Chapter 59
Alzheimer’s Disease and
Dementia
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Dementia and
Delirium
● Cognitive disorders
● Cognitive impairment is any deficit in intellectual
functioning
○ Includes memory, orientation, attention, and
concentration problems
○ May have devastating consequences for patient and
caregiver
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Dementia and
Delirium
● Dementia
○ Adversely affects
functional ability and
ability to work, fulfill
responsibilities and
perform ADLs
○ High risk for injury,
impaired nutrition, and
social isolation
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Dementia and Delirium
● Depression
○ Patients with dementia and
delirium may have symptoms
of depression
○ Depression and dementia are
often mistaken for one
another, especially with older
adults
○ Manifestations: sadness,
difficulty concentrating,
fatigue, apathy, feelings of
despair, and inactivity
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Dementia and Delirium
● Severe depression leads to poor
concentration and attention which
leads to impaired function and
memory
● When dementia and depression
occur together they can indicate
intellectual deterioration
● Comparison of dementia, delirium,
and depression
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Dementia
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6
Dementia
●
Disorder characterized by a decline in function from a
previous level of function in one or cognitive domains:
○
Complex attention
○
Executive function
○
Language
○
Learning and memory
○
Perceptual-motor
○
Social cognition
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Dementia
● Cognitive decline interferes with
ability to function and perform daily
activities
● Decline does not occur with:
○ Onset of acute confusion; delirium
○ Major mental disorder; depression
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Dementia
● As average life span increases, more patients are
diagnosed with dementia
○ Alzheimer’s disease (AD) is most common
form; 60% to 80%
○ In 2018, 5.7 million Americans over age 65
are living with AD
○ By 2050, this may increase to 14 million
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Dementia
Causes of Dementia (Fig.
59-1)
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10
Dementia
Etiology and
Pathophysiology
● Caused by treatable and
untreatable conditions
○ Treatable causes may be
reversible
○ Prolonged exposure or
disease can cause
irreversible changes
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Dementia
Etiology and
Pathophysiology
● Causes (Table 59-2 in the textbook):
○ Neurodegenerative disorders
○ Vascular diseases
○ Toxic, metabolic, or nutritional
diseases
○ Immunologic diseases or infections
○ Systemic diseases
○ Trauma
○ Tumors
○ Ventricular disorders
○ Drugs
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Dementia
Etiology and
Pathophysiology
● Most common causes
○ Irreversible neurodegenerative disorders (Table 59-3
in the textbook)
■ Alzheimer’s disease
■ Dementia with Lewy bodies (DLB)
■ Frontotemporal dementia (FTD)
■ Down’s syndrome
■ Parkinson’s disease with dementia (PDD)
■ Huntington’s Disease
■ Amyotrophic Lateral Sclerosis
○ Vascular or multi-infarct dementia (VaD)
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Dementia
Etiology and
Pathophysiology
● Mixed dementia
○ Two or more types of dementia present at the same time
○ Characterized by hallmark abnormalities of AD and
another type of dementia, generally vascular
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Dementia
Etiology and
Pathophysiology
● Normal pressure hydrocephalus
○ Rare disorder caused by meningitis,
encephalitis, or head injury
○ Characterized by obstruction of CSF
leading to buildup in the brain
○ Manifestations:
■ Dementia, urinary incontinence, and
difficulty walking
○ Treatment (with early diagnosis):
■ Shunt to divert CSF away from brain
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Dementia
Clinical Manifestations
● Onset depends on cause
○ Neurologic degeneration has gradual onset with
progression
○ Vascular dementia has abrupt onset with stepwise
progression
● Patterns of symptoms can guide HCP to the cause
○ Acute change occurs in days to weeks or subacute
change occurs in weeks to months
■ Infectious or metabolic causes
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Dementia
Diagnostic Studies
● Focused on determining the
cause
○ Reversible versus
irreversible
● First step: medical,
neurologic, and psychosocial
history
○ Review of cognitive and
behavioral changes
○ Include family members
and significant others
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Dementia
Diagnostic
Studies
○ Important information to gather:
■ Problems with judgment
■ Reduced interest in hobbies/activities
■ Repeating questions, stories, or statements
■ Trouble learning how to use a tool or appliance
■ Forgetting the correct month or year
■ Problems handling finances
■ Difficulty remembering appointments
■ Consistent problems with thinking and/or memory
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Dementia
Diagnostic Studies
○
Medication history
■ Prescribed and OTC medications
■ Herbal supplements
■ Recreational substances
■ Others medications associated with cognitive
impairment
●
Analgesics
●
Anticholinergics
●
Psychotropics
●
Sedative-hypnotics
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Dementia
Diagnostic Studies
○
Physical examination
■ Neurologic assessment including mental status
exam or screening test
■ Review findings to rule out other potential medical
conditions
○
Based on history and physical the American
Academy of Neurology (AAN) recommends:
■ Electrolyte panel, liver function tests, serum
vitamin B12 level, CBC, and thyroid function tests
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Dementia
Diagnostic Studies
● Specialized tests
○ RBC folate (alcoholism)
○ Ionized calcium (multiple myeloma)
● Neuroimaging: CT or MRI of head
○ Indicated with:
■ Acute onset of cognitive impairment
■ Rapid neurologic deterioration
■ Findings that suggest subdural hematoma, thrombotic
stroke, or cerebral hemorrhage
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Dementia
● Nursing and interprofessional management
○ Covered with Alzheimer’s disease
○ Preventative measures:
■ Treat risk factors:
● HTN
● Diabetes
● Smoking
● Hypercholesterolemia
● Dysrhythmias
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Alzheimer’s
Disease
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23
Alzheimer’s Disease
(AD)
●
●
Chronic, progressive, neurodegenerative brain
disease
○
11% of people age 65 and older
○
Approximately 1/3 people over age 85
○
Early-onset AD less than or equal to 65 years old
○
Late-onset AD greater than 65 years old
Ultimately fatal
○
Death typically occurs 4 to 8 years after diagnosis
○
6th leading cause of death in U.S.
