INTERFERE with social and occupational functioning
      • Judgment and moral/ethical behaviors decline
      • Disorganization of the personality
    • Both chronic and terminal (fatal) illness
  • Dementia – Impaired Cognitive Function
    • Profound effect on MEMORY
      • Begins with difficulty remembering recent events ( short-term memory impairment )
      • Deterioration progresses over time
    • ATTENTION is preserved until late in the disease
    • ~8 million older adults affected
    • Not a “Normal” Part of Aging
  • Mini-Cog Assessment Instrument DEMENTIA
  • Dementia: Clinical Diagnosis
    • Dx of dementia – at least two cognitive deficits:
      • Short-term memory
      • Aphasia – impairment in use of language
      • Apraxia – impairment in coordinated movements
      • Agnosia – loss of ability to recognize common objects
      • Impaired ability to plan, organize, sequence, or think abstractly (executive dysfunction)
    • Delirium must be ruled out
  • How Common is Dementia?
    • < 65 years Rare
      • Less than 4% of all cases of dementia
    • 65 – 85 years 10%
      • At age 65, risk increases 1% per year
    • 86 – 100+ years 50%
      • At age 86, risk increases 11% per year
    Age is biggest risk factor!
  • Causes of Dementia for People 71 Years of Age & Older
    • 70% Alzheimer’s Disease
    • 17% Vascular dementia
    • 13% Other dementias, including Lewy body dementia
    • Source: Alzheimer’s Association
  • Alzheimer’s Disease (AD)
  • Alzheimer’s Dementia (AD)
    • Organic brain disease : affects memory , thinking & behavior
    • 5 th leading cause of death
    • Most common form of dementia
      • 4 - 5% of older adults
    • Aging biggest risk factor
      • ~50% > 85 years old may develop AD
      • Lasts 2-20 yrs with average duration 8 yrs
    • Not a normal part of aging!
  • Alzheimer’s Dementia (AD)
    • 5.4 million Americans diagnosed with AD (1 in 8 older Americans!)
      • Projected 7.7 million by 2030
      • Projected 11–16 million Americans by 2050
    • 80% of people with AD live at home until latest stages, being cared for mainly by family
      • 15 million unpaid family/friend caregivers
    • Annual expenditures: $183 billion ($200 billion when considering lost wages)
    • http://www.alz.org/downloads/Facts_Figures_2011.pdf
  •  
  • Alzheimer’s Effects on the Brain
    • Nerve cells in brain affected:
      • Neuritic plaques with beta-amyloid protein
      • Neurofibrillary tangles deep in the brain (cortex)
      • Loss of connections between nerve cells (neurons)
    • Loss of neurons and synapses
    • Beta-amyloid protein fragments – cluster outside cells in brain to form sticky clumps/ plaques (early in AD)
    • Tau protein tangles – aggregates inside brain cells, forming twisted strands of neurofibrillary tangles (later in AD, more direct effect on cognitive function)
  • Alzheimer’s Effects on the Brain
    • Changes in neurotransmitter systems
      • Serotonin and acetylcholine
    • Disrupts three processes that keep neurons healthy  memory failure + personality changes + difficulty with ADLs
      • Communication
      • Metabolism
      • Repair
    • Results:
      • Loss of memory
      • Thinking & language skills
      • Behavioral changes
  • Alzheimer’s Effects on the Brain http://www.alz.org/brain/10.asp Plaques & tangles form in and around nerve cells of the brain
  • How Alzheimer’s Spreads in the Brain http://www.alz.org/brain/08.asp
  • Risk Factors of Alzheimer’s Disease
    • 1. Age - Likelihood of developing AD doubles every 5 yrs after age 65. After age 85, risk reaches ~50 %
    • 2. Family hx/ genetics
    • 3. Head injury
    • 4. Heart health – Same risk factors as vascular dz (diabetes, HTN, high cholesterol)
    • 5. Latino & African American ethnicity
    • 6. Lifestyle (healthy aging) – Weight; tobacco & alcohol, physical exercise, healthy diet (whole grains, fruits & vegetables, low in saturated fat), regularly exercise the brain (learning a new language, puzzles, word searches)
    • http:// www.alz.org/alzheimers_disease_causes_risk_factors.asp
  • Possible Causes of Alzheimer’s Disease
    • Majority of cases: complex interactions between genetic and environmental factors (important point!)
    • Genetics
      • Chromosomal abnormalities
      • Insulin-resistant neurons in brain
    • Environmental factors
      • Free radicals
      • Aluminum and mercury?
