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  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page Safety== home safety, driving, compliance Families often blame themselves or blame patient for behavior they cannot control. Caregivers need to get into education of what to expect. They need to have time to grieve and accept this sudden change in normalcy. Advance planning of wills, proxies appointed, advance directives of care—living wills etc. Patient ’s family has the right to know what is happening and what to expect. The burden of care directly and indirectly will fall on them. New medications do allow for care.
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page Comfortt measure: Companionship, light, reassurance, warmth, and reorientation.
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page Suicide::80% visited their physician within a month of the act.
  • UNIVERSITY OF MIAMI School of Nursing NUR 624: Lecture Oct. 17, 2003 Dementia and Cognition Page Suicide::80% visited their physician within a month of the act.
  • Cognitive lecture3(1)

    1. 1. Dementia & Alzheimer ’s Disease <ul><li>Dementia </li></ul><ul><li>syndrome of progressive change in cognitive function </li></ul><ul><li>memory loss and at least one other type of cognitive deficit. </li></ul><ul><li>Senile Dementia of the Alzheimer ’s Type </li></ul><ul><li>one cause of dementia </li></ul><ul><li>insidious onset </li></ul>
    2. 2. Cognitive Impairment <ul><li>a range of disturbances in cognitive functioning. </li></ul><ul><li>diagnosis depends on assessment of cognitive function and a complete mental status examination </li></ul>
    3. 3. Cognitive Impairment Problem Areas <ul><li>Attention span </li></ul><ul><li>Concentration </li></ul><ul><li>Intelligence </li></ul><ul><li>Judgment </li></ul><ul><li>Learning ability </li></ul><ul><li>Memory </li></ul><ul><li>Orientation </li></ul><ul><li>Perception </li></ul><ul><li>Problem solving </li></ul><ul><li>Psychomotor ability </li></ul><ul><li>Reaction time </li></ul><ul><li>Social intactness </li></ul>
    4. 4. Confusion <ul><li>Non clinical term to describe acute onset of inability to understand cir cumstances without loss of consciousness. </li></ul><ul><li>Acute onset is over hours or days. </li></ul>
    5. 5. Normal Aging vs Dementia Characteristics Normal aging Alzheimer ’s/Dementia Memory loss Mild forgetfulness (able to use reminders) Progressive memory loss (gradually unable to use reminders, eventually no ability to learn or recall information) Thinking (cognitive impairment) None Progressive loss in thinking skills (the ability to make decisions, to judge, to follow directions) Paranoia, hallucinations Some paranoia related to vision & hearing loss (may think others are talking about them) Function of the illness although symptoms will vary among individuals. Paranoia and hallucinations are more prevalent, especially in the middle stage. Self-care capacity Usually able to perform all self-care tasks Progressively unable to care for themselves (eventually requires total assistance)
    6. 6. Dementia <ul><li>Causes </li></ul><ul><ul><li>Reversible </li></ul></ul><ul><ul><li>Irreversible </li></ul></ul>
    7. 7. Dementia <ul><li>Reversible causes </li></ul><ul><ul><li>nutritional deficiencies </li></ul></ul><ul><ul><li>endocrine disorders </li></ul></ul><ul><ul><li>trauma </li></ul></ul><ul><ul><li>depression </li></ul></ul><ul><ul><li>sensory deficits </li></ul></ul>
    8. 8. Reversible Cause Normal Pressure Hydrocephalus <ul><li>accumulation of cerebrospinal fluid in brain </li></ul><ul><li>symptoms </li></ul><ul><ul><li>mild dementia </li></ul></ul><ul><ul><li>gait disturbance </li></ul></ul><ul><ul><li>urinary incontinence </li></ul></ul><ul><li>diagnosis: CT scan, ventricular enlargement </li></ul><ul><li>treatment: ventriculoperotonial or ventriculoatrial shunting </li></ul>