○
Cannot be prevented or cured; cannot slow
progression
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Alzheimer’s Disease (AD)
● Caregiver burden
○ 25% of people caring for
someone with AD are also caring
for a child or grandchild
■ 60% describe high or very
high emotional stress
■ 1 in 6 stopped working to
provide care
■ 74% have concerns about
their own health
maintenance
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25
Alzheimer’s
Disease (AD)
● Gender differences
○ Men—higher incidence
of vascular dementia
○ Women
■ 2/3 of people dx
with AD are women
■ More likely to
develop AD due to
longer life
■ Twice as many die
each year from AD
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Alzheimer’s
Disease
(AD)
● Cultural and Ethnic Health Disparities
○ Older Blacks are two times more likely and older
Hispanics are 1.5 times more likely to have AD as older
Whites
○ Differences in risk for AD are due to health, lifestyle
and socioeconomic variations
○ Increased incidence of CV disease and diabetes may be
related to increased prevalence of AD in Blacks and
Hispanics
■ Risk increased with lower education levels and
socioeconomic factors
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Alzheimer’s
Disease
Etiology
● Exact etiology is unknown but likely due to multiple
factors
○ Greatest risk factor for AD is age
■ Most diagnosed at or after age 65
■ AD is not a normal part of aging
■ Age alone does not cause AD
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Alzheimer’s Disease
Etiology
● Family history is an important risk factor
○ Those with a first degree relative (parent or
sibling) with dementia are more likely to
develop AD
○ Even higher risk with more than 1 relative
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Alzheimer’s Disease
Genetic Link
● Familial AD (FAD) shows clear pattern of inheritance
○ Onset before age 60 and more rapid disease course
● Sporadic AD has no familial connection
● FAD and sporadic AD have similar pathogenesis
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Alzheimer’s
Disease
Genetic Link
● Epsilon (E)-4 allele of
apolipoprotein E (ApoE) gene of
chromosome 19—first gene
associated with late onset AD
and sporadic AD
● ApoE may have a role in
clearing amyloid plaques
○ Mutations may lead to more
amyloid plaques
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Alzheimer’s Disease
Genetic Link
ApoE comes in different
forms
○ ApoE-2
○ ApoE-3
○ ApoE-4—risk-factor gene for late-onset
AD; increases reliability of diagnosis but
not all people with ApoE-4 get AD
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Alzheimer’s Disease
Genetic Link
●
●
●
Early-onset AD, three genes identified:
○
Presenilin-1
○
Presenilin-2
○
Amyloid precursor protein (APP)
Genetic mutations cause brain cells to overproduce Betaamyloid
○
Presenilin-1 mutations causes AD before age 60; sometimes age
50
○
Presenilin-2 causes early onset FAD
See Genetics in Clinical Practice Box in the textbook
○
Genetic testing should coincide with counseling
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33
Alzheimer’s Disease
Etiology
● Brain health is closely linked with
the health of the heart and blood
vessels
● Many factors increase risk of CV
disease
○ Diabetes
○ Hypertension
○ Obesity
○ Hypercholesterolemia
○ Smoking
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Alzheimer’
s Disease
Etiology
● Diabetes significantly increases risk of
developing AD or other dementia
○ Contributing factors
■ Chronic high levels of insulin
and glucose may be toxic to
brain
■ Insulin resistance may interfere
with ability to break down
amyloid
■ High glucose and cholesterol
lead to vascular dementia
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Alzheimer’s
Disease
Etiology
● Head trauma
○ Risk factor for dementia
○ Traumatic brain injury and PTSD
have increased risk for AD or
other dementia
■ Football players
■ Military veterans
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Alzheimer’s
Disease
Pathophysiology
● Characteristic changes in brain structure and function
○ Amyloid plaques
○ Neurofibrillary tangles
○ Loss of connections between neurons
○ Neuron death
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Alzheimer’s Disease
Pathophysiology
Fig. 59-2
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38
Alzheimer’s Disease
Pathophysiology
● As part of aging, people develop
plaques in the brain; with AD, there are
more plaques in certain parts of the
brain
○ Plaques are clusters of insoluble
deposits of β-amyloid, other
proteins, remnants of neurons, nonnerve cells like microglia, and other
cells, such as astrocytes
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Alzheimer’s Disease
Pathophysiology
● β-Amyloid is from amyloid
precursor protein (APP) which is
associated with the cell
membrane
● Genetic factors may play a
critical role in how the brain
processes β-amyloid protein
● Overproduction of β-amyloid,
an important risk factor for AD,
causing cell damage either
directly or by eliciting the
inflammatory response and
neuron death
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Alzheimer’s Disease
Pathophysiology
● In AD, plaques develop first in areas of brain for memory and
cognitive function then progress to the cerebral cortex areas for
language and reasoning.
