Enhancing Care Coordination Program
For Cognitively Impaired Older Adults and Their Family Caregivers
Resource Nurse Care
Training Modules
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Dementia and Delirium Education Modules © 2006
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Contents
Contents ........................................................................................................................................................ 2 Introducing Enhancing Care Coordination in the Presence of Memory and Thinking Problems: A WebBased Education Program ............................................................................................................................ 3 I. Understanding Cognitive Impairment......................................................................................................... 6 What is Dementia? .................................................................................................................................... 7 What is Delirium? .................................................................................................................................... 11 Complicating Factors ............................................................................................................................... 15 References .............................................................................................................................................. 24 II. Assessing Your Patient with Cognitive Impairment (Memory and Thinking Problems) ......................... 25 Neuropsychologic Screening and Assessment ....................................................................................... 26 Nursing Assessment in the Presence of Cognitive Impairment .............................................................. 28 Physical Assessment in the Presence of Cognitive Impairment ............................................................. 31 References .............................................................................................................................................. 34 III. Providing Education and Support From Hospital to Home .................................................................... 35 Discharge Planning ................................................................................................................................. 36 Understanding and Managing Common Behaviors Associated with CI in the Elderly ............................ 38 From Hospital to Home: Educating Families on Day to Day Issues ....................................................... 43 Advance Care Planning and Assessing Capacity ................................................................................... 46 Additional Resources............................................................................................................................... 50 References .............................................................................................................................................. 51 IV. Enhancing Care Coordination ............................................................................................................... 53 Case Study: Parkinson's Disease Dementia ........................................................................................... 54 V. Building on the Foundation: Managing Memory Impairment .................................................................. 59 Appendix ..................................................................................................................................................... 60 Module Questions Answer Guide ............................................................................................................ 60 Dementia and Delirium Pre-Test ............................................................................................................. 61 Dementia and Delirium Pre-Test Answer Guide ..................................................................................... 71 Understanding Cognitive Impairment - Proficiency Questions ................................................................ 73 Understanding Cognitive Impairment - Answer Guide ............................................................................ 79 Assessing Patient Risk for Cognitive Impairment - Proficiency Questions ............................................. 80 Assessing Patient Risk for Cognitive Impairment - Answer Guide ......................................................... 83 Hospital to Home: Educating and Supporting Patient and Family - Proficiency Questions .................... 84 Hospital to Home: Educating and Supporting Patient and Family - Answer Guide ................................ 87 Building on the Foundation: Managing Memory Impairment - Imagine If...Thinking Outside the Box .... 88 University of Pennsylvania School of Nursing
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IntroducingEnhancingCareCoordinationinthePresenceofMemory
andThinkingProblems:AWeb‐BasedEducationProgram
Purpose: To enhance the health and quality of life of cognitively impaired older adults, enrich
the experience of caregivers, and decrease the use of unnecessary acute care services.
Background. This Web-Based Education Program, "Enhancing Care Coordination in the
Presence of Memory and Thinking Problems," is made possible through generous support from
the Marian S. Ware Alzheimer Program at the University of Pennsylvania and the National
Institute on Aging, National Institutes of Health (R01 AG023116).
This innovative clinical project will compare the effects of interventions of varying intensities
across the three University of Pennsylvania Health System (UPHS) hospitals. Each intervention
is designed to improve outcomes of hospitalized cognitively impaired older adults and their
caregivers.
The project will:
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Develop and test interventions to enhance care coordination of cognitively impaired older
adults.
Evaluate the effects of interventions on quality and cost outcomes.
Disseminate findings to inform changes in clinical practice and health care policy.
Presbyterian Medical Center is implementing the Resource Nurse Care Intervention, which
includes this web-based education program for staff nurses and nurse specialists. It will equip
them with a broader understanding of the many variables involved in enhancing care
coordination for cognitively impaired older adults and their caregivers. Participation in the
program will improve the Resource Nurse's ability to promote patient and caregiver adaptation to
change across settings and in the presence of acute and chronic illness. Improved
communication among and between staff, providers, patients, and caregivers will be influenced
dramatically in this intervention as a result of the model for organizational involvement.
Program Mission. To improve the care and management of cognitively impaired hospitalized
older adults, facilitate their transition from hospital to home, and enhance the interactions
between and among their care providers.
This program contains five sections:
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2.
3.
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5.
Understanding Cognitive Impairment
Assessing Patient Risk for Cognitive Impairment
Hospital to Home: Educating and Supporting Patient and Family
Enhancing Care Coordination: Pearls for Practice
Building on the Foundation: Managing Memory Impairment
Before proceeding with the first section, please review the program objectives by clicking on the
first subsection under the heading for this page, Course Home, titled "Program
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Objectives," which is located on the left side of the screen. Further directions can be found
there.
Program Objectives
In this Web-Based Education Program, “Enhancing Care Coordination in the Presence of
Memory and Thinking Problems,” you will explore information regarding the care of older
adults with cognitive impairment. The term cognitive impairment will be used interchangeably
with memory and thinking problems. Cognitive impairment is the term we use to discuss the
dysfunction experienced by patients with dementia and/or delirium who have memory and
thinking problems. We hope you will apply the information provided and the knowledge
obtained via the case studies in your clinical setting.
This web-based education program will enable you to:
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Understand dementia and delirium.
Utilize appropriate tools in the measurement of dementia and related issues such as
depression, pain, and self-care abilities.
Improve your ability to assess and manage hospitalized elders with cognitive impairment,
and implement methods to lessen the effects of dementia and delirium in the hospital
setting.
Promote optimal transition of older adults with any form of cognitive impairment from
the hospital setting to home; tailoring necessary support and guidance for caregiver.
Promote cognitively impaired older adults' adaptation to change across settings in the
presence of acute and chronic illness.
Promote collaboration on best practices for cognitively impaired elders among your
health care team, sharing knowledge with Physicians, nursing assistants, social workers,
discharge planners, and other involved care providers.
After the completion of this Web-Based Education Program you should be equipped to better:
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Understand cognitive impairment (memory and thinking problems) in the elderly.
Assess patients with cognitive impairment (memory and thinking problems).
Support and guide the cognitively impaired hospitalized patient and his or her caregiver.
Improve overall care coordination from hospital to home for this population.
Manage the care and complex needs of older adults with memory and thinking problems.
Our objectives in having you participate in this study and complete this webbased education program include:
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Providing guidance and support for your practice and the practice of your team in
providing care for this vulnerable population.
Provide you with population specific techniques and strategies to:
- Enhance care management and decision making.
- Guide collaboration with caregivers on discharge plan.
- Coordinate, consult, and collaborate in developing and implementing an individualized
plan of care.
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- Facilitate transition from hospital to home.
- Provide you with the fundamentals necessary to influence other providers.
Q & A. If you have questions, concerns, or comments regarding the content of this course,
please click on Q&A in the left navigation area under Course Home. You may post your
questions at any time. This Q&A threaded discussion area will be monitored on Mondays,
Wednesdays, and Fridays and questions will be answered by 5:00 p.m. on those days.
Navigating the Web Based Training Module. This module should be completed in a stepwise
fashion. To proceed from one section to the next, you will need to click on the topics in
the column to the left. The section you are currently working on will have a circle around the
black bullet to the left of the title. There are no arrows or buttons at the bottom of each section to
lead you into the next section, so you will need to manually open each section.
Next Step...Click on "Pre-Test." The Pre-Test must be completed before moving on with the
rest of the modules. Once you have completed the Pre-Test, click "Understanding" on the left
side of the screen to begin the first module. You will need to click on each individual subheading under the titles of the modules to move from one topic to the next.
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I.UnderstandingCognitiveImpairment
Cognitive Impairment (CI) among older adults hospitalized for a common medical or surgical
condition is associated with increased mortality and morbidity. These patients typically
experience prolonged hospital stays, higher rates of complications, delayed rehabilitation,
increased hospital readmissions and higher health care costs. In a rapidly aging society, the
prevalence of dementia and delirium, the most common causes of CI, is expected to increase
dramatically. This presents us with a challenge and an opportunity to explore interventions
aimed at improving the care management of cognitive impairment and comorbid conditions in
hospitalized cognitively impaired older adults.
Cognitive Impairment (CI) in the Older Adult. Cognitive impairment in the elderly is
associated with multiple causes and effects. The memory and thinking problems associated with
cognitive impairment and resulting from some form of dementia and/or delirium are often
difficult to diagnose. The goal of this section of the program is to present you with a broad
overview of many of these causes and some of their effects.
Topics to be covered in this program include:
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Dementia
o Alzheimer's disease
o Frontotemporal dementia
o Lewy body dementia
o Vascular dementia
Delirium
o Superimposed on dementia
Complicating Factors
o Depression
o Comorbid conditions
o Nutrition issues
o Polypharmacy
o Alcohol use
Measurement Tools
o Mini Mental Status Exam (MMSE)
o Lawton’s Instrumental Activities of Daily Living
o Katz Activities of Daily Living
o Confusion Assessment Method-diagnostic Algorithm (CAM)
o Symptom Bother Scale
o Center for Epidemiologic Studies Depression Scale (CES-D)
o Geriatric Depression Scale
o Cornell Scale for Depression in Dementia
o Checklist for Nonverbal Pain Indicators
o Mini Nutritional Assessment (MNA)
Evaluation, Prevention, and Treatment Options
Proficiency Questions
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WhatisDementia?
Dementia is marked by a slow and progressive decline in intellectual functioning; often affecting
memory, thinking, concentration, perception, and problem solving. The intellectual and mental
decline interferes with your patient's overall thought process and impairs "usual" performance.
Clinical features often include impaired long- and short-term memory and/or thinking problems
without impairment of consciousness.
The neurodegenerative dementias we will focus on in this program are Alzheimer’s disease,
frontotemporal dementia, Lewy body dementia, and vascular dementia. Realize however that
your patients may have more than one type of dementia co-existing. An example: a patient with a
history of cardiovascular disease may have vascular dementia as well as Alzheimer's disease.
Review the "try this" link below for:
http://consultgerirn.org/uploads/File/trythis/try_this_d5.pdf
Alzheimer’s Disease (AD)
AD is the most common cause of dementia and represents up to 75% of all cases. It is estimated
that 4.5 million Americans are diagnosed with Alzheimer's disease. Onset of Alzheimer's disease
typically occurs in the sixth decade of life or later.