    9. 9. Irreversible Causes <ul><ul><li>Arteriosclerosis changes </li></ul></ul><ul><ul><li>Multiple infarctions </li></ul></ul><ul><ul><li>Alzheimer ’s disease </li></ul></ul><ul><ul><li>Pick ’s disease </li></ul></ul><ul><ul><li>Parkinson ’s disease </li></ul></ul><ul><ul><li>Huntington ’s disease </li></ul></ul><ul><ul><li>Alcohol abuse </li></ul></ul>
    10. 10. What is Alzheimer ’s Disease? <ul><li>amyloid ß peptide (Aß) that accumulates in the AD brain is deposited within senile plaques and cerebral vessels </li></ul><ul><li>Aß accumulation initiates AD pathology </li></ul>
    11. 11. Classic triad of AD pathology <ul><ul><li>senile plaques containing Aß </li></ul></ul><ul><ul><li>neurofibrillary tangles (NFTs) </li></ul></ul><ul><ul><li>widespread neuronal loss in the hippocampus and select cortical and subcortical areas </li></ul></ul>
    12. 12. Alzheimer ’s Disease <ul><li>Characteristics </li></ul><ul><li>Memory problems the first sign </li></ul><ul><li>Language difficulties early in the illness </li></ul><ul><li>Attention intact for most of illness </li></ul><ul><li>Motor and seizure disorders occur late if at all </li></ul><ul><li>Slowly but steadily progressive over 10-15 years </li></ul>
    13. 13. Early Warning Signs of AD <ul><li>Developing memory loss </li></ul><ul><li>Losing things, repetitive questions </li></ul><ul><li>Suspiciousness of others </li></ul><ul><li>Less active </li></ul><ul><li>Trouble driving </li></ul><ul><li>Difficulty with finances </li></ul><ul><li>Self-neglects —not eating, bathing </li></ul><ul><li>Irritability, stubbornness, anxiety </li></ul>
    14. 14. Importance of Early Detection of Alzheimer ’s Disease <ul><li>Safety </li></ul><ul><li>Family understanding </li></ul><ul><li>Early education of caregiver </li></ul><ul><li>Advanced planning </li></ul><ul><li>Patient ’s family right to know </li></ul><ul><li>Stabilizing treatments now available </li></ul>
    15. 15. The Challenges <ul><li>Patients with dementia do not recognize that they need help. </li></ul><ul><li>If a patient suspects he/she has a problem can go to great lengths to try and hide it. </li></ul><ul><li>Social skills are often preserved in early stages. </li></ul>
    16. 16. Diffuse Lewy Body Dementia <ul><li>Second most common cause of dementia </li></ul><ul><li>Name comes from the presence of abnormal lumps which develop inside nerve cells called Lewy bodies. </li></ul>
    17. 17. Diffuse Lewy Body Disease Dementia Early problems with attention, executive function, and visuospacial abilities even preceding memory impairment Fluctuating cognitive ability (day to day changes) Visual (93%) and auditory (50%) hallucinations are common and not always troubling to patients Early Parkinson-like motor abnormalities and falls
    18. 18. Diffuse Lewy Body Disease Dementia At risk for exaggerated Parkinsonian drug side effects from haloperidol and risperidone psychosis with dopaminergic drugs
    19. 19. Vascular Dementia Dementia related to strokes Variety of presenting signs with attention disturbances, memory loss and changes in social behavior being common Course is progressive, commonly with a step-wise decline being related to each new stroke Focal neurologic signs are often present Patients have other vascular diseases such as DM, HTN, High Cholesterol and a history of smoking Commonly occurs with Alzheimer ’s Disease (10-15%)
    20. 20. Frontotemporal Dementia & Pick ’s Disease Early Behavioral changes: lack of social skills, poor hygiene, sexual disinhibition, constant touching and rearranging objects, putting objects in mouth Age of onset earlier than Alzheimer ’s Calculation and visuospacial skills intact until late in illness Slow and steady progression
    21. 21. Parkinson ’s Dementia Dementia occurs late in the history of Parkinson ’s Disease (different pattern than DLBD) Steadily progressive