● Neurofibrillary tangles
○ Abnormal collections of twisted protein threads inside nerve
cells
○ Main component is a protein called tau; important for supporting
intracellular structure through microtubule support
○ In AD, tau proteins are altered
○ Plaques and neurofibrillary tangles are more abundant in the
brains of people with AD
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Alzheimer’s Disease
Pathophysiology
●
Etiologic development of AD
Fig. 59-3
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42
Alzheimer’s Disease
Pathophysiology
● Gradual loss of connections
between neurons and
neuron death
○ Results in structural
damage
○ Affected parts of brain
shrink
■ Brain atrophy
■ Significant in final
state of AD
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Alzheimer’s Disease
Clinical Manifestations
● Effect of Alzheimer’s disease on the brain
Fig. 59-4
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44
Alzheimer’s Disease
Clinical Manifestations
● Pathologic changes precede
clinical manifestations by at least
15 years
● The Alzheimer’s Association has
developed a list of 10 warning
signs that are common
manifestations of AD
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Alzheimer’s Disease
Clinical Manifestations
● Early warning signs of AD
○ Memory loss that affects
job skills
○ Difficulty performing
familiar tasks
○ Problems with language
○ Disorientation to time and
place
○ Poor or ↓ judgment
○ Problems with abstract
thinking
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Alzheimer’s
Disease
Clinical
Manifestations
● Early signs of AD
○ Misplacing things
○ Changes in mood or
behavior
○ Changes in
personality
○ Loss of initiative
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Alzheimer’s Disease
Clinical Manifestations
● Symptoms do not always correlate
with abnormal changes in the brain
● Categorized as stages
○ Mild
○ Moderate
○ Severe
● Progression: mild to severe
○ Highly variable from person to
person
○ Ranges from 3 to 20 years
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Alzheimer’s Disease
Clinical Manifestations
● Initial symptoms are usually related
to changes in cognitive function
● Family members often report to
HCP
○ Memory loss
○ Mild disorientation
○ Trouble with words and numbers
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Alzheimer’s
Disease
Clinical
Manifestations
● Normal age-related memory decline does
not interfere with ADLs
○ Recent memory loss
○ Remote memory loss
○ Interference with ADLs
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Alzheimer’s Disease
Clinical Manifestations
● As the disease progresses
○ Personal hygiene decreases
○ Decline in concentration and
attention
○ Unpredictable behavior
■ Unintentional and
uncontrollable agitation or
aggression
○ Delusions and hallucinations
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Alzheimer’s Disease
Clinical Manifestations
● Additional cognitive impairments with progression
○ Dysphasia
○ Apraxia
○ Visual agnosia
○ Dysgraphia
○ Long-term memory loss
■ Inability to recognize family and friends
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Alzheimer’s Disease
Clinical
Manifestations
● Further progression
○ Unable to communicate
○ Cannot perform ADLs
○ Wandering
● Late stages
○ Patient becomes unresponsive
and incontinent
○ Total care is required
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Alzheimer’s Disease
Clinical Manifestations
● Retrogenesis
○ Process where degenerative
changes mirror, in reverse
order, brain development
from birth
■ Developmental stages in
children compared with
deterioration in AD
patients
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Alzheimer’s Disease
Clinical Manifestations
● Retrogenesis in Alzheimer’s disease
Fig. 59-5
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55
Alzheimer’s Disease
Diagnostic Criteria
● National Institute on Aging and the Alzheimer’s
Association
○ Criteria and guidelines for diagnosis
■ Imaging and biomarkers
● Spectrum of Alzheimer’s disease
● Preclinical AD
○ Mild cognitive impairment
○ Dementia (terminal stage of disease)
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Alzheimer’s Disease
Preclinical Stage
● Long lag time between brain changes and
manifestations of AD
● Future goal
○ Modify disease before:
■ Plaques and tangles have formed
■ Symptoms emerge
○ Current attempts not successful; research is ongoing
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Alzheimer’s
Disease
Mild Cognitive
Impairment
● Mild cognitive impairment (MCI)
○ Second stage in spectrum of AD
○ Problems with memory, language,
other essential cognitive functions
○ Noticeable to family members
■ Seem normal to others
○ Show up on screening tests
○ Able to perform ADLS—does not
meet criteria for dementia
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Alzheimer’s Disease
Mild Cognitive
Impairment
● MCI classified on cognitive skills affected:
○ Amnestic MCI: forget important information that would
have easily recalled; person is aware of change in memory
○ Nonamnestic MCI: affects ability to make sound decisions
or complete a complex task
● 15% to 20% of people over the age of 65 have MCI
○ High risk for developing AD
○ 15% of people with MCI develop AD
○ Drug therapy currently not available
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Alzheimer’s Disease
Mild Cognitive
Impairment
● Primary treatment of MCI is
currently based on careful
monitoring
○ Note declining memory or
thinking skills
○ Early warning signs of AD
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Alzheimer’s
Disease
Diagnostic
Studies
●
No definitive diagnostic
test exists for AD
○ Diagnosis of exclusion
○ Made once all other
possible conditions causing
cognitive impairment have
been excluded
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Alzheimer’s Disease