Check out the Alzheimer's Association Fact Sheet about AD:
http://www.alz.org/alzheimers_disease_facts_and_figures.asp
The primary features of dementia your patient with Alzheimer's disease will exhibit:
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Gradual progression
Memory impairment
At least one of the following:
o Aphasia (language disturbance)
o Apraxia (inability to carry out motor activity)
o Agnosia (failure to identify objects)
o Disturbance of executive function (planning, organizing and/or sequencing)
Julia, the nursing assistant assigned to work with you and your patient, Mr. Wilson, in room 12
has just approached you saying, “Mr. Wilson sure is unhappy. He keeps trying to ask me for
something, but cannot seem to find the word, then he yells at me and tells me to leave.”
Knowing that Mr. Wilson has the documented history of a "poor short term memory," and
knowing what you do about the primary features of Alzheimer’s disease, how might you respond
to Julia’s comment?
You might say,” Mr. Wilson has memory and thinking problems, and is having difficulty with
language (agnosia); I am so glad that you told me about the conversation you had with Mr.
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Wilson, because we can assess him further for Alzheimer’s disease. This is particularly
important because his confusion can worsen while he is here in the hospital under our care.”
In further assessing Mr. Wilson for Alzheimer’s dementia, you can consider the staging of the
dementia. Reviewing the staging will give you an understanding of the course of dementia and
augments a mental status assessment. The staging is associated with the patient’s functional,
behavioral, cognitive and communication abilities; changes in some or all of these abilities result
in the decline of social and occupational performance seen with AD.
Below are the five stages of AD. When reviewing the stages, be aware people experience loss at
uneven rates, and it may appear that a person "skips" a step, or lingers for a long time at a certain
stage. The point is that the brain is complex, and each person with Alzheimer's disease presents
differently.
Mild stage
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Self-sufficient in all or most of the Instrumental Activities of Daily Living (IADL).
Independent in Activities of Daily Living (ADLs).
Recognizes and communicates with family members.
Generally the “same” person as before the disease but less engaged.
Moderate stage
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Independent in feeding and transferring, assistance needed in other ADLs.
IADL dependent or assistance needed.
Problems with recognizing and communicating with family.
Substantial memory loss.
Behavior problems emerge – psychotic symptoms, wandering, sleep disturbance, physical
agitation.
Severe stage
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ADL dependent, assistance with feeding and transferring, IADL dependent.
Cannot consistently recognize or communicate with family.
Inability to focus on task.
Behavior problems may improve in this stage.
Patient is likely described as “a different person.”
Profound stage
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Dependent in IADL & ADL.
Significant problems with recognition and communication.
Markedly different personality.
Repetitive vocalizations, calling out, more passive.
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Terminal stage
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Dependent in IADL & ADL.
Ten percent or more weight loss, stage III pressure sore, UTI, or aspiration pneumonia.
Impressionistic communication.
Frontotemporal dementia (FTD)
FTD occurs with the degeneration of the frontal and temporal lobes of the brain, which control
speech and personality. This degeneration occurs in a variety of rare brain disorders; (some
examples: Pick's disease, Creutzfeldt-Jakob disease and ALS). People with FTD usually show
personality changes first. As the disease progresses, speech and behavior, and eventually
memory may also be affected. FTD most often occurs in adults between the ages of 40 and 64.
Your patient with FTD may exhibit:
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Uninhibited and socially inappropriate behavior.
Inappropriate sexual behavior.
Loss of concern about personal appearance and hygiene.
Compulsive eating and oral fixation.
Apathy, lack of motivation, lack of concern for others.
Speech and language problems.
Memory loss.
Mrs. Howard is admitted to your unit to rule out sepsis. She is pulling her hospital gown up over
her head and grabbing George, the nursing assistant's buttocks. Her behavior and the things she
says may initially indicate a psychiatric illness and prompt a referral to a psychiatrist. A
psychiatrist may be able to assist in modifying some of the behaviors with medications, but the
underlying brain degeneration is not yet treatable. You could suggest consultation with a
neurologist specializing in Dementia/FTD with your health care team.
Frontotemporal dementia (FTD) vs. Alzheimer's: What's the difference?
Type of
Dementia
Age at which
it usually
Areas of the brain affected
starts
FTD
In early stages, personality and
Primarily the frontal and
Between ages
behavior changes.
temporal lobes, which control
40 and 64.
In later stages, loss of memory,
speech and personality.
motor skills and speech.
Alzheimer's
After age 65.
Often starts in the medial
temporal lobe but eventually
affects the whole brain.
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Progression
In early stages, increasing and
persistent forgetfulness.
In later stages, personality and
behavior problems, possibly
hallucinations and delusions.
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Link to more information about FTD: http://www.mayoclinic.com/health/frontotemporaldementia/DS00874
Lewy Body Dementia (LBD)
LBD disease is differentiated from AD by early visual hallucinations, fluctuating cognition, and
Parkinsonian motor deficits. The Lewy bodies, or concentric hyaline intracytoplasmic inclusions,
are also found in Parkinson disease.
Your patient with LBD may exhibit:
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Gait disorder, resting tremor, postural instability, and orthostatic hypotension.
Visual hallucinations.
Fluctuation in their attention or alertness.
Your patient with LBD may also experience:
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Difficulty sleeping.
A predisposition to syncope and falls.
Specific tips for bedside assessment and management for your patient with LBD:
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Falls risk assessment.
Orthostatic blood pressure monitoring.
Physical Therapy consult to maintain function in presence of acute illness.
Having a family member close at hand.
Parkinson's disease (PD), Alzheimer's disease and Lewy body dementia are often interrelated as
demonstrated by the overlap in features and in presentation.
The overlapping pathophysiology of these diseases is one of the reasons it is often difficult to
distinguish between and among these complex neurodegenerative disorders.
Vascular Dementia (VaD)
VaD is caused by a decreased blood flow to the brain. Individuals with hypertension, diabetes,
hyperlipidemia, heart disease, or peripheral vascular disease are at increased risk for vascular
dementia. Patients who have experienced a cerebral vascular accident (CVA) or stroke, or have a
history of transient ischemic attacks (TIAs), experience decreased blood flow to the brain and are
very likely to develop VaD. You may also hear the term "multi infarct dementia," which refers
most often to patients with CVAs or TIAs.
Your patient with Vascular Dementia may exhibit:
• An abrupt onset of memory impairment and cognitive changes.
• Evidence of stroke - focal neurologic signs on physical exam or neuroimaging exam.
• Gait dysfunction with falls.
• Progressive deterioration.
• Moodiness or sudden personality changes.
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Dementia and Delirium Education Modules © 2006
WhatisDelirium?
Delirium is an acute reversible syndrome that can be described by the following features:
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Acute change in baseline mental status developing over hours or days.
Fluctuating symptoms throughout the day.
Inattention.
Altered level of consciousness.
Delirium is diagnosed when an individual demonstrates an acute change in attention and
cognition. As delirium decreases your patient's ability to think and function, it increases the
length of hospitalization, as well as the incidence of long-term care placement and mortality, for
up to 12 months following hospital discharge.
The strongest risk factor for the development of delirium is dementia; 25% to 75% of patients
with delirium have dementia. Delirium affects approximately 40% of hospitalized elderly
patients and the risk for delirium increases in patients who are in intensive care or those with
terminal medical conditions. Although delirium and dementia have seemingly similar effects,
delirium represents an acute medical condition that requires immediate attention.
If you had to describe delirium, which of the following statements would you choose?
a. Delirium is a chronic condition requiring close monitoring in the hospital setting.
b. Delirium is an irreversible condition, which can occur in older adults after they receive
anesthesia.
c. Delirium is an acute reversible syndrome, which can occur in any setting.
Answer Guide: Page 60
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Here is a table describing some of the implications delirium might have on patient, family, and
staff:
Other implications of delirium are:
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Increased morbidity and mortality.
Higher rates of complications.
Increased length of hospital stay.
Delayed initiation of rehabilitation.
Higher rates of rehospitalization.
Higher rates of nursing home placement.
Delirium can be caused by:
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An infection such as a urinary tract infection or pneumonia.
Electrolyte imbalance.
Substance intoxication (alcohol and/or drugs).
Substance withdraw.
A change in the patient's environment or normal surroundings.
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Risk factors for delirium in the hospitalized elderly include:
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Advanced age (especially > 80 yrs. old).
Nursing home residence.
Pre-existing cognitive impairment.
Pre-existing depression.
Previous episode of delirium.
Multiple comorbid conditions.
Severity of comorbid conditions.
Renal insufficiency.
Visual and hearing impairments.
Decreased functioning (decreased mobility/physical activity).
Dehydration and/or malnutrition.
Pain.
History of alcohol or substance abuse.
Sleep deprivation.
Bladder catheters and other tubes.
Environmental factors.
Low cardiac output.
Peri-operative hypotension.
Postoperative hypoxia.
Medications (Table 39-1).
Delirium Superimposed on Dementia (DSD)
As you know, delirium often occurs on top of an existing dementia, and the two conditions can
be difficult to separate. The goal is to reverse the delirium; returning the patient to his or her
baseline. Patients admitted to the hospital with existing cognitive impairment are at increased
risk for developing delirium. The characteristics of the condition are the same as those for
delirium, but when the patient returns to his or her baseline, evidence of memory or thinking
problems will remain. Review the "try this" link below. It will provide you with more
information and a great algorithm for assessing and managing delirium.
As a nurse, you are in a unique position to directly impact these negative outcomes through early
identification and intervention. Collaboration is vital to an efficient and effective care process;
ultimately to your patient's ability to achieve the best possible outcome. As a health care
provider, working together to share your unique knowledge with each member of the care team:
from social workers, discharge planners, physicians and nursing assistants, to home care nurses
and family caregivers, you will make a difference enhancing the care coordination for older
adults in the presence of memory and thinking problems.
Can you take a minute and think about the last patient you worked with who demonstrated signs
and symptoms of delirium....
What were the early indicators of a problem?
How did you deal with the situation?
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What went right?
What would you change, if anything?
By now you should realize that patients who are older, sicker, and cognitively impaired are the
most vulnerable to delirium. The best delirium management strategy is to prevent it from
happening in the first place. But if it happens....early identification is the key!
http://consultgerirn.org/uploads/File/trythis/try_this_d8.pdf
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ComplicatingFactors
There are several factors that can complicate the picture of dementia, make it difficult to
recognize, and at times seem worse than it really is. Some examples of complicating factors are
comorbid conditions, depression, nutrition issues, polypharmacy, and alcohol use. This is not a
comprehensive list of complicating factors, but the ones presented are the most common. If you
can remember these factors and take them into consideration when caring for a patient with
cognitive impairment, you will be able to get at the root of the problem more quickly and have
some time to implement interventions before the patient is discharged. The patient's family will
surely thank you, because most complicating factors are issues that were present prior to
hospitalization.