    22. 22. Characteristics of Common Dementias Memory problems Attention Cognition Hallucinations Distress Behavior Motor Problems AD Early Hallmark Early Intact attention Late or never Late occurring DLBD Not first symptoms Early Fluctuating cognition Early and Common Parkinson-like Early VAS Early attention problems Common Early PD Precedes dementia by years
    23. 23. Stages of Dementia <ul><li>Early </li></ul><ul><li>Loss of Recent memory </li></ul><ul><li>Mild Confusion </li></ul><ul><li>Mild Communication Difficulties </li></ul><ul><li>Impaired Judgment </li></ul><ul><li>Personality and Behavior Changes (e.g., anxious, withdrawn, depressed, irritable, mellow, sensitive, frustrated, inconsiderate) </li></ul><ul><li>Mild Difficulties with ADLs and advanced activities (e.g., driving, managing finances, telephoning, cooking) </li></ul>
    24. 24. The Stages of Dementia Middle <ul><li>Increased Memory Loss </li></ul><ul><li>Significant Confusion </li></ul><ul><li>Frustration </li></ul><ul><li>Moderate to severe communication difficulties </li></ul><ul><li>“ When do we eat?” </li></ul><ul><li>anger and anxiety if unable to express needs </li></ul><ul><li>verbal or physical outbursts, such as yelling or throwing furniture </li></ul><ul><li>major word finding problems; sentences may not make sense; it may be difficult to understand others; speech may be slow </li></ul>
    25. 25. Stages of Dementia Middle <ul><li>Poor Judgment </li></ul><ul><li>Increased personality and behavior problems </li></ul><ul><li>Difficulty in completing activities of daily living </li></ul><ul><li>inappropriate comments to friends, questions to strangers, or an attempt to undress in a public place </li></ul><ul><li>restlessness, fidgeting, pacing, aimless wandering, hallucinations or delusions </li></ul><ul><li>bathing, toileting, grooming, dressing. </li></ul>
    26. 26. Symptoms of Dementia Middle <ul><li>loss of impulse control </li></ul><ul><li>agnosia </li></ul><ul><li>apraxia </li></ul><ul><li>perceptual disturbances </li></ul><ul><li>yells out when disturbed or strikes out when awoken </li></ul><ul><li>unable to recognize a fork </li></ul><ul><li>forgets how to use a fork </li></ul><ul><li>thinks the person in the mirror is someone else </li></ul>
    27. 27. Stages of Dementia Late <ul><li>Limited memory </li></ul><ul><li>Extremely limited ability to perform any activities of daily living including feeding. Loss of bowel and/or bladder control </li></ul><ul><li>Limited communication </li></ul><ul><li>Increasing vulnerability and frailty </li></ul><ul><li>May not recognize family or friends; </li></ul><ul><li>May not recognize self in the mirror; </li></ul><ul><li>may think spouse is a stranger </li></ul><ul><li>Dependent on 24 hour assistance. Often no longer ambulatory. </li></ul><ul><li>May be mute or unable to understand words </li></ul><ul><li>More susceptible to infections, physical illnesses </li></ul><ul><li>More nutritional problems </li></ul>
    28. 28. Stages of Dementia Late <ul><li>urinary incontinence </li></ul><ul><li>delusions </li></ul><ul><li>hallucinations </li></ul><ul><li>inability to control bladder functions </li></ul><ul><li>mistakenly accuses a spouse of affairs </li></ul><ul><li>sees people or things that are not there </li></ul>
    29. 29. Dementia Diagnostic Criteria <ul><li>Characterized by multiple cognitive deficits </li></ul><ul><ul><li>orientation </li></ul></ul><ul><ul><li>memory </li></ul></ul><ul><ul><li>judgment </li></ul></ul><ul><ul><li>abstract thinking </li></ul></ul><ul><ul><li>problem solving </li></ul></ul><ul><li>Fluctuations in mood </li></ul><ul><li>Shallowness of affective range </li></ul>
    30. 30. Dementia Diagnostic Criteria <ul><li>loss of intellectual abilities-interference with functioning </li></ul><ul><li>at least one: </li></ul><ul><ul><li>impaired abstract thinking </li></ul></ul><ul><ul><li>impaired judgment </li></ul></ul><ul><ul><li>personality change </li></ul></ul><ul><ul><li>disturbed cortical functioning </li></ul></ul>