Diagnostic Studies
● Comprehensive patient evaluation
○ Complete health history
○ Physical examination
○ Neurologic and mental status
assessments; depression screening
○ Laboratory tests
■ Serum: glucose, creatinine, BUN,
vitamins B1, B6, and B12; CBC
■ Thyroid and liver function tests
○ ECG
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Alzheimer’s Disease
Diagnostic Studies
● Brain imaging tests
○ CT and MRI
●
PET Scan of Normal and AD
Brain
■ Show brain atrophy
○ MR Spectroscopy
○ PET
■ Distinguishes AD from
other dementia; detects
amyloid
● Detect early changes in disease
process
Fig. 59-6
● Monitoring of treatment
response
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Alzheimer’s Disease
Diagnostic Studies
● Definitive diagnosis of AD usually requires brain tissue
exam at autopsy
● Biomarkers are promising, but more research is indicated
○ Level of β-amyloid accumulation in the brain
○ Injured or degenerating nerve cells
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Alzheimer’s Disease
Diagnostic Studies
● Biomarkers include
○ CSF neurochemical markers
■ β-amyloid and tau proteins
● Level of tau in CSF is indicative of
neurodegeneration
■ Plasma levels are not diagnostic of AD
○ Imaging biomarkers
■ Volumetric MRI and PET
■ Used in research
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Alzheimer’s Disease
Diagnostic Studies
● Neuropsychologic testing
○ Document degree of cognitive
impairment
○ Also used to establish a baseline
from which to evaluate changes
over time
○ Given at regular intervals to
assess changes in cognitive status
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Alzheimer’s
Disease
Diagnostic Studies
● Neuropsychologic testing tools:
○ Mini-Cog
■ Clock drawing test to assess cognitive
function
○ Mini-mental state examination (MMSE)
■ Assesses orientation, recall, attention,
calculation, language manipulation, and
constructional praxis
○ Montreal cognitive assessment (MoCA)
■ Assesses memory, language, attention,
visuospatial, and executive functions
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Alzheimer’s Disease
Diagnostic Studies
●
Clock drawing test
Fig. 59-7
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68
Alzheimer’s Disease
Interprofessional Care
● No cure
○ No treatment exists to stop the
deterioration of brain cells in AD
● Interprofessional care is aimed at
○ Controlling undesirable behavioral
manifestations
○ Providing support for family
caregiver
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Alzheimer’s Disease
Medications
● Medications do not cure or
reverse progression of the
disease
○ Some modest decreases in
rate of decline of cognitive
function
○ No effect on overall disease
progression
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Alzheimer’s Disease
Medications
● Decreased memory and cognition
○ Cholinesterase inhibitors
■ Examples: donepezil (Aricept),
rivastigmine (Exelon), galantamine
(Razadyne)
○ N-methyl-D-aspartate (NMDA)—blocks
action of glutamate
■ Example: memantine (Namenda)
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Alzheimer’s Disease
Medications
●
Cholinesterase Inhibitors
Fig. 59-8
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72
Alzheimer’s Disease
Medications
● Depression
○ Selective serotonin reuptake inhibitors
(SSRIs)
■ Examples: fluoxetine (Prozac),
sertraline (Zoloft), fluvoxamine
(Luvox), citalopram (Celexa)
● Sleep disturbances
○ Related to depression: trazadone
○ Other: zolpidem (Ambien)
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Alzheimer’s Disease
Medications
○ Behavioral problems (severe,
dangerous and/or cause significant
distress; risk of death and cognitive
decline)
■ Antipsychotic drugs
● Examples: haloperidol
(Haldol), risperidone
(Risperdal), olanzapine
(Zyprexa), quetiapine
(Seroquel), aripiprazole
(Abilify)
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Nursing Management
Nursing Assessment
● Subjective data
○ Important health information
■ Past health history
■ Medications
○ Functional health patterns
■ Health perception–health
management
■ Nutritional–metabolic
■ Elimination (incontinence)
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Nursing Management
Nursing Assessment
○
Functional health patterns
■ Activity–exercise
■ Sleep–rest pattern
■ Cognitive–perceptual
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Nursing Management
Nursing Assessment
● Objective data
○ General
■ Disheveled appearance,
agitation
○ Neurologic
■ Mild
■ Moderate
■ Severe
○ Possible diagnostic findings
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Nursing Management
Nursing
Diagnoses
● Confusion
● Risk for injury
● Altered perception
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Nursing Management
Planning
● Overall goals for patients
○ Maintain functional ability as long as possible
○ Live in a safe environment
○ Minimize injuries
○ Address personal care needs
○ Maintain dignity
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Alzheimer’s Disease
Planning
● Overall goals for
caregivers
○ Reduce caregiver
stress
○ Maintain personal,
emotional, and
physical health
○ Cope with long-term
effects of caregiving
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Nursing Implementation
Health Promotion
● Keep your brain healthy and
modify risk for developing
dementia
○ Avoid harmful substances
○ Challenge your mind
○ Exercise regularly
○ Stay socially active
○ Avoid trauma to the brain
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Nursing Implementation
Health Promotion
● Keep your brain healthy and
modify risk for developing
dementia
○ Take care of mental health
○ Treat diabetes
○ Take care of your heart
○ Get enough sleep
○ Get the right fuel
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Nursing Implementation
Health Promotion
● Early recognition and