Comorbid Conditions
You already know that older patients have multiple chronic conditions. When these conditions
begin to impact each other, they are called comorbid conditions. Some comorbid conditions can
present with the symptom of confusion, but in an older person with dementia, it can appear that
they are delirious. The following conditions can cause confusion: heart failure, hypoxia, thyroid
disorders, anemia, infections, and depression. Treating these underlying disorders will usually
help clear up confusion or delirium, so that the patient's true mental status can be assessed.
Cognitive impairment makes some chronic conditions difficult to treat because the patient cannot
clearly express his symptoms, and the patient may not fully comply with the treatment regimen,
even though it was explained.
Just a quick reference to keep in mind.
The eight most prevalent chronic conditions in older Americans are:
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Arthritis
Hypertension
Heart disease
Respiratory disease
Diabetes
Cancer
Cerebrovascular disease
Atherosclerosis
The ten most common causes of hospitalization in the elderly are:
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Heart disease
Cancer
Cerebrovascular disease
Pneumonia
Fractures
Bronchitis
Osteoarthritis
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Diabetes
Diseases of the nervous system
Prostate hyperplasia
Notice any overlaps? A patient with dementia AND any one of these conditions is likely to have
a more difficult time recovering from hospitalization than would a person without dementia.
Depression
There is a very high degree of association between depression and dementia, and it is a common
misconception that depression is a normal consequence of aging. This is why depression
deserves specific mention in understanding dementia, particularly as a complicating factor.
Older adults experience changes in their physical capabilities, personal relationships, and living
situations, just to name a few. These changes can lead to depression. But at the same time,
depression can lead to dementia. Confused yet? These conditions, along with delirium, often
overlap, making exact diagnosis difficult. Further, there may not be one specific diagnosis. A
patient with cognitive impairment or delirium may already have underlying depression, or may
be at risk for depression in the near future.
The initial signs that something is wrong may be cognitive in nature, such as forgetfulness,
confusion, or generalized sadness. These signs can sometimes be construed as dementia.
Conversely, the patient may truly have dementia, and may be experiencing depression from the
recognition of recent losses.
The take home message is that depression can make underlying dementia appear worse than it is,
but if treated, the patient's true level of cognitive impairment can be ascertained. This may not be
accomplished during the acute hospital stay, but you can suggest further work-up after discharge
to the patient, family member, social worker, or doctor.
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Here is a quick comparison of the classic "3 D's":
Characteristics of Delirium, Depression, and Dementia
Characteristic
Delirium
Depression
Onset
Sudden
Recent
Course over 24hrs
Fluctuating
Stable
Consciousness
Reduced
Clear
Alertness
Variable
Normal
Psychomotor Activity
Variable
Variable
Duration
Hours to weeks
Six wks.-years
Attention
Fluctuates
Little impairment
Orientation
Usually impaired Usually normal
Speech
Often incoherent
May be slow
Affect
Variable
Flat
(Rapp, 2001)
Dementia
Slow
Fairly stable
Clear
Generally normal
Normal
Months to years
Generally normal
Often impaired
Difficulty finding words
Labile
Nutrition Issues
Mr. Ditmar is an 86 year old man who was widowed three years ago. Before his wife died, he
spent a year caring for her as well as himself. After she passed, Mr. Ditmar experienced some
depression, but was still able to go shopping, cook for himself, pay his bills, and do his own
laundry. Having no family nearby, his relationship with his neighbors, whom he has known for
decades, strengthened. Over the past year his neighbor, Joe, has become concerned because Mr.
Ditmar appeared to be losing weight. One day in August, Joe went to visit Mr. Ditmar. When Joe
rang the bell, Mr. Ditmar yelled at him to go away. Joe proceeded to enter and found Mr. Ditmar
confused and agitated. The house was disheveled and the refrigerator was empty. Joe was able to
calm Mr. Ditmar down and coax him into a cab to go to the hospital. You are now caring for
him, with an admit diagnosis of dehydration.
Elderly patients with CI are particularly vulnerable to poor nutrition. Nutritional intake declines
with normal aging and is correlated to a decrease in muscle mass and activity. Elders with CI
usually drink less, putting them at risk for dehydration. At the same time, dehydration can
worsen CI.
In addition, many elders restrict fluid intake in an effort to prevent incontinence. This leads to a
cycle of dehydration, confusion, orthostatic hypotension, limited mobility and possibly falls.
What do you think is going on with Mr. Ditmar? His diagnosis is dehydration, but based on your
reading up to this point you see more. That's right, he has acute delirium most likely brought on
by dehydration and anorexia. But you also know that his history of depression is an underlying
risk factor. See how a nutritional issue can be so complex?
Polypharmacy
You are doing the admission assessment for Mr. Cassidy, with his wife present. He does not
know the names of his medications, but knows that he takes one for blood pressure and one for
his prostate. Mrs. Cassidy interjects and tells you that her husband has been up during the night a
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lot lately and when she tries to lead him back to bed, he is disoriented and says, "Leave me
alone." Mrs. Cassidy mentioned this to Mr. Cassidy's doctor on his last visit for blood pressure
follow-up, and the doctor prescribed a medication to help him sleep through the night. Mr.
Cassidy has taken the medication for only three nights when he had an early morning fall. Mrs.
Cassidy tells you that when she found him, he was complaining of dizziness, so she called 9-1-1.
Mr. Cassidy now has no recollection of the fall, and does not know where he is.
Polypharmacy describes not only the number of medications a patient takes, but also the
chemical combination of medications. Approximately 80% of community dwelling older adults
take at least one medication to manage a chronic medical condition; the number of medications
increases with age and presence of co-morbid disease. Whenever a medication is added to an
existing regimen, it can have a deleterious effect. This holds true for herbal and over the counter
medications too. When the patient is admitted to the hospital for an acute event closely following
a medication change, seriously consider polypharmacy as the cause of delirium.
Once the patient is in the hospital, he or she will probably be given many different medications
in a short period of time, and is at constant risk for polypharmacy. Hospitalized elders receive an
average of 10 medications. Of course, the risks associated with polypharmacy are augmented in
the patient with existing cognitive impairment. Further, prescription medications such as
anticholinergics, sedative-hypnotics, and narcotics are known to cause acute delirium in the
elderly. Because you cannot watch the patient constantly, educate the nursing assistant and any
visiting family members about signs and symptoms of polypharmacy for the medications the
patient is currently receiving.
Alcohol Use
Alcoholism in the elderly is often overlooked in the clinical setting and can have a significant
impact on cognitive function. Chronic alcoholism can cause dementia, so it is important to
breach this sensitive topic with your patients. Tell them that the more they open up and answer
your questions, the better you can help them. Alcoholism affects up to 16% of men and 8% of
women over the age of 65, and it is estimated that 20% of patients hospitalized in medical
surgical units have alcohol related health problems. Furthermore, withdrawal from alcohol can
cause delirium.
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MeasuringToolsforCI
As a nurse in the hospital, you probably assess your patient’s cognitive function by ascertaining
his or her orientation to person, place and time. This is very useful qualitative information, but at
times a more quantitative or measurable assessment needs to be done.
Here are some tools that can enhance your current assessment and assist in addressing the needs
(across continuum) of the older adult with memory and thinking problems and their caregiver:
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Mini Mental State Examination (MMSE)
The MMSE is a widely used tool consisting of 11 questions that measure orientation to time and
place, recall ability, short-term memory and arithmetic ability in elderly patients. The MMSE
total score ranges from 0 to 30 and reflects the number of correct responses. In general, scores >
23 indicate intact cognition, 20-23 mild impairment, 19-12 moderate impairment and <12 severe
impairment. This instrument is easily administered, well tolerated, and can be completed within
five to ten minutes. Link to handout: http://www.minimental.com/
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Lawton’s Instrumental Activities of Daily Living (IADLs)
Lawton's IADL is designed to measure the patient’s ability to perform money and medication
management, shopping, and household chores. Lower scores mean lower functioning. It takes
five minutes to administer. Link to handout:
http://consultgerirn.org/uploads/File/trythis/try_this_23.pdf
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Katz Basic Activities of Daily Living (BADLs)
The Katz BADL is used to measure the patient's ability to perform self-care as assessed by an
interview with caregivers. This six-item instrument, which takes five minutes to administer,
assesses independence or dependence in the activities of bathing, dressing, toileting, transferring,
continence and feeding. Scores range from 0-6, with lower scores indicating more disability.
Link to handout: http://consultgerirn.org/uploads/File/trythis/try_this_2.pdf
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Confusion Assessment Method-Diagnostic Algorithm (CAM)
The CAM is a four-item diagnostic algorithm that enables clinicians without formal psychiatric
training to quickly and accurately identify delirium in hospitalized older adults. Patients are
identified as positive for delirium if three of the four following elements are present as reported
by caregivers (acute onset and fluctuating course, altered level of consciousness, disorganized
thinking, and inattention). Link to handout:
http://consultgerirn.org/uploads/File/trythis/try_this_13.pdf
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Symptom Bother Scale
The Symptom Bother Scale measures the presence and severity of 13 physical symptoms
typically associated with aging or chronic illness. Patients will rate the degree to which they were
bothered by each symptom on a 0 to 3 scale, with higher scores indicating worse symptoms.
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Center for Epidemiologic Studies Depression Scale (CES-D)
The CES-D measures caregiver depression because caregivers are expected to be both younger
and older adults. The scale has been tested with general population and clinical samples. Twenty
items are rated on a four-point scale indicating the degree of their occurrence during the last
week.
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Geriatric Depression Scale
The Geriatric Depression Scale is a basic measure for depression in older adults. In its original
form it is thirty questions long. An abbreviated 15 question form is an especially helpful tool for
use in the hospital setting. Link to handouts:
Short Version of Geriatric Rating Scale (15 items) http://www.stanford.edu/~yesavage/Testing.htm
Original version of Geriatric Depression Scale (30 items) http://consultgerirn.org/uploads/File/trythis/try_this_4.pdf
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Cornell Scale for Depression in Dementia (CSDD)
For patients with more than mild dementia, the Cornell Scale for Depression in Dementia
(CSDD) can be used to determine the presence of depression. It is a 19-item scale that has been
validated specifically for detecting depression in patients with dementia. One clinician gathers
information from the caregiver, makes observations of the patient, and interviews him if
possible. The final score is based on the clinician’s judgment. A score of six or higher is
indicative of depression.
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Assessing Pain in Older Adults with Dementia
Cognitively impaired older adults are often under-treated for pain. As with all older adults, those
with dementia are at risk for multiple sources and types of pain. Untreated pain in CI older adults
can delay healing, disturb sleep and activity patterns, reduce function, reduce quality of life and
prolong hospitalizations.