    31. 31. Dementia Diagnostic Criteria <ul><li>disturbed cortical functioning </li></ul><ul><ul><li>aphasia: impaired language </li></ul></ul><ul><ul><li>apraxia: impaired motor activity </li></ul></ul><ul><ul><li>agnosia: failure to recognize </li></ul></ul><ul><ul><li>constructional difficulty </li></ul></ul><ul><li>no clouded consciousness </li></ul>
    32. 32. Diagnostic Workup <ul><li>History: from patient and family </li></ul><ul><li>Physical exam & vital signs </li></ul><ul><li>Mental status exam </li></ul><ul><li>Neurological exam </li></ul><ul><li>CT scan & EEG </li></ul><ul><li>Thyroid function tests </li></ul>
    33. 33. Diagnostic Workup <ul><li>Serum B12 and folic acid </li></ul><ul><li>Chest Xray, ECG </li></ul><ul><li>CBC, Urinalysis, Glucose, BUN, serum albumin, electrolytes, VDRL </li></ul>
    34. 34. Diagnostic Work up <ul><li>Rule out </li></ul><ul><li>treatable causes of cognitive impairment </li></ul><ul><li>common co-occuring conditions </li></ul><ul><li>Brain imaging studies can rule out </li></ul><ul><ul><li>vascular disease </li></ul></ul><ul><ul><li>tumor </li></ul></ul><ul><ul><li>subdural hematoma </li></ul></ul><ul><ul><li>normal pressure hydrocephalus </li></ul></ul>
    35. 35. Delirium <ul><li>Diffuse disruption of cognitive state </li></ul><ul><li>Prevalence </li></ul><ul><ul><li>10-30% in the hospitalized medically ill </li></ul></ul><ul><ul><li>10-15% hospitalized elders on admission </li></ul></ul><ul><ul><li>10-40% elders while in the hospital </li></ul></ul><ul><ul><li>60% of nursing home residents over 75 experience delirium </li></ul></ul><ul><ul><li>80% with terminal illness </li></ul></ul>
    36. 36. Delirium <ul><li>Causes </li></ul><ul><ul><li>drugs </li></ul></ul><ul><ul><li>fever </li></ul></ul><ul><ul><li>dehydration </li></ul></ul><ul><ul><li>anesthesia </li></ul></ul><ul><ul><li>sleep deprivation </li></ul></ul><ul><ul><li>medical problems: CHF, CVA, renal failure, anemia </li></ul></ul><ul><ul><li>psychosis </li></ul></ul><ul><ul><li>tumors </li></ul></ul>
    37. 37. Delirium <ul><li>Suspect delirium when </li></ul><ul><ul><li>Prodromal symptoms develop </li></ul></ul><ul><ul><ul><li>Anxiety </li></ul></ul></ul><ul><ul><ul><li>Restlessness </li></ul></ul></ul><ul><ul><ul><li>Irritability </li></ul></ul></ul><ul><ul><ul><li>Disorientaion </li></ul></ul></ul><ul><ul><ul><li>Distractibility </li></ul></ul></ul><ul><ul><ul><li>Sleep disturbance </li></ul></ul></ul><ul><ul><li>Condition changes throughout the day </li></ul></ul><ul><ul><li>Familiar figures unable to soothe </li></ul></ul>
    38. 38. Delirium <ul><li>May progress to </li></ul><ul><ul><li>Stupor </li></ul></ul><ul><ul><li>Coma </li></ul></ul><ul><ul><li>Seizures </li></ul></ul><ul><ul><li>Death </li></ul></ul>
    39. 39. Delirium Diagnostic Criteria <ul><li>Disturbance of consciousness </li></ul><ul><ul><li>Reduced clarity of awareness of the environment </li></ul></ul><ul><ul><li>Reduced ability to focus, sustain, or shift attention </li></ul></ul>
    40. 40. Delirium Diagnostic Criteria <ul><li>At least two of the following: </li></ul><ul><ul><li>1. Perceptual disturbances </li></ul></ul><ul><ul><ul><li>Misinterpretations </li></ul></ul></ul><ul><ul><ul><li>Illusions </li></ul></ul></ul><ul><ul><ul><li>Hallucinations-usually visual </li></ul></ul></ul>
    41. 41. Delirium Diagnostic Criteria <ul><li>At least two of the following: </li></ul><ul><ul><li>1. Speech </li></ul></ul><ul><ul><ul><li>Rambling </li></ul></ul></ul><ul><ul><ul><li>Irrelevant </li></ul></ul></ul><ul><ul><ul><li>Pressured </li></ul></ul></ul><ul><ul><ul><li>Incoherent </li></ul></ul></ul><ul><ul><ul><li>Switching from subject to subject </li></ul></ul></ul>
    42. 42. Delirium Diagnostic Criteria <ul><li>2. Disorientation </li></ul><ul><li>3. Short onset-hours to days </li></ul>