treatment are important
● Inform patients and their
families regarding early
signs of AD
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Nursing Implementation
Acute Care
● Diagnosis is traumatic for patient and
caregiver
● Patient often responds with
○ Depression
○ Denial
○ Worry
○ Fear
○ Feelings of loss and dread
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Alzheimer’
s Disease
Acute Care
● Assess your patients for
depression
○ Counseling and
antidepressants may be
indicated
● Family caregivers may be in
denial, delaying critical early
care
○ Accept their ability to cope
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Alzheimer’s Disease
Acute Care
● Ongoing monitoring important
○ Work in collaboration with patient’s caregiver
○ Teach caregiver how to manage clinical
manifestations effectively as they change over time
○ Regular assessment and support
■ Severity of problems and required nursing care
increase over time
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Alzheimer’s Disease
Acute Care
● Specific manifestations depend on area
of the brain involved
○ Nursing care focuses on:
■ Decreasing manifestations
■ Preventing harm
■ Supporting the patient and
caregiver
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Alzheimer’s Disease
Acute Care
●
●
AD patients hospitalized for other problems can
precipitate:
○
Worsening of dementia
○
Development of delirium
Inability to communicate symptoms places responsibility
on caregiver and health care professionals
○
Require close observation for safety
○
Need frequent reorientation and reassurance
○
Consistent nursing staff may decrease anxiety or disruptive
behaviors
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Nursing Management
Ambulatory Care
● Family members and friends care
for most AD patients in their
homes
● Various facilities should be
evaluated
○ Consider stage of AD patient
when choosing
○ Nursing care intensifies over
time
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Nursing Management
Ambulatory Care
●
After initial diagnosis, patients need to be aware that
progression varies
○
Effective management may slow symptom progress and
reduce burden on the patient, caregiver, and family
○
Decisions related to care should be made early in
collaboration with interprofessional care team while the
patient still has the capacity to participate; will ease
burden later as disease progresses
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Nursing Management
Ambulatory Care
●
●
In early stages, memory aids may be
beneficial
○
Depression often develops related to
impaired ADLs including driving, socializing,
and recreational activities
○
Teach caregivers to perform tasks to
maximize quality of life and safety
Adult day care can provide
○
Caregiver respite in protective environment
○
Stimulation for AD patient
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Nursing Management
Ambulatory Care
● Severity of problems and amount of care
intensifies over time
○ Demands on caregiver can exceed
resources
○ May need long-term care placement
■ Special dementia units are
common
■ Emphasis is on safety
■ Secure environment allows patient
to walk freely but not wander
outside
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Nursing Management
Ambulatory Care
● Late stage—severe impairment
○ Difficult to perform basic functions
○ Total care is needed
○ Specific problems related to care of the
patient in all phases of the disease include:
■ Behavioral problems, safety, pain
management, eating and swallowing
difficulties, oral care, infection prevention,
skin care, elimination problems, and
caregiver support
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Nursing Management
Behavioral Problems
● Occur in approximately 90% of patients with AD
● These problems include:
○ Repetitiveness; asking same questions
○ Delusions
○ Hallucinations
○ Agitation
○ Aggression
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Nursing Management
Behavioral Problems
● Problems:
○ Altered sleep patterns
○ Wandering
○ Hoarding
○ Resisting care
● Can be unpredictable and challenging
○ Unintentional and difficult to control
○ Often lead to placement of patients in
institutional care settings
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Nursing Management
Behavioral Problems
● Often a patient’s way of responding
to a precipitating factor
○ Pain
○ Frustration
○ Temperature extremes
○ Anxiety
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Nursing Management
Behavioral Problems
● Assess patient’s
○ Physical status, VS, elimination patterns, and pain
○ Environment, including temperature or noise
■ Move patient or remove stimulus
● Reassure patient about safety
■ Remove tubes and dressings from visual field
● Rely on emotional state rather than verbal communication;
not logical
■ Use validation; don’t ask patient “why”
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Nursing Management
Behavioral Problems
● Nursing strategies for difficult behaviors
○ Redirection
○ Distraction
○ Reassurance
● Do not threaten to restrain patient
○ Calming family presence
● Use positive nursing actions
● Exhaust options before using drugs
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Nursing Management
Behavioral Problems
● Sundowning
○ Specific type of agitation; unclear cause
○ Patient becomes more confused and
agitated in late afternoon or evening
■ May be due to disruption of circadian
rhythms
■ Other potential causes: pain, hunger,
noise, unfamiliar environment,
medications, reduced lighting, and
fragmented sleep
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Nursing
Management
Behavioral
Problems
● Nursing interventions for
sundowning
○ Remain calm, avoid
confrontation
○ Create a quiet, calm
environment
○ Maximize exposure to daylight
○ Evaluate medications
○ Limit naps and caffeine