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Assessing Nutrition in Older Adults
The Mini Nutritional Assessment (MNA) is an 18-item scale designed to assess nutrition in older
adults. Link to handout: http://consultgerirn.org/uploads/File/trythis/try_this_9.pdf
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In the outpatient setting a dementia evaluation would consist of:
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History of present illness (includes duration, symptoms, exacerbating or alleviating
events, treatments, current psychiatric symptoms, sleep, concentration, changes in
personality or socialization, energy, irritability, inappropriate behaviors, stressors,
supports, etc.).
Safety assessment (getting lost, aggression, fire, wandering, falls, etc.).
Functional status assessment (driving, cooking, finances, social contacts, Activities of
Daily Living [ADL], Instrumental Activities of Daily Living [IADL], etc.).
Past medical history
Medications
Psychiatric history (an assessment of depression is integral).
Social history
Family history
Mental status examination: (includes presentation, appearance, eye contact, alertness,
behavior, posture, movement, cooperation, speech, vocabulary, mood, affect, psychotic
symptoms, suicidal or homicidal ideations, thought content, thought process, judgment,
insight, impulse control, Folstein MMSE or Functional Assessment Staging Test (FAST http://www.acsu.buffalo.edu/~drstall/fast.html) and Physical Self-Maintenance Scale).
Physical and neurologic examination
Review of symptoms (especially ambulation, constipation, urinary incontinence, hearing
or vision deficits, dentition and pain).
Laboratory Tests (screening for reversible causes of Dementia).
B12 and folate
Thyroid profile
Complete blood count
Comprehensive metabolic panel
Urine culture and urinalysis
Diagnostic Tools
Once the initial evaluation for dementia is completed and causes of reversible delirium or
dementia have been ruled out or successfully treated, neuroimaging can be performed. This will
allow the clinician to rule out conditions like normal pressure hydrocephalus, brain lesions,
stroke, or subdural hematoma.
There are two basic approaches to brain imaging, structural and functional. Structural imaging
includes MRIs and CT scans, and functional imaging includes PET scans and functional MRIs.
While MRIs and CT scans are frequently used in the workup for Alzheimer's disease, the value
of functional imaging in the diagnosis and treatment of dementia is a current topic in this field.
Take the Alzheimer's Association's Inside the Brain: Interactive Tour
(http://www.alz.org/braintour/3_main_parts.asp). The Brain Tour explains how the brain works
and how Alzheimer's affects it.
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Preventative Measures Prior to Onset of Symptoms
Dementia is a frightening disease, and obviously those who do not yet have any signs and
symptoms would like to do all they can to prevent it. This is especially true for family members
and friends of those who are currently suffering with dementia. Although significant strides have
been made in the ability to diagnose and treat conditions such as Alzheimer's disease, only basic
information is available on preventative measures.
Research shows that there is a strong link between head injury and development of Alzheimer's
disease. Therefore, you can prevent head injury by wearing seatbelts and helmets when
appropriate, and minimizing the risk of falling. Other ways to keep your brain healthy are a
healthy diet, stay socially active, avoid tobacco and excess alcohol, and exercise regularly.
Lastly, brain health is closely linked to heart health, so keeping tabs on your blood pressure and
cholesterol are more important than you may have thought.
Preventative Measures After Onset of Symptoms
Once a person is in the early stage of dementia, some things can be done to slow the progression
of the disease. This will be important for you to know, so that you can educate and support
family members and patients themselves, who still have substantial self-care abilities. Simple
steps such as making sure hearing aids and dentures are in place, and that glasses are clean and
have the correct prescription lenses, will minimize challenges to the sensory system. Also, if the
patient has been putting off cataract surgery, educate him or her that this is a good time to have
the procedure.
Whether the patient is in the hospital or at home, try to create familiar surroundings. Sometimes
family members feel helpless when a patient is in the hospital, so tell them that bringing in
pictures or small objects from home can help prevent worsening dementia or delirium in the
hospital. If possible, allow the patient to wear familiar personal items such as a baseball cap or a
robe. At home, tell family members not to rearrange the house too much, as people with memory
impairment depend on normalcy.
Here are some other helpful hints to help minimize confusion:
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Leave lights on at night to reduce disorientation (this may or may not be helpful,
depending on the patient's regular habits regarding use of night lights, as it could interfere
with the patient's circadian rhythm).
Keep the activity schedule simple and as regular as possible, try not to introduce too
many new activities at once.
Practice subtle reminders of orientation, such as "isn't it a beautiful Sunday morning?"
Be sure that physiologic needs are met, for example, bowel and bladder management,
regular meals, and pain control.
Treatment Options
It is common for patients in the moderate stage of dementia and later in the early stage to
experience aggressive or agitated behavior. This behavior is distressing for families, but it is
important for them to realize that it is also distressing to the patient.
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If the above interventions are not completely successful in alleviating behavioral symptoms,
medications can be used. It is common for both patients and families to have a negative feeling
toward medications, so your support in helping them realize that low doses of medications,
administered under the careful watch of a physician, can relieve many of the symptoms
associated with early dementia and also decrease stress on the caregiver.
Possible medications for this use include the following:
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Anti-psychotics, given at night to improve sleep and decrease night time awakening.
Serotonin-affecting drugs (trazodone, buspirone) to alleviate depression.
Dopamine blockers (haloperidol, risperidal, olanzapine, clozapine) to help control
agitation and aggression.
Fluoxetine, imipramine, or Celexa to help stabilize mood.
Stimulant drugs (such as methylphenidate) to increase activity and spontaneity.
For patients who have good insight into their condition, psychological counseling can be helpful
to help combat depression. Psychological counseling is also useful for caregivers. Formal
psychiatric treatment, however, is not commonly recommended for patients with dementia.
There are several medications that are currently approved for the treatment of mild to moderate
Alzheimer’s disease. They work by inhibiting the breakdown of acetylcholine, a neurotransmitter
that becomes deficient in the brain of a person with AD. Although these drugs do not slow
progression of the underlying disease process, they may temporarily stabilize or delay worsening
of memory problems and other cognitive symptoms. Some examples of these medications are:
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Donepezil (Aricept)
Rivastigmine (Exelon)
Galantamine (Razadyne, formerly called Reminyl)
Keep in mind that although these medications are promising, they are not for all patients. They
have side effects such as nausea and vomiting, diarrhea, sleep and appetite disturbance, and they
can also increase the risk of bleeding in patients with existing or healed stomach ulcers.
For moderate to severe Alzheimer's disease, a medication called memantine (Namenda) works
by blocking glutamate, a chemical in the brain that has been linked to the development of AD. It
may help improve or maintain certain daily functions and patients may have better awareness
with its use. However, this medication is also not without side effects. Side effects can be
fatigue, pain, dizziness, headache, joint pain, or more severely, mood changes, swelling of hands
and feet, or shortness of breath.
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References
American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental
Disorders. (4th ed.) Washington, DC: Author.
Arnold, E. (2005). Sorting out the 3 D's: Delirium, dementia, depression. Holistic Nursing
Practice, 19(3), 99-105.
Boxer, P. & Shorr, R. (2004). Principles of Drug Therapy: Changes with Aging, Polypharmacy,
and Drug Interaction. In C.S.Landefeld, R.M.Palmer, M.A.Johnson, C.B.Johnston, & W.L.Lyons
(Eds.), Current Geriatric Diagnosis and Treatment (pp. 421-435). New York: McGraw-Hill.
Campbell, J. W. (2004). Use of Alcohol, Tobacco, and Nonprescribed Drugs. In C.S.Landefeld,
R.M.Palmer, M.A.Johnson, C.B.Johnston, & W.L.Lyons (Eds.), Current Geriatric Diagnosis
and Treatment (pp. 407-413). New York: McGraw-Hill.
Clark, C. M. (2000). Dementia: Diagnosis and Management. In M.B.Stern, M.J.Brown,
S.L.Galetta, & A.K.Asbury (Eds.), (pp. 205-261). Irvington, NY: AlphaMedica Press.
Cotter, V. T. (2002). Dementia. In V.T.Cotter & N.E.Strumpf (Eds.), Advanced Practice Nursing
with Older Adults, Clinical Guidelines (pp. 183-199). New York: McGraw-Hill.
Federal Interagency Forum on Aging-Related Statistics (2004). Older Americans 2004: Key
indicators of well-being Washington, DC: US Government Printing Office.
Johnson, L. E. & Sullivan, D. H. (2004). Nutrition and Failure to Thrive. In C.S.Landefeld,
R.M.Palmer, M.A.Johnson, C.B.Johnston, & W.L.Lyons (Eds.), Current Geriatric Diagnosis
and Treatment (pp. 391-406). New York: McGraw-Hill.
Kurlowicz, L.H., Evans, L.K., Strumpf, N.E., & Maslin, G. (2002). A psychometric evaluation of
the cornell scale for depression in dementia in a frail nursing home population. American
Journal of Psychiatry 10, 600-608.
McNicoll, L. & Inouye, S. K. (2004). Common Disorders in the Elderly. In C.S.Landefeld,
R.M.Palmer, M.A.Johnson, C.B.Johnston, & W.L.Lyons (Eds.), Current Geriatric Diagnosis
and Treatment (pp. 53-59). New York: McGraw-Hill.
Rapp, C.G. (2001) Acute confusion/delirium protocol. Journal of Gerontological Nursing, 27(3),
21-25.
Schretzman, D. & Strumpf, N. E. (2002). Principles Guiding Care of Older Adults. In V.T.Cotter
& N.E.Strumpf (Eds.), Advanced Practice Nursing with Older Adults, Clinical Guidelines (pp. 525). New York: McGraw-Hill.
www.webmd.com. Retrieved August 23, 2005. Last updated 2007.
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II.AssessingYourPatientwithCognitiveImpairment
(MemoryandThinkingProblems)
In the Presence of Acute Illness
An accurate assessment of an older adult with cognitive impairment (CI) will help you develop
individualized and goal directed interventions so you can ensure a smooth transition from
hospital to home. When assessing the hospitalized older adult patient with cognitive impairment,
keep in mind that he or she may be experiencing numerous physical, functional and emotional
changes. It is part of your role to assist them in adapting to these changes, realizing some of these
changes may be short-term or temporary while others may be more permanent. Once
hospitalized, pain, sleep deprivation, bladder catheters, tubes, frequent room changes and the
lack of a clock or reading glasses may precipitate delirium in a patient with or without existing
memory and thinking problems and substantially complicate their ability to adapt.
The goal of this section is to familiarize you with the evaluation and assessment process for
patients with CI who are facing acute illness in the hospital.