    43. 43. Delirium Associated Features <ul><li>Sleep disturbance </li></ul><ul><ul><li>Daytime sleepiness </li></ul></ul><ul><ul><li>Night time agitation </li></ul></ul><ul><ul><li>Difficulty falling asleep </li></ul></ul><ul><ul><li>Wakefulness during the night </li></ul></ul><ul><ul><li>Reversal of day-night sleep cycle </li></ul></ul>
    44. 44. Delirium Associated Features <ul><li>Disturbed psychomotor behavior </li></ul><ul><ul><li>Restless </li></ul></ul><ul><ul><li>Hyperactive </li></ul></ul><ul><ul><li>Picking at bed clothes </li></ul></ul><ul><ul><li>Attempting to get out of bed when it is unsafe to do so </li></ul></ul>
    45. 45. Delirium Associated Features <ul><li>Disturbed psychomotor behavior </li></ul><ul><ul><li>Sluggishness </li></ul></ul><ul><ul><li>Lethargy </li></ul></ul>
    46. 46. Delirium Associated Features <ul><li>Emotional disturbance </li></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Fear </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Anger </li></ul></ul><ul><ul><li>Euphoria </li></ul></ul><ul><ul><li>Apathy </li></ul></ul>
    47. 47. Delirium Associated Features <ul><li>Behaviors accompanying emotional disturbance </li></ul><ul><ul><li>Screaming </li></ul></ul><ul><ul><li>Cursing </li></ul></ul><ul><ul><li>Muttering </li></ul></ul><ul><ul><li>Moaning </li></ul></ul>
    48. 48. Delirium Treatment <ul><li>Manage the causative </li></ul><ul><li>e.g. hypoxia and pain </li></ul><ul><li>Comfort measures to calm patient </li></ul><ul><li>Antipsychotics for psychotic behavior </li></ul><ul><li>Ativan for excessive anxiety </li></ul>
    49. 49. Mini Mental State Exam <ul><li>Standardized, widely used </li></ul><ul><li>Assesses orientation, memory and cognitive skills </li></ul><ul><li>Scoring 0-30 </li></ul><ul><ul><li>0 rating- severe impairment </li></ul></ul><ul><ul><li>24-30 rating- normal range </li></ul></ul><ul><li>Untreated patients with dementia have an annual decline of 10% </li></ul>
    50. 50. Secondary Dementia <ul><li>Alcoholism </li></ul><ul><li>Parkinson ’s disease </li></ul><ul><li>Huntington ’s disease </li></ul>
    51. 51. Depression in Dementia <ul><li>Harder to diagnose in the older adults especially with dementia. </li></ul><ul><li>May not exhibit sadness </li></ul>
    52. 52. Depression in Dementia <ul><li>Harder to diagnose in the older adults especially with dementia. </li></ul><ul><li>May not exhibit sadness </li></ul>
    53. 53. Causes of Depression in Dementia <ul><li>Psychosocial factors </li></ul><ul><ul><li>inability to communicate </li></ul></ul><ul><ul><li>loss of function </li></ul></ul><ul><ul><li>loss of pleasurable activities </li></ul></ul><ul><ul><li>loss of home </li></ul></ul><ul><ul><li>loss of independence </li></ul></ul><ul><ul><li>loss of relationships </li></ul></ul><ul><li>Biological factors </li></ul>
    54. 54. Consequences of Depression in Dementia <ul><li>Accelerates decline </li></ul><ul><ul><li>increases memory loss </li></ul></ul><ul><ul><li>causes delusions </li></ul></ul><ul><ul><li>causes agitation </li></ul></ul><ul><ul><li>causes giving up </li></ul></ul><ul><li>Excessive disability </li></ul><ul><ul><li>loss of functional abilities </li></ul></ul>
    55. 55. Clinical Cues of Depression in Dementia <ul><ul><li>irritability </li></ul></ul><ul><ul><li>somatic complaints </li></ul></ul><ul><ul><li>no tears </li></ul></ul><ul><ul><li>ruminating </li></ul></ul><ul><ul><li>critical </li></ul></ul><ul><ul><li>refusing to eat </li></ul></ul><ul><ul><li>low self-esteem </li></ul></ul>
    56. 56. Supportive Therapy <ul><li>One to one very helpful </li></ul><ul><ul><li>Conversation to reduce isolation </li></ul></ul><ul><ul><li>Exercise </li></ul></ul><ul><li>Group approaches can also be effective </li></ul><ul><li>Combination of support and drugs most effective for major depression </li></ul>
    57. 57. Primary Prevention <ul><li>Healthy lifestyle preserves cardiovascular health and subsequently brain health </li></ul>

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