○ Consult health care provider
on drug therapy
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s Disease
Safety
● Risks
○ Injury from falls
○ Ingesting dangerous substances
○ Wandering
○ Injury to others and self with sharps
○ Burns
○ Inability to respond to crisis
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s
Disease
Safety
● Minimize risks in home environment
○ Assist caregiver in assessing home environment for
safety risks
○ Implement all possible safety strategies
● Supervision is needed
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s Disease
Safety
● Wandering is major concern
○ Related to loss of memory , side effects of
medications, physical or emotional need,
curiosity or stimuli that triggers memory or
earlier routines
○ Observe for precipitating factors or events
○ Every second counts when someone with AD
is missing
■ Patient can be registered with Medic
Alert + Alzheimer’s Association Safe
Return
■ GPS
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s Disease
Pain Management
● Pain should be recognized and treated promptly
○ Monitor patient’s responses
○ Patients can have difficulty communicating
complaints
○ May exhibit changes in behavior
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s Disease
Eating and Swallowing
Difficulties
● Undernutrition is a problem in
moderate and severe stages
○ Loss of interest in food
○ Decreased ability to selffeed (feeding apraxia)
○ Co-morbid conditions
○ Long-term care, inadequate
assistance may be a problem
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s Disease
Eating and Swallowing
Difficulties
● When chewing and swallowing become difficult, use:
○ Pureed food
○ Thickening liquids
○ Nutritional supplements
● Remind patients to chew and swallow; offer liquids
frequently
● Quiet and unhurried environment
● Easy-grip utensils and finger food for self-feeding
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s Disease
Eating and Swallowing
Difficulties
● Alternatives:
○ Nasogastric (NG) feedings
■ Short-term
○ Percutaneous endoscopic gastrostomy
(PEG) tube
■ Risk of aspiration and tube
dislodgment
● Weigh positive outcomes versus potential
risks.
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s Disease
Oral Care
● In late stages, patient will be unable to perform oral self-care
○ Dental problems are likely to occur
○ Patient may retain food, adding to potential tooth decay,
leading to caries and abscesses which can cause
discomfort and agitation
○ Inspect mouth regularly and provide mouth care
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s Disease
Infection Prevention
● Most common infections:
○ Urinary tract infection
○ Pneumonia
● Cause of death in many AD patients
● Manifestations need prompt evaluation and treatment
○ Note: change in behavior, fever, cough, and pain with
urination
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s Disease
Skin Care
● In late stages, patients are at risk
for skin breakdown
○ Incontinence, immobility, and
undernutrition
● Identify and treat rashes and areas
of redness
● Keep skin dry and clean
● Change patient’s position
regularly
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s
Disease
Elimination
Problems
● During moderate to severe stages, urinary and fecal
incontinence lead to a need for increased nursing care
○ Behavioral retraining by scheduled toileting may
decrease episodes
● Constipation as a result of immobility, dietary intake, and
decreased fluids
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s Disease
Caregiver Support
● More than 16 million unpaid caregivers in United States
○ Many family members provide home care
● AD disrupts all aspects of patient and family life; very stressful
○ Caregivers also exhibit adverse consequences
■ Emotional and physical health suffers; chronic stress
increases risk of dementia
■ Can result in changes in : family role, employment,
decision making, and sexual relations
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s Disease
Caregiver Support
● Caregivers Face
Incredible Challenges
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113
Alzheimer’s
Disease
Caregiver
Support
● Assess stressors and identify
coping strategies
● Prioritize according to degree of
disruption to family life
● Patient safety is a high priority
○ Assess caregiver’s expectations
of patient’s behavior
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Alzheimer’s Disease
Caregiver Support
● Provide education based on stages of AD and
guidelines for care
○ See eNursing Care Plan 59-2 on the Evolve
website
○ Support groups and systems may be helpful
and provide current information
■ The Alzheimer’s Association: www.alz.org
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Support Groups
● Support groups are an effective way to help caregivers cope.
Copyright © 2020 by Elsevier, Inc. All rights reserved.
116
Alzheimer’s Disease
Evaluation
● Expected outcomes
○ Functions at highest level of cognitive ability
○ Performs basic personal care activities of daily living by
self or with assistance, as needed
○ Maintain safety, minimize injury
○ Stay in a restricted area during ambulation and activity
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Audience Response
Question
The daughter of a patient with early familial Alzheimer’s
disease (AD) asks how AD is different from forgetfulness.
You describe early warning signs of AD, including:
a. forgetting a colleague’s name at a party.
b. repeatedly misplacing car keys or a wallet.
c. leaving a pot on the stove that boils dry and burns.
d. having no memory of preparing a meal and forgetting to
serve or eat it.
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118
Audience Response
Question
ANS: D
having no memory of preparing a meal and
forgetting to serve or eat it
Copyright © 2020 by Elsevier, Inc. All rights reserved.