The following topics will be covered in this session:
Neuropychologic Assessment and Screening
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Appearance
Activity Level
Emotional State
Insight and Judgment
Level of Consciousness
Speech and Language
Thought Content
Perceptual Disturbance
Nursing Assessment in the Presence of Cognitive Impairment
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Pain
Nutrition and Hydration
Fall and Fall Risk
Sleep Alterations
Incontinence
Physical Assessment in the Presence of Cognitive Impairment
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Cardiovascular
Pulmonary
Gastrointestinal
Genitourinary
Musculoskeletal
Skin
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NeuropsychologicScreeningandAssessment
You probably assess your patient’s neuropsychological status by asking a few basic questions,
usually within the course of normal conversation. If you detect some memory and thinking
problems, what do you do with that information? Does it alter the way you will care for the
patient? What about the patient’s ability to care for himself when he gets home?
Screening tools are useful for gauging a patient's mental status and were discussed in detail in
Section I. But it is important to remember that results may not reflect the patient's day-to-day
level of cognition due to the fact that the patient is facing an acute illness in an unfamiliar
environment. Furthermore, the patient may be without key personal items such as glasses,
dentures, hearing aid, cane, etc.
Your ability to assess for cognitive impairment will have a huge impact on your patient’s
outcome. You can assess your patient’s mental status by observing his or her appearance, activity
level, emotional state, and level of insight and judgment. Through simple conversation, you can
ascertain his or her level of consciousness, speech and language abilities, thought content, and
perception.
Here are some tips to help guide your assessment:
Appearance
It is sometimes difficult to assess the patient's usual physical appearance in the hospital setting
because the patient may have spent several hours in the ER and is most likely wearing a hospital
gown However, try to determine the patient’s general state of grooming and whether or not he or
she appears the stated age.
Activity Level
Although most patients in the hospital spend their days in bed, what can you gather about their
general level of activity? Does the patient seem unusually weak for a person who lives alone? Is
the patient constantly moving, picking at things, or rearranging items on the tray table?
Emotional State
Your patient may exhibit emotions that seem inappropriate for the current situation. What would
you think if the doctor tells your patient he needs bypass surgery tomorrow, and the patient
laughs and says, “Doctor, you are the funniest person I’ve ever met. How do you keep such a
straight face when telling a joke?”
Insight and Judgment
What would you think if you came in to check your patient’s chest tube site and he told you to
come back tomorrow because his favorite TV show was on? Do you think this patient has good
insight into his current medical condition? How will this affect his ability to care for himself at
home?
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Level of Consciousness
Is the patient alert and responsive when you speak to him, or does he seem slow to respond to
your questions? Is your patient disoriented to place or time? Don’t be fooled, ask for more
specific information when your patient responds, “of course I know where I am!”
Speech and Language
Aphasia is a disturbance of speech and comprehension. Can you recognize aphasia in the
following scenarios?
Nurse: “Tell me what brought you to the hospital.”
Patient: “I went out for a walk, and then I got hungry, so I went back home.”
Nurse: “What medications do you take at home?”
Patient: “Oh, you know, this one and that one.”
Nurse: “What would you like to drink with your dinner?”
Patient: “Where did you say my socks were?”
Nurse: “Your procedure is scheduled for 10:30.”
Patient: “OK, my grandson should be here soon.”
Nurse: “I see you are reaching for something, can I help you?”
Patient: “Yes, I’m looking for that thing for my hair.”
Thought Content
Alterations in thought can take on many forms. Have you ever heard phrases like these?
“That nurse came to take my blood, but I know she’s trying to kill me.” (delusions)
“I need 15 sugar packets on my lunch tray.” (obsessive behavior)
“I’m no good any more, I’d be better off dead.” (suicidal ideation)
“If I don’t get better, I’m just going to be a burden on my family.” (depressive thoughts)
Perceptual Disturbance
Agnosia is the inability to recognize things or people. Hallucinations are sensory perceptions
without external stimuli, and can be visual, auditory, or olfactory.
Can you recognize agnosia in the following examples?
“When I came back from my procedure, I was so happy to see my old dog, Buddy, there waiting
for me.” (visual hallucinations)
“Can somebody take those children away? They are screaming and laughing so loudly and I’m
trying to rest!” (auditory hallucinations)
“Nurse, I’d like you to meet this lady here, I’ve known her all my life.” (inability to recognize a
family member)
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NursingAssessmentinthePresenceofCognitiveImpairment
Once you have determined that your patient may have some cognitive impairment, how will you
change your perspective and the way you communicate with this patient? How will you alter
other aspects of your nursing assessment? You normally assess patients for pain, nutritional
status, falls, sleep patterns, incontinence, and polypharmacy. Here is a review of these topics and
how they may present in a patient with cognitive impairment.
Pain
If your patient has some cognitive impairment, he or she may not be able to communicate pain
directly. Research shows that pain is poorly recognized and under treated in the elderly. Reported
incidence of pain is approximately 45% in hospitalized elders, 25 to 50% in community dwelling
elders, and 45 to 80% in those living in nursing homes. What if the patient also has cognitive
impairment? Consider pain as a factor in these examples.
You are changing the patient’s abdominal wound dressing and you see him grimacing and
clenching his eyes closed. You ask if he has pain, but he says no.
You observe the patient vigorously rubbing his leg. You ask if he has pain and he says “No, I’m
trying to get the fire out.”
You hear the patient sighing and moaning, but the patient is lying still. You go in and ask if he
has pain and he says, “I just don’t feel good.”
Nutrition and Hydration
Due to “NPO” status and restrictions because of the patient’s acute illness, it is unlikely that you
will get an accurate picture of the patient’s regular eating and drinking habits. At best, you may
be able to determine existing nutritional status from family reports, weight, and lab values, such
as serum albumin, prealbumin, serum cholesterol, hemoglobin, hematocrit, B12, and total
lymphocyte count.
What if the nursing assistant says to you, “Mr. Johnson hardly ate any breakfast or lunch today. I
guess he’s a light eater.” It may be because he was unable to open the containers due to
weakness, or maybe he wasn’t sure what to do because the food was presented in an unfamiliar
way.
We don’t usually worry about dehydration in the hospital because we can use IV fluid quickly
and easily. Due to shortened length of stay, patients don’t usually experience malnutrition over
the course of a few days. But what will happen to Mr. Johnson once he is discharged? Is his
nutritional status at risk?
Falls and Fall Risk
In the older adult, falls are the sixth leading cause of mortality. Identifying your patient's risks
for a fall on admission, and eliminating those risks if possible will be a tremendous help to both
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you and your patient. Your patient probably has some inherent risk factors, for example
cognitive impairment, physical disability, sensory impairment, exacerbation of chronic disease,
side effects of medications, or acute illness. Couple these with risk factors that exist in the
hospital environment, such as inadequate lighting, difficult to reach items, and clutter in the
room, and you're set for disaster!
Incontinence
About half of the elderly who are house bound or in nursing homes are incontinent of urine. 25 30% of older adults experience incontinence after hospitalization from a serious illness. As a
patient loses cognitive function, activities of daily living become more difficult to perform. The
task of going to the bathroom incorporates several "activities" and can become quite challenging.
Urge incontinence accounts for two-thirds of incontinence cases in the elderly, but functional
incontinence, which pertains to the logistics of going to the bathroom, is another big issue
especially in the hospital setting.
If your patient has episodes of incontinence, consider the cause. Has he been given a large dose
of a diuretic? Is he immobile or unable to reach the urinal or call bell? Try to determine whether
or not the incontinence was present before hospitalization. If the incontinence is new, urinary
tract infections should be highly suspected, even in the absence of other symptoms. This is a
sensitive subject for many elderly people, so approach carefully!
Sleep Disturbance
The patient’s normal sleep pattern will be extremely difficult to assess in the hospital setting for
obvious reasons, but you can get an idea of his or her normal patterns by asking the patient or
caregiver whether or not he or she experiences difficulty falling asleep, early awakening, or
frequent awakening during the night. The elderly patient with cognitive impairment is vulnerable
to extraneous light and sounds, so try to keep the hospital environment as "homelike" as
possible.
Persons with dementia often have a reversal of their sleep/wake cycle (sleeping during the day
and remaining awake at night), which can be exacerbated by a change in environment (admission
to the hospital). There are several interventions that can be tried to help regulate their sleep/wake
cycle. Some are not possible in the hospital setting, but you can suggest these tips to family
members if the patient has this problem at home. The interventions are to: increase exposure to
natural light first thing in the morning, increase daily structured activities to decrease napping
during the day, minimize caffeine and excess fluids after 3:00 p.m., minimize time spent in bed
during the day, provide quiet activities in the evening such as listening to music to help the
patient prepare for sleep.
The Reality of Caring for a Patient with Cognitive Impairment
Agitation is one of the most commonly experienced behaviors of hospitalized elderly with
cognitive impairment, delirium, and/or depression. For nurses, it is very challenging to deal with,
because it impedes your ability to provide safe, effective, and timely care in the hospital setting.
As you have probably experienced, it is extremely difficult to assess and apply treatment to a
patient who is agitated and physically combative. Agitation can be characterized as
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aggressiveness, combativeness, hyperactivity, and disinhibition. There are very few resources
available to you to effectively care for an agitated patient. Many of the interventions posed, such
as sitting with the patient, or coming back at a later time, are simply not realistic.
When caring for a patient with agitation who is combative, a few minutes alone may benefit the
patient immensely. But on the other hand, the patient's safety may be at risk. There are no easy
answers here, so remaining open minded is key. Remember that interacting with the patient at
the same level of agitation and anxiety is definitely counterproductive. Utilize your care team. If
you can't calm the person, maybe the nursing assistant, social worker, family member, or
physical therapist can help.
Once the patient's needs are ascertained, the situation becomes much more clear. Try nonpharmacological interventions first. Sedatives could have an opposite effect, or cause worse
symptoms later on as they wear off. Overall, realize that the cause is usually reversible and will
likely subside in the near future.
Here are some pearls for dealing with the combative and agitated patient in the hospital setting:
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There is almost always a simple underlying cause, such as the patient is hungry or the
lights are too bright. Take a minute to look for clues, and the solution may be quite easy!
Understand that the patient's behavior is not a personal attack on you. This is important to
explain to ancillary care providers, because they may not understand the behavior.
Although it is easy to get upset, try your best to remain calm and speak softly. If you
cannot interact with the patient, explain the situation to the physician, nurse practitioner,
social worker, or whoever can help you brainstorm to come up with a solution.
Although using medication seems like an easy answer, it may be counterproductive in the
long run, so try to avoid it if at all possible.
Utilize input from family and friends, they may know just the remedy to calm the patient
down!
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PhysicalAssessmentinthePresenceofCognitiveImpairment
Your physical assessment of a patient with cognitive impairment will not be as straightforward
as it is in a patient with normal cognitive status. You may have to change your approach and the
way you explain what you are doing. You also need to be aware of normal age related changes,
and further be able to detect atypical signs and symptoms. It will be critical for you to educate
your nursing assistants about normal age related changes in body systems, especially how
cognitive impairment can complicate the picture.