  • Symptoms of Alzheimer’s Disease
    • Progressive, degenerative, and fatal ( 5 th leading cause of death)
      • Terminal diagnosis
    • Symptoms develop gradually and progress at different rates among individuals
    • Staging of Alzheimer’s disease
      • Global Deterioration Scale/Functional Assessment Staging (GDS/FAST), p. 415
    • Personal awareness: early stages of dz
    • Dx: based on symptoms/ medical evaluation
    • 10 Warning Signs of Alzheimer's Disease
  • The difference between Alzheimer's and typical age-related changes http://www.alz.org/alzheimers_disease_10_signs_of_alzheimers.asp Losing things from time to time Misplacing things and being unable to retrace steps to find them Sometimes forgetting which word to use Difficulty having a conversation Forgetting which day it is and remembering later Losing track of the date or the season Missing a monthly payment Inability to manage a budget Making a bad decision once in a while Poor judgment and decision making Typical age-related changes Signs of Alzheimer's
  • Question
    • According to the Alzheimer's Association, about how many people in the United States over the age of 65 have Alzheimer's disease?
      • A. 5.4 million
      • B. 6.5 million
      • C. 7.1 million
      • D. 8.6 million 
  • Question
    • The average time period from diagnosis of Alzheimer's disease to death is
      • A. 6 years
      • B. 8 years
      • C. 10 years
      • D. 12 years 
  • Question
    • The most common early symptom of Alzheimer's is difficulty remembering newly learned information.
    • True or false?
  • Stages of Alzheimer’s Disease
  • Stages of Alzheimer’s (p. 415)
    • Stage 1: Normal Adult
    • Stage 2: Normal Older Adult
    • Stage 3: Mild Cognitive Impairment/ Early AD
    • Stage 4: Mild AD
    • Stage 5: Moderate AD
    • Stage 6: Moderately Severe AD
    • Stage 7: Severe/ Terminal AD
    • http:// www.alz.org/alzheimers_disease_stages_of_alzheimers.asp
    Know!
  •  
  • Stage 3: Mild Cognitive Impairment/ Early AD
    • Cognitive impairments recognized by others
      • Word or name-finding
      • Names of new people
      • Impaired performance in work/ social settings
      • Forgetting recently learned information
      • Losing/ misplacing valuable object
      • Decline in ability to plan/ organize
    • http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp#stage3
    • Mild memory impairment
    • Anxiety
    Easily flustered in social situations
  • Stage 4: Mild AD
    • Withdrawal, denial, depression
    • Flat affect
    • Decreased ability to perform IADLs/ complex tasks
    • Cognitive impairment apparent on exam
    • Diagnosis of Alzheimer’s
    • http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp#stage4
  •  
  • Stage 5: Moderate/ Mid-Stage AD
    • Major gaps in memory
    • Deficits in cognitive function
      • Disoriented to time and place
      • May become lost in unfamiliar locations
    • Some assistance with IADLs becomes essential
      • Clothing selection
      • http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp#stage5
  •  
  • Stage 6: Moderately Severe AD
    • Severe loss of cognitive function & memory
      • Recent memory
      • Names of spouse & family
    • Inability perform many ADLs
      • Dressing, toileting
      • Some urinary/ fecal incontinence
    • Personality changes
      • Agitation, resistive to care
      • Wandering
    • Disruption sleep/ wake cycle
    • Institutionalization
    http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp#stage6
  • Stage 6: Moderately Severe AD
  • Stage 6: Moderately Severe AD
  •  
  • Stage 7: Severe/ Terminal AD
    • Final stage
    • Recent/ remote memories lost
    • Loss verbal & psychomotor skills
    • Impaired swallowing
    • Incontinence
    • Total assistance
    http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp#stage7
  • Question
    • When assessing a client with early-stage Alzheimer's disease, the nurse should expect to find which of these symptoms?