119
Delirium
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120
Delirium
●
State of confusion that develops over hours to days;
presentation may include:
○
Decreased ability to direct, focus, sustain, and shift
attention and awareness
○
Deficient memory, orientation, language, visuospatial
ability, or perception
○
Hypoactivity or hyperactivity
○
Emotional problems such as fear, depression, euphoria, or
perplexity
○
Sleep disturbances
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
● Symptoms represent a change from baseline
and may fluctuate
● Do not occur due to change in level of arousal
and cannot be explained by another
preexisting, evolving, or established
neurocognitive disorder
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Etiology and
Pathophysiology
●
Exact cause is unknown
●
Main contributing factor
○
Impairment of cerebral oxidative metabolism
○
Multiple neurotransmitter abnormalities and
proinflammatory cytokines may also be involved
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Etiology and
Pathophysiology
● Rarely caused by a single factor
○ Occurs most often in hospitalized
older adults; affects up to 60%
■ Linked to stress, surgery, and sleep
deprivation; most common surgical
complication
■ Other contributing factors are pain
and depression
○ Often result of interaction of patient’s
underlying condition with a
precipitating event or a combination
of factors
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Etiology and
Pathophysiology
●
Dementia is a leading risk factor for
delirium
○
Delirium is a risk factor for
subsequent development of dementia
related to permanent neuronal
damage
○
Many factors can precipitate delirium
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Precipitating Factors
●
●
Demographic characteristics
○
Age 65 or older
○
Male gender
Cognitive status
○
Dementia
○
Cognitive impairment
○
Depression
○
History of delirium
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126
Delirium
Precipitating
Factors
● Environmental
○ Admission to ICU
○ Use of physical restraints
○ Pain (especially untreated)
○ Emotional stress
○ Prolonged sleep deprivation
● Functional status
○ Functional dependence
○ Immobility
○ History of falls
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Precipitating
Factors
●
Sensory
○ Sensory deprivation
○ Sensory overload
○ Visual or hearing impairment
●
Decreased oral intake
○ Dehydration
○ Malnutrition
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Precipitating
Factors
● Drugs
○ Sedative-hypnotics
○ Opioids
○ Anticholinergic drugs
○ Aminoglycosides
○ Treatment with multiple
drugs
○ Alcohol or drug abuse or
withdrawal
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Precipitating Factors
● Coexisting medical conditions
○ Severe acute or terminal illness
○ Electrolyte imbalances
○ Chronic kidney or liver disease
○ History of stroke
○ Neurologic disease
○ Infection/sepsis/fever
○ Fracture or trauma
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Precipitating Factors
● Surgery
○ Orthopedic surgery
○ Cardiac surgery
○ Prolonged cardiopulmonary
bypass
○ Noncardiac surgery
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Mnemonic for Causes
●
●
●
●
●
●
●
●
D is for dementia, dehydration
E is for electrolyte imbalances, emotional stress
L is for lung, liver, heart, kidney, brain
I is for infection, ICU
R is for Rx Drugs
I is for injury, immobility
U is for untreated pain, unfamiliar environment
M is for metabolic disorders
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Etiology and
Pathophysiology
● Understanding causative
factors can help determine
effective interventions
● Many factors that can
precipitate delirium are
more common in older adults
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Etiology and
Pathophysiology
●
●
Older patients have limited compensatory mechanisms
to deal with physiologic insults such as
○
Hypoxia
○
Hypoglycemia
○
Dehydration
Older patients are more often treated with multiple
drugs
○
More susceptible to drug-induced delirium
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Clinical Manifestations
●
Can present with a variety of
manifestations
○
●
From hypoactive and lethargic to
hyperactive, agitated , and
hallucinating
Delirium usually develops over a
2- to 3-day period
○
Can develop within hours
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Clinical Manifestations
● Early manifestations often
include
○ Inability to concentrate
○ Disorganized thinking
○ Irritability
○ Insomnia
○ Loss of appetite
○ Restlessness
○ Confusion
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Clinical Manifestations
● Later manifestations may
include
○ Agitation
○ Misperception
○ Misinterpretation
○ Hallucinations
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Clinical Manifestations
Can last from 1 to 7 days
Some manifestations may persist for
months or years
Some patients do not completely
recover
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Clinical Manifestations
● Manifestations are sometimes
confused with dementia
● Key distinctions of delirium
rather than dementia
○ Sudden cognitive
impairment
○ Disorientation
○ Clouded sensorium
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Diagnostic Studies
● Diagnosis complicated by inability
to communicate; especially
critically ill patients
○ Medical history
○ Psychologic history
○ Physical examination
○ Careful attention to medications
○ Confusion Assessment Method
(CAM)
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Diagnostic Studies
● Laboratory tests to explore the cause:
○ Complete blood count (CBC)
○ Serum electrolytes
○ Blood urea nitrogen level
○ Creatinine level
○ Drug and alcohol levels
○ Electrocardiogram (ECG)
○ Urinalysis
○ Liver and thyroid function tests
○ Oxygen saturation level
○ Other: lumbar puncture, brain imaging
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Nursing and
Interprofessional
Management)
●
●
Treatment is important since many
cases are potentially reversible
Your role in caring for a patient with
delirium
○
Prevention: identify high-risk patients
○
Early recognition: eliminate
precipitating factors
○
Treatment: address underlying cause
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Nursing and
Interprofessional
Management
● Nursing care
○ Protect patient from harm
○ Encourage family members
to stay at bedside; provide
familiar objects
○ Private room or one near
nurses’ station
○ Consistent staffing
○ Reduce environmental
stimuli
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Nursing and
Interprofessional
Management
● Reorientation and behavioral interventions
○ Create a calm and safe environment
○ Provide reassurance
○ Reorient
■ Clocks, calendars, list of scheduled
activities
○ Reduce environmental stimuli
■ Noise and light levels
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Nursing and
Interprofessional
Management
● Personal contact
○ Touch and verbal
communication
● Use patient’s glasses and
hearing aids to reduce sensory
limitations
● Avoid restraints
● Relaxation techniques
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Nursing and
Interprofessional
Management
● Interprofessional team to address:
○ Polypharmacy
○ Pain
○ Nutrition
○ Elimination
○ Immobility
■ Skin breakdown
■ Exercise
● Nurse should also focus on supporting the family and caregivers
○ Patient education: www.ICUdelirium.org
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Medication Therapy
● Reserved for those patients with severe
agitation when:
○ Interferes with needed medical
therapy
○ Puts patient at increased risk for falls
and injury
○ Nonpharmacologic interventions
have failed
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Delirium
Medication Therapy
● Dexmedetomidine (Precedex) for sedation
(ICU setting)
● Antipsychotics (controversial; monitor side
effects)
○ Haloperidol (Haldol)
○ Risperidone (Risperdal)
○ Olanzapine (Zyprexa)
○ Quetiapine (Seroquel)
● Short-acting benzodiazepines (cautious
use; may worsen delirium)
○ Lorazepam (Ativan)
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Audience Response
Question
An older patient is admitted to the hospital with a urinary infection and
possible bacterial sepsis. The family is concerned because the patient
is confused and not able to carry on a conversation. Which statement by
the nurse is most appropriate?