In the previous section, you learned that patients with cognitive impairment may not be able to
express themselves and may have atypical presentations to common problems. You have
collected quite a bit of data on the patient up to this point, so how will cognitive impairment
change your physical assessment? This section will discuss the age related changes of the various
body systems and review the unique approach necessary in older adults with cognitive
impairment.
Cardiovascular
The elderly have a higher likelihood of dropping their blood pressure when changing position,
for example, from sitting to standing. They are also more likely to have abnormal heart rhythms,
which can decrease their cardiac output. These changes can lead to various complications,
namely dizziness and falls. You may find that a patient is unable to explain how or why he or she
fell. He or she may have trouble explaining the feeling of dizziness or palpitations. Keep an eye
on heart rate and blood pressure changes, and frequently remind the older adult with cognitive
impairment to move slowly. The vascular system also becomes stiffened and more tortuous with
age, which can make it difficult for you to place and maintain IV catheters.
Pulmonary
The chest wall stiffens and the respiratory muscles weaken with age, causing decreased elasticity
of the lungs with age. Older adults may also be less active than their younger counterparts, so
they are not used to expanding their lungs to full capacity. When the patient does not fully
expand his or her lungs, the ability to detect abnormal lung sounds deep at the bases may be
difficult.
The pulmonary assessment typically consists of listening to the patient’s lungs while asking him
or her to breathe deeply, and also observing the patient’s breathing patterns. What if the patient
can’t understand your instructions to breathe deeply, or is simply not able to do so? Try to think
of some concrete explanations for breathing deeply, such as blowing out birthday candles or
holding your breath before swimming under water. You can also have the patient breathe
through his or her mouth to enhance the air exchange and improve your ability to detect
abnormal breath sounds.
Coupling your physical assessment with respiratory rate and oxygen saturation should give you a
pretty good picture. What else can you do to assess pulmonary status in the older adult with
cognitive impairment? Be on the lookout for signs and symptoms such as coughing, fatigue,
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malaise, change in respiratory secretions, and change in skin color as they may indicate early
infection.
Gastrointestinal
Older adults may experience a blunting of symptoms that usually indicate acute abdominal
problems, or their symptoms may be vague and difficult to quantify. A patient with acute
perotonitis or gastroenteritis may not appear to be in any pain, but if he or she guards his or her
abdomen during exam, refuses to move, or tries to hit you when you come close, these are sure
signs of pain. Sudden immobility and change of dietary pattern in the hospital can quickly lead to
constipation, but the patient with cognitive impairment facing acute illness may not complain of
such a symptom. It is important to work closely with your nursing assistant to monitor the bowel
function. Further, medications used to treat acute illnesses can cause either constipation or
diarrhea. Remember that the elderly are at increased risk for dehydration, and also have a
decreased ability to feel thirst. Therefore, dehydration can occur very quickly.
Genitourinary
Age associated changes in this area are gender specific. Men with benign prostatic hyperplasia
(BPH) have symptoms of urgency, hesitancy, dribbling, frequency, and overflow incontinence.
Women experience symptoms related to estrogen loss after menopause, such as atrophic
vaginitis and urethritis. Both men and women have a delay in the signal telling them to void as
well as a decreased bladder capacity and increased amount of urine retained in the bladder after
voiding, which leads to a cycle of rapid bladder filling. While incontinent episodes can be
frustrating for both you and the patient, if you anticipate that this may be an issue and take some
simple steps to combat it, you can prevent frustrations for all parties involved.
Urinary tract infections are a common complication for the hospitalized elderly with cognitive
impairment. Remember that patients with cognitive impairment may have difficulty verbalizing
their symptoms, so here are some clues you can look for: foul smelling, cloudy, or bloody urine,
complaints of burning on urination flank or suprapubic pain, frequency and urgency, or new
incontinence.
Musculoskeletal
As people age, their skeletal muscles decrease in bulk and the ligaments lose some of their
elasticity and strength. The elderly lose height and tend to have a forward flexed posture due to
osteoporosis. This can affect balance and lead to falls. Arthritis is a general term for the
degeneration and inflammation of the joints, and is extremely common in the elderly. They may
experience significant pain with movement and have limited range of motion. With cognitive
impairment, the older patient may not be able to tell you what is going on, and you may not be
able to tell just by looking at him or her. Anticipate needs in this area and use PRN pain
medications as appropriate. Ask the patient or caregiver what is used at home, and facilitate the
use of that method in the hospital if possible.
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Skin
Older adults have thinning skin secondary to a decrease in subcutaneous fat, which increases risk
for skin tears and skin breakdown. The periods of immobility that these patients experience in
the hospital can lead to pressure ulcers, sometimes in less than an hour. The acutely ill older
adult with cognitive impairment may not experience the discomfort associated with immobility
and may not be able to reposition him or herself. Work with your nursing assistant to pay close
attention to bony areas and ensure frequent repositioning. In older adults, skin can tear easily, so
more pillows or padded side rails may be necessary to prevent injury to the skin.
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References
Amella, E. J. (2003). Mealtime Difficulties. In M.D.Mezey, T.Fulmer, I.Abraham, & D.Zwicker
(Eds.), Geriatric Nursing Protocols for Best Practice (2nd ed., pp. 66-82). New York: Springer
Publishing Company.
Ayello, E. A. (2003). Preventing Pressure Ulcers and Skin Tears. In M.D.Mezey, T.Fulmer,
I.Abraham, & D.Zwicker (Eds.), Geriatric Nursing Protocols for Best Practice (2nd ed., pp.
165-184). New York: Springer Publishing Company.
Baum, T., Capezuti, E., & Driscoll, G. (2002). Falls. In V.T.Cotter & N.E.Strumpf (Eds.),
Advanced Practice Nursing with Older Adults, Clinical Guidelines (pp. 245-269). New York:
McGraw-Hill.
Bonomo, R. A. & Johnson, M. A. (2004). Common Infections. In C.S.Landefeld, R.M.Palmer,
M.A.Johnson, C.B.Johnston, & W.L.Lyons (Eds.), Current Geriatric Diagnosis and Treatment
(pp. 348-358). New York: McGraw-Hill.
Boxer, P. & Shorr, R. (2004). Principles of Drug Therapy: Changes with Aging, Polypharmacy,
and Drug Interaction. In C.S.Landefeld, R.M.Palmer, M.A.Johnson, C.B.Johnston, & W.L.Lyons
(Eds.), Current Geriatric Diagnosis and Treatment (pp. 421-435). New York: McGraw-Hill.
Campbell, J. W. (2004). Use of Alcohol, Tobacco, and Nonprescribed Drugs. In C.S.Landefeld,
R.M.Palmer, M.A.Johnson, C.B.Johnston, & W.L.Lyons (Eds.), Current Geriatric Diagnosis
and Treatment (pp. 407-413). New York: McGraw-Hill.
Horgas, A. L. & McLennon, S. M. (2005). Pain Management. In M.D.Mezey, T.Fulmer,
I.Abraham, & D.Zwicker (Eds.), Geriatric Nursing Protocols for Best Practice (pp. 229-250).
New York: Springer Publishing Company.
Polomano, R. C. (2002). Pain. In V.T.Cotter & N.E.Strumpf (Eds.), Advanced Practice Nursing
with Older Adults, Clinical Guidelines (pp. 333-360). New York: McGraw-Hill.
Poole, J. & Mott, S. (2003). Agitated older patients: Nurses' perceptions and reality.
International Journal of Nursing Practice. 9, 306-312.
Strub, R. L. & Black, F. W. (2005). The Mental Status Examination in Neurology. (3rd ed.)
Philadelphia: F.A. Davis Company.
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III.ProvidingEducationandSupportFromHospitaltoHome
Sections I and II have provided you with an overview of cognitive impairment. In Section I you
reviewed common terms and definitions, ways to measure CI, contributing factors to CI, and
evaluation, prevention, and treatment options. Section II provided you with further insight into
the neuropsychologic screening and assessment for CI, and how to tailor your nursing and
physical assessments accordingly. So what comes next?
The goal of this section is to help you take what you've learned and use it as a basis for educating
and supporting patients and caregivers while the patient is hospitalized, and more importantly,
during the transition to home. Caregivers may feel overwhelmed and unprepared to take care of
someone with cognitive impairment in the home setting, so this section will equip you with the
information necessary to provide comprehensive and individualized care as your patient and his
or her caregiver adapt to the home environment.
Throughout this program, the terms CI, memory and thinking problems, and dementia have been
used interchangeably. When you speak with family members, try to use more explanatory terms
like memory and thinking problems to describe CI.
Topics to be covered in this section include:
•
•
•
•
•
•
•
Discharge Planning
Understanding and Managing Common Behaviors Associated With CI in the
Elderly
o Anxiety and Agitation
o Hallucinations, Delusions, and Paranoia
o Communication Difficulties
o Depression and Apathy
o Disinhibition
o Sleep Disturbances
o Wandering
Transition from Hospital to Home: Educating Families on Day to Day Issues
o Activities of Daily Living
o Concerns About Driving
o Hiding or Misplacing Items
o Incontinence
Advance Care Planning and Putting Affairs in Order
o Advance Care Planning
o Assessing Capacity
What is it Like to be a Caregiver?
o Working with the Health Care Team
o Tips for the Caregiver
Elder Abuse and Neglect
Additional Resources
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DischargePlanning
Patients with cognitive impairment and their caregivers obviously have unique discharge needs.
In addition to dealing with the acute illness, there are many other factors that are not usually
anticipated by the patient, the caregiver or hospital staff. Two of the biggest consequences of
inadequate discharge planning are rehospitalization and institutionalization.
Some of the concerns most important to families and caregivers are:
•
•
•
Managing visits and information from multiple care providers.
Managing transportation, equipment, and specific treatment required.
Dealing with psychosocial aspects of the illness and coping.
Keep these in mind as you plan for discharge. Start early and be sure to work closely with the
social worker or discharge planner. Inform this person that the patient has some cognitive
impairment, and be sure to tell him or her if you suspect depression or if the patient experienced
any delirium or agitated behavior thus far.
Here are some tips for successful discharge planning:
•
•
•
•
•
Ask patient and caregiver frequently about their anticipated needs or questions and try to
get the ball rolling for interventions early on.
Do not underestimate functional disability that may be associated with the acute illness.
Suggest home physical or occupational therapy, and order necessary equipment as early
as possible. The sooner the social worker is aware of the need, the sooner he or she can
arrange services.
Assess the patient and caregiver's readiness and ability to learn about the illness and
dementia. Repeat yourself often and provide information in various forms.