      • A. Incontinence
      • B. Aphasia
      • C. Awareness of cognitive losses
      • D. Total dependence for all activities of daily living (ADLs)
  • New Diagnostic Guidelines for Alzheimer’s Disease (04/19/2011)
  • New Diagnostic Guidelines for AD
    • Three stages of disease
    • 1. Preclinical AD (biomarkers) – intended purely for research purposes
    • 2. Mild cognitive impairment (MCI)
    • 3. AD dementia
    • http://download.journals.elsevierhealth.com/pdfs/journals/1552-5260/PIIS1552526011001002.pdf
  • New Diagnostic Guidelines for AD
    • First update in 27 yrs
    • Inclusion of AD biomarkers
      • PET scan, MRI scan, spinal taps
    • Actual disease present decade or more before dementia appears
    • New guidelines = two to threefold increase in number of people dx with AD
  • Treatment for Alzheimer’s Disease
  • Treatment of Alzheimer’s Disease
    • Variety of nursing interventions, interdisciplinary approach
    • No treatment to prevent or cure the disease
      • Treatments for cognitive symptoms
      • Treatments for behavioral symptoms
    • Clinical trials: improve function/ slow disease progression
      • Antioxidants, anti-inflammatory agents, folic acid, vitamins B6 and B12, gene therapy, and vaccine
  • Tx for Cognitive Symptoms: Medications
    • Medications (Aricept, Namenda): slow progress but do not change disease course
    • Temporarily delay worsening of symptoms (6-12 mos)
    • Cholinesterase inhibitors
      • Donepezil (Aricept) – all stages
      • Rivastigmine (Exelon) – mild to moderate
      • Galantamine (Razadyne) – mild to moderate
    • Glutamine regulator
      • Memantine (Namenda) – mild to moderate
    • http://www.alz.org/alzheimers_disease_standard_prescriptions.asp#2
  •  
  • Tx for Behavioral and Psychiatric Symptoms: Non-Drug
    • * Monitor personal comfort – check for pain, hunger, thirst, constipation
    • Do not confront or argue facts
      • Redirect attention
    • Calm environment
      • Simplify environment & routine
      • Ensure adequate rest
    • * Safety
      • Locks on doors/ gates
      • No guns/ car keys out of reach
    http://www.alz.org/alzheimers_disease_standard_prescriptions.asp#3
  • Tx for Behavioral and Psychiatric Symptoms: Medications
    • Antidepressant medications:
      • Citalopram (Celexa)
      • Sertraline (Zoloft)
    • Anxiolytics:
      • Lorazepam (Ativan)
    • Antipsychotic medications:
      • Haloperidol (Haldol)
      • Ziprasidone (Geodon)
    http://www.alz.org/alzheimers_disease_standard_prescriptions.asp#3 Know!
  • Question
    • The wife of a client taking donepezil (Aricept) asks the nurse when her husband’s Alzheimer’s disease will be cured. The nurse’s best response is:
      • A.“This medication takes about 6 weeks to cure Alzheimer’s.”
      • B. “Your husband will be cured in 2 weeks.”
      • C. “This medication slows the degeneration of the disease. It doesn’t cure it.”
      • D. “This medication alone doesn’t cure Alzheimer’s; you have to take two other medications to cure the disease.” 
  • Nursing Care
  • Caring for Persons With Dementia: Safety
    • Ensuring patient safety
    • Environmental safety
    • Poor judgment/ misperceptions
    • Consistent, controlled environment
    • Items to trigger memory
    • Wandering behavior
  • Caring for Persons With Dementia: Physical Care
    • Close observation/ attention: physical needs
      • Eating and drinking
      • Bathing and skin care
      • Consideration of inability to communicate needs
      • Consistency in caregivers
  • Caring for Persons With Dementia: Resistance/ Agitation
    • Be alert to cues
    • Distract
    • Direct eye-contact
    • Safe environment
    • Be calm, clear
    • Do not rush Pt
  • Caring for Persons With Dementia: Respect
    • Need to promote:
      • Individuality
      • Independence
      • Freedom
      • Dignity
      • Connection
  • Caring for Persons With Dementia: Support for Family
    • Physical, emotional, and socioeconomic difficulties of caregiving
    • Education on basic care needs
    • Feelings accompanying caregiver role
    • Community resources
  • Safe Environment & Support
    • Tour home with caregiver to identify safety issues and develop a plan to rectify them
    • Make home safe with modifications
    • Similar strategies as ones used to prevent injury to toddlers to provide safer physical environment
    • Support family/ caregiver
    • Caregiver role strain
    CPSC Home Safety Tips
  • Advance Directives and Proxy Establishment
    • While patients have decision-making capacity, include them in discussions
    • Initiate discussion about desired treatment modalities
    • Select a healthcare proxy
    • Inform proxy about desired care to be provided when patient is unable to make decisions
    • As dementia progresses, likely to be institutionalized
  • Nursing Process
  • Nursing Diagnoses/ Care Plan (pp. 419-420)
    • Self-Care Deficit
    • Risk for Injury
    • Disturbed Sleep Pattern
    • Impaired Verbal Communication
    • Disturbed Thought Processes
    • Interrupted Family Processes
    • Caregiver Role Strain
  • Planning and Outcome Identification
    • The client will
      • Remain safe and free from injury
      • Experience a level of arousal that promotes the meaningful perception of stimuli
      • Remain oriented to time, place, person, and situation to maximum extent possible
      • Perform self-care activities appropriate to own functional capability