a.
“Depression is a common cause of confusion in older adults in the
hospital.”
b.
“It is normal for an older person to have cognitive problems while
in the hospital.”
c.
“The mental changes are most likely caused by the infection and
most often reversible.”
d.
“Drug therapy with antipsychotic agents is indicated to slow the
progression of dementia.”
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Audience Response
Question
ANS: C
“The mental changes are most likely caused by the
infection and most often reversible.”
Copyright © 2020 by Elsevier, Inc. All rights reserved.
Reflection Question
● It can be difficult to care for confused and combative patients, especially when it happens
unexpectedly.
● What are some things you can do to deal with such behavior in a clinical environment such as a
hospital?
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151
Case Study (1 of 6)
● 72-year-old D.B. was brought by his daughter to see his primary physician.
● He was asked to retire because of erratic performance at work recently.
● He has had no appetite or energy since wife’s death 6 months ago.
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152
Case Study (2 of 6)
●
●
●
●
D.B. recently lost his car downtown and had to take a cab home.
He is unable to recognize surroundings.
Today, he is unshaven with oversized slacks and a worn shirt.
What possible problems do his symptoms suggest?
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153
Case Study (3 of 6)
● D.B. lives with his daughter.
● She works at a local office full time.
● What important teaching should you do with both of them?
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154
Case Study (4 of 6)
● You see D.B. in the clinic 4 months later.
● His condition is fairly stable.
● However, his daughter confides in you she is very stressed by the need to provide constant care for
him.
● What should you say or do?
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155
Case Study (5 of 6)
Audience Response
Question
D.B. is admitted to a long-term care facility. He has a
nursing diagnosis of impaired memory related to effects of
dementia. An appropriate nursing intervention for him is to:
a. let him know what behavior is socially appropriate.
b. assist him with all self-care to maintain self-esteem.
c. maintain familiar routines of sleep, meals, drug
administration, and activities.
d. promote orientation at every encounter with the patient
by asking the day, time, and place.
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156
Case Study (6 of 6)
ANS: C
maintain familiar routines of sleep, meals, drug administration, and activities.
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157
Reflection Question
● Long-term care can be unaffordable for some patients
and their families.
● What do you do in situations when a patient cannot
afford the care that is needed?
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158
Case Study (1 of 8)
● 84-year-old K.P. has been in ICU for 3 days after unexpected major abdominal surgery.
● He had part of descending colon removed for obstruction for diverticula.
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159
Case Study (2 of 8)
●
●
●
●
He is becoming increasingly confused and agitated.
His vital signs are within normal limits.
His abdominal incision is healing with no redness or drainage.
He is starting to tolerate an oral diet.
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160
Case Study (3 of 8)
● Before surgery K.P. was sad, but alert and oriented.
● He is repeatedly trying to climb out of bed and states he needs to “get out of here.”
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161
Case Study (4 of 8)
● He is angry at family members for not “taking me home.”
● Family members are very upset about his confusion.
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162
Case Study (5 of 8)
● What type of cognitive impairment do you think K.P. has?
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163
Case Study (6 of 8)
Audience Response
Question
You administer the Confusion Assessment Method (CAM)
tool to K.P. to differentiate among various cognitive
disorders, primarily because:
a. delirium can be reversed by treating the underlying
causes.
b. depression is a common cause of dementia in older
adults.
c. nursing care should be based on the cause of the
cognitive impairment.
d. drug therapy with antipsychotic agents is indicated in
the treatment of dementia.
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164
Case Study (7 of 8)
Audience Response
Question
ANS: A
delirium can be reversed by treating the underlying causes.
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165
Case Study (8 of 8)
● What is your priority regarding K.P.’s mental status?
● What is the next priority for you while caring for him?
● Regarding his family and their anxiety, what is your priority?
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166