Ask the social worker to make a list of the providers with whom the patient will need to
follow up with upon discharge. Include the phone number, address, and possibly the
receptionist's name. Calling ahead for the patient to determine what the patient should
bring and how the physical environment is organized in terms of stairs, parking, etc. is
also not a bad idea.
The first two weeks after discharge is the most critical time for the patient and caregiver.
If visiting nurse services are available, find out how the patient can qualify and obtain the
services early in the hospitalization. Try to speak with the agency to provide specific
information on the patient. The patient and caregiver may have specific questions, so you
can act as a liaison while the patient is still hospitalized.
A Note About Depression
The first days and weeks after hospital discharge can be very isolating for a patient, even if he or
she has a caregiver. The patient may be frustrated with his new disabilities, and may feel
powerless or even worthless in his current condition. Be sure to warn the patient and caregiver
that depression is quite common in people with dementia, and can really become evident during
this difficult time. Remind the patient and caregiver that feelings of depression are treatable with
medications and/or psychological counseling, and that they should take these feelings seriously.
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Furthermore, caregivers may notice behaviors in the patient that were not present before the
hospitalization, such as easy agitation, anger, apathy, or withdrawal. Or, maybe these symptoms
were present and the caregiver did not know what to make of them. These may signal depression,
and the caregiver should notify the patient's primary care provider immediately.
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UnderstandingandManagingCommonBehaviorsAssociatedwithCIin
theElderly
Anxiety and Agitation
Agitation, aggression, and psychosis occur in more than 80% of patients with Alzheimer’s
Disease. Agitation may be an attempt to express feelings or needs that the patient cannot
verbalize such as hunger, need to void, fear, or pain. Talk with family members to find out if this
type of behavior is new, or how the family deals with the behavior if it is not new.
Sometimes agitation can be dealt with by changing the environment, moving a patient to a
different part of the room, or by fulfilling the need if it is need driven or purposeful.
Aggressive behaviors are considered a form of agitation in the Cognitively Impaired elder
Verbal aggressions are marked by inappropriate language or screaming, may arise from anxiety,
fear or depression, and may be the only way the patient can communicate if they are unable to
express feelings adequately. Physical aggressions are signs of agitation, and consist of waving
arms, making a fist, grabbing someone, and making threatening gestures.
The following are methods you can suggest to caregivers to manage aggressive behaviors:
•
•
•
•
•
•
•
•
Stay calm and quiet.
Safety first. Step away or out of sight briefly, re-approach later if possible.
Redirect all efforts towards controlling the situation.
Speak softly and use reassuring words.
Dim lights if they are extremely bright.
Limit noise.
Limit choices and create environmental cues.
Look for patterns or warning signs for aggressive behavior. This will also allow you to
determine if these are new behaviors.
Hallucinations, Delusions, Paranoia
Hallucinations are sensory experiences that cannot be confirmed by anyone but the patient. The
most common are auditory and visual, and examples were reviewed in Section II. Patients may
hear sounds or voices, or see people or objects that are not present.
Delusions are ideas which are not based in reality, but which the patient believes to be true. The
content of delusions often revolves around people stealing money or other possessions, or the
patient may have fixed ideas about people trying to harm them.
Paranoia is characterized by unrealistic beliefs. Patients with memory and thinking problems
may be suspicious, believe that someone is out to get them, or accuse you or others of stealing
from them. Another common accusation is that the patient’s partner is being unfaithful.
Factors that may cause or make hallucinations, delusions, or paranoia worse are:
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•
•
•
•
•
•
•
•
•
Sensory defects, poor eyesight or hearing.
Side effects from medications.
Psychiatric illness.
An unfamiliar environment.
Poor lighting, making visual cues less clear.
Acute illness.
Unfamiliar caregivers.
Disruption of daily routine.
Sensory overload – too many things going on at one time.
Suggestions you can make to caregivers:
•
•
•
•
•
•
Do not argue. It is better to acknowledge that the person may be frightened by the
delusion or hallucination.
Investigate suspicions to make sure they are not based on fact.
Attempt to distract the patient if possible, with techniques such as music, exercise,
conversations with friends or family, or looking at photos.
Physical contact may be reassuring, but be sure the patient is willing to accept this.
Know that some hallucinations and false ideas do not require intervention if they are not
bothersome to the patient and do not present a danger to the patient or others.
Medication will sometimes help to control delusions or hallucinations in patients with
dementia but side effects can cause additional problems.
Communication Difficulties
Some people with cognitive impairment have difficulty expressing their thoughts or
comprehending and responding to what other people say. This is commonly referred to as
aphasia, and can be frustrating for caregivers.
Suggest these methods to improve communication between family members and their relatives
with memory and thinking problems:
•
•
•
•
•
•
•
•
•
•
Choose simple words and short sentences and use a gentle, calm tone of voice.
Ask simple yes/no questions where appropriate to avoid confusing the patient.
Give the patient time to respond.
Provide the patient with reassurance through your words and your facial expressions.
Call the patient by name, and make sure you have his or her full attention before speaking
to him or her.
Minimize distractions and noise, such as the television or radio or other people in the
room. This will help the patient focus.
Try pictures if necessary. Having the patient point to a picture of something can help
prompt a memory.
Put important information in writing.
Keep a calendar posted in the house to help orient the patient.
Try not to let repetitive questions or stories frustrate or upset you. Redirect the
conversation, and be prepared for this to happen.
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For more resources and information on dealing with dementia and communication difficulties,
check out: http://consultgerirn.org/uploads/File/trythis/try_this_d7.pdf
Depression and Apathy
Determining the presence of depression can be difficult because many of the classic symptoms of
depression overlap with the symptoms of dementia. Some of these symptoms are sadness,
irritability, anxiety, taking a long time to complete tasks, and sleep problems. Medications can be
helpful in alleviating the patient's symptoms, but deciding whether or not to use medications can
be a difficult choice. Many non-pharmacological interventions can help, and parallel those
discussed above.
The most important message you can convey to patients and caregivers is that they remain open
to all treatment options that can potentially be helpful to the patient. This is an area where the
social worker will likely be able to intervene. Many social workers can not only provide
resources, but they also provide counseling, and often make home visits.
Dealing with Apathy
Some people with memory or thinking problems lose interest in doing the things they used to.
They may even stop doing basic activities like getting dressed.
Here are some non-pharmacological suggestions on how to deal with apathy:
•
•
•
Ask the patient how they are feeling and ask if the family member or friend helping to
provide care has noticed less patient interest in everyday activities. The patient may be
able to explain why he or she is not interested.
Getting started or getting going on tasks can be difficult, sometimes a few reminders of
the basic steps on how to do things will help get the patient motivated.
The patient’s lack of interest in doing every day activities can sometimes be the
medication's side effects. The patient’s primary care provider can review medications.
Remind family members to bring a complete list.
Disinhibition
Some people with cognitive impairment forget appropriate public behavior. This may lead to
disrobing in public, fondling themselves in public, use of excessive profanity or acting sexually
aggressive with others, such as a spouse. Again, a social worker may be extremely helpful in this
situation.
The sexually inappropriate behavior is not exhibitionism, but often due to the patient not
remembering to stay clothed or how to wear clothes appropriately. It may not even be sexual at
all.
As stated earlier, try to determine what the reason is for the behavior, for example:
•
•
Clothing is too tight, too big, or uncomfortable.
A patient tugging at their genitals may need to go to the bathroom or have a possible
medical condition such as:
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Urinary tract infection
Constipation
Yeast or vaginal infection
Manipulation of the genital area is more commonly associated with an unmet need than a
sexually driven behavior.
o
o
o
•
Sleep Disturbances
Circadian rhythm disturbances commonly occur with CI, but consider other causes, because
many of them are easy to fix. Sleep problems can be caused by:
•
•
•
•
•
•
•
•
•
•
Health conditions such as angina, congestive heart failure, diabetes, or ulcers.
Pain, caused by such things as arthritis.
Urinary tract infections, which cause a frequent need to urinate.
Leg cramps or 'restless legs', which can indicate a metabolic problem.
Depression, which causes early morning awakening and an inability to get back to sleep.
Side effects of medication such as diuretics.
Snoring and sleep apnea.
Increased fragmentation of sleep leading to irregular sleep patterns.
Changes in environment, such as being hospitalized.
Disorientation due to poor lighting.
Management of sleep disturbances in the hospital is often difficult, but there are some things you
can do, such as clustering care to decrease interruptions, dimming the lights at night, and
minimizing unnecessary noise.
At home, there are several things caregivers can try:
•
•
•
•
•
•
•
•
Develop a sleep schedule.
Limit stimulants such as caffeine at the end of the day.
Provide a five minute back massage before going to bed.
Offer a small amount of herbal tea or warm milk before bed.
Decrease fluid intake before bedtime.
Toilet the patient before bed.
Treat pain with an analgesic at bedtime.
Provide adequate lighting/darkness.
Wandering
Twenty-five to forty percent of people with dementia will wander. Many people get disoriented
and lost, even in a familiar place like their own neighborhood or their home. Treatment options
are based on the causes and clinical features of the behavior.
Ask the caregiver the following questions to carefully assess the problem so an effective
treatment plan can be made:
• How often does the person wander?
• How long does it occur?
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•
•
•
What time of day?
Any other behaviors present during wandering behavior?
Is this a new or old behavior?
Common reasons people wander:
•
•
•
Hunger, thirst, and urinary or fecal urgency.
Pain, boredom and social isolation.
A medical, cognitive or psychiatric change in status.
Treatment depends on the specific wandering behaviors:
•
•
Behavioral treatments for wandering, such as putting the patient on a toileting and/or
feeding schedule, can improve wandering behaviors associated with physical symptoms.
Encourage the patient to be as active as possible, depending on medical constraints and
setting. This can help reduce restlessness and agitation.
For information on wandering in the hospitalized older adult with dementia check out:
http://consultgerirn.org/uploads/File/trythis/try_this_d6.pdf
Although this behavior is common, it can be dangerous. If the individual gets lost and is not
found within 24 hours, he or she risks serious injury or death. Educate the family about this topic
if it is an issue and provide them with the following helpful tips:
•
•
•
•
•
Provide appropriate supervision.
Reduce environmental triggers for wandering.
Make sure the patient carries some kind of identification or wears a medical bracelet
when they go out. If he or she gets lost, this information can help get the patient home
safely. Perhaps the best is the Alzheimer’s Association’s Safe Return® Program
identification supplied by the Alzheimer’s Association.
The Alzheimer’s Association’s Safe Return® Program provides a national, 24-hour, tollfree number to contact when someone is lost or found. One call activates the support
network to help locate someone who is lost. http://www.alz.org/Services/SafeReturn.asp
or call (800) 232-0851
Tell families to keep a recent picture of their loved one with CI. If the patient becomes
lost, it can be given to police.
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FromHospitaltoHome:EducatingFamiliesonDaytoDayIssues
Here are four key principles to share with family members to help minimize and prevent
behavior problems:
•
•
•
•
Be consistent. Develop a routine at home with daily activities, such as getting up, getting
dressed, eating meals, going out.
Always try to plan ahead or prepare ahead of time.
Provide, but limit choices to help keep the patient focused.
Redirection to a new topic of conversation or a new place, as needed.
The following day to day issues are explored below:
•
•
•
•
Difficulty with activities of daily living.
Concerns about driving.
Hiding or misplacing objects.
Incontinence.
Activities of Daily Living
While some people with CI do not mind bathing, grooming, dressing, etc., for others it can be a
frightening and confusing experience. Planning in advance can help make daily activities easier
for patients and their caregivers. Plan the bath or shower or what the patient will wear in
advance, and for the time of day when the patient is most calm and agreeable.
The following are some precautions to take for bathing safely:
•
•
•
For bathing, minimize safety risks by using handheld showerhead, shower bench, and
nonskid bath mats.
For dressing, try to dress the patient at the same time each day so he or she will come to
expect it as part of the daily routine. Encourage the patient to dress him or herself to
whatever extent possible. Allow the patient to choose from a limited number of outfits.
Provide clear, step-by-step instructions.
For toileting, suggest a schedule such as every two hours or a bed-side commode for
patients with a higher risk for falls. Educate family members about their relative’s
continence needs before they leave the hospital so they are not surprised
Concerns About Driving
Even though a patient may be upset by the loss of independence, driving is a privilege, not a
right. Safety must be the priority. How can you decide whether the patient is safe to drive?
•
•
•
Family members and friends are usually the best key informants about driving.
Ask those closest to the patient to observe the patient’s driving skills.
They should be looking for clues that safe driving is no longer possible. This might
include getting lost in a familiar place, driving too fast or too slow, disregarding traffic
signs, or getting angry or confused.
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Resources for caregivers:
•
•
The AARP offers Driver Safety Programs and additional resources. 1-888-OUR-AARP
(1-888-687-2277) http://www.aarp.org/home-garden/transportation/driver_safety/
AAA offers a Seniors Program. Mid Atlantic (1-800-763-9900)
Hiding or Misplacing Items
People with memory and thinking problems often hide objects on purpose to keep them safe, and
then forget where they are or that they have hidden them at all. Family members may not be fully
aware of this issue until you ask them to think about it. This can be an extremely frustrating issue
for caregivers, especially for items such as keys, glasses, dentures, and medications.
Here are some suggestions to help caregivers with this issue:
•
•
•
•
•
•
Limit the number of possible hiding places by locking drawers, cabinets, closets, and
extra rooms. Lock up all valuables when possible.
Arrange for the mail to be delivered to a post office box or out of the patient's reach.
Restrict access to garbage cans. Check all garbage cans and hampers before disposing of
their contents in case objects have been hidden there.
Help families to understand that they should avoid scolding or accusing the patient of
hiding things, or trying to reason with him or her. Instead, the family member should try
to reassure and help the patient look for the items. In this way, they may become familiar
with common places where things are misplaced.
Advise family members of patients with memory and thinking problems that they should
consider, if possible, keeping spares of frequently misplaced items on hand, like glasses
and keys.
Explain that sometimes the patient may accuse family members of taking things and it is
important to avoid becoming defensive. This is a normal reaction to gaps in memory and
increasing confusion.
Incontinence
About half of the elderly who are house bound or in nursing homes are incontinent; and between
25% to 30% of older adults experience incontinence after hospitalization. For people with
memory and thinking problems, the issue of incontinence may be compounded by loss of
executive function. Above all, incontinence is embarrassing for both patients and caregivers,
especially if they are out in public.
If incontinence is a new problem, rule out potential causes such as:
• Delirium
• Infection (urinary tract)
• Atrophic urethritis or vaginitis
• Pharmacology (i.e., diuretics, anticholinergics)
• Psychological disorder (especially depression)
• Endocrine disorder (i.e., diabetes)
• Restricted mobility (i.e., post-operative)
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•
Stool impaction
Try This: http://consultgerirn.org/uploads/File/trythis/try_this_11_1.pdf
http://consultgerirn.org/uploads/File/trythis/try_this_11_2.pdf
Helping family members to understand the patient’s continence issues and capabilities is
important. Offer the following suggestions to help:
•
•
•
Explain the concept of a toileting schedule (i.e., taking their relative to the bath room
every two to four hours).
Should an accident occur, stay calm, be understanding.
Educate family members about the products the patient may need, such as pads or inserts,
diapers or disposable underwear as well as underpads to protect beds and other furniture.
These products are available at local drug stores.
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AdvanceCarePlanningandAssessingCapacity
Advance Care Planning
Planning for the future is something that often gets put off for various reasons. For persons with
memory and thinking problems, this planning is crucial. Without this planning for the future,
caregivers are left to make decisions for the patient without knowing what he or she would have
wanted.
An acute illness requiring hospitalization usually serves as a wake-up call to patients and
caregivers that they need to prepare for the future, but there never seems to be a good time to talk
about advance directives.
During hospitalization, the patient and caregiver will be focused on getting through the acute
event, and will not likely be able to make long term decisions due to the uncertainty of the
present situation. Once the patient goes home, he or she and the caregiver will have many
pressing issues to deal with, namely a potential new diagnosis of cognitive impairment.
How can you help the patient and caregiver develop advance directives? First of all, utilize your
care team. Because this is a sensitive topic, patients and caregivers may respond better if all
members of the care team are involved. Again, the social worker may have literature that the
patient and caregiver can review together.
Advance directives can take several forms, for example:
•
•
•
•
•
A living will.
Durable Power of Attorney for Health Care (DPOAHC).
Health care proxy.
A checklist provided by the hospital with the patient's and a witness' signature.
An official document prepared by the patient.
What exactly are advance directives? They are decisions made on a variety of topics or issues
that indicate the patient's wishes for care. For those patients who are still able to communicate
their wishes, encourage them to convey their preferences. Advance directives are currently made
around topics such as:
•
•
•
•
Feeding tubes and IV use.
Surgery and other medical procedures.
Mechanical ventilation and intensive care.
Wishes for resuscitation.
These are obviously serious topics and developing advance directives usually takes patients and
caregivers a considerable amount of time. Reassure them that being prepared for future events
will cause less stress for all parties involved than if no plans are in place.
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Assessing Capacity
Just because a patient has some memory and thinking problems, it does not mean they do not
have the capacity to express their health care preferences. Capacity is a clinical decision, it is not
a question of competency. Capacity can vary from issue to issue, as some issues are more
concrete than others.
A preliminary way to assess capacity is to assess whether or not the patient has the ability to:
•
•
•
•
Understand the factors that go into making the decision.
Understand the pros and cons of the decision.
Reason through that decision.
Make a choice consistently.
Every decision varies in the amount of capacity necessary to make the decision. For example, a
patient with dementia may be able to make choices about what to order for lunch or what shoes
to put on, but may not have the capacity to make a medical treatment decision.
To learn more about decision making and dementia, check out:
http://consultgerirn.org/uploads/File/trythis/try_this_d9.pdf.
What is it Like to be a Caregiver?
Background
Throughout our lives we work, spend time with friends and enjoy hobbies. The role of caregiver
brings with it the responsibility of 24 hour care. This often can lead the caregiver to isolation and
a feeling of loss. How can caregivers successfully balance caregiving responsibilities and meet
their own needs?
There are numerous studies of caregiver burden and distress. The literature tells us that:
•
•
•
•
•
•
The majority of caregivers are spouses, primarily wives.
Most caregivers care for patients in the home.
Caregivers experience high levels of depression.
Caregivers report tiredness, sadness and less satisfaction with life.
Caregiver depression is predicted by the severity of psychiatric symptoms in the patient.
Delusions and agitation contribute to emotional distress in caregivers.
Both patients and family members often view feelings of sadness or depression as a personal
weakness. Patients and families have often stated, “I just need to pull myself up by the boot
straps." In addition, many patients and family members are not willing to share the problems of
hallucinations, sadness, despair, or anxiety with health professionals as they may feel
embarrassed.
Helping the Caregiver work with the Health Care Team
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The caregiver is an integral part of the health care team. The first step in helping the caregiver is
to provide education on the common psychiatric symptoms experienced by patients with
dementia and delirium. Through early identification of psychiatric or medical problems in the
older adult with CI, the health care team can often find a solution to treat the symptom and
reduce the burden of care.
Educating the caregiver about resources available to support him or her is essential in supporting
the patient with CI in the community. As a nurse in the hospital, assist the caregiver in obtaining
the necessary resources to contact providers in the community, such as physicians, nurses, social
workers, physical, occupational, and speech therapists, and psychologists. This will aid in a
successful transition home.
Caregivers need to be taught the skills of how to have successful encounters with the patient’s
health care team. This will increase the quality of care provided and reduce the time spent on
managing care.
The following are suggestions you give caregivers for when they interface with the care team:
•
•
•
•
•
•
•
•
•
•
Make a list of health care concerns ahead of time and bring it to the visit.
Bring a list of all current medications to every appointment or hospital admission. If
possible, bring extra copies so they can be put in the chart.
Keep a history of medications that have been tried and discontinued, and the reason for
the discontinuation.
Make a list of medications that need to be refilled before the next visit.
Be familiar with generic and trade names for all medications being prescribed. A
pharmacist can help you develop this list.
Check with the pharmacy and medical plan to see if they will fill a prescription for a 90day supply of medication. This will reduce time and effort in obtaining new prescriptions
and reduce the likelihood of running out of a drug before the next refill is available.
If the health care provider increased the number of tablets of a certain medication to be
taken in a day, request a new prescription so you don’t run out.
Call before a problem becomes a crisis. Most health care providers would rather have a
phone call than see a patient in the emergency room.
Make a list of all health care providers involved in the care of the patient and give each
health care provider a copy of the list. This will assist with coordination of care.
Provide a copy of any advance directives to all health care providers.
Tips for the Caregiver
Life as a caregiver is difficult and caregivers need to learn to take care of themselves. Many
caregivers express guilt over the thought of not providing 24-hour a day care for an ill family
member. However, once the caregiver experiences the benefits of a break from caregiving, they
can return home with a renewed sense of strength and commitment.
Take a Break! There are several ways to provide care for a family member while taking a muchdeserved break.
Some examples of ways to arrange for temporary care are:
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•
•
•
•
•
Purchase in-home care from a licensed and bonded home care agency.
Have a relative or friend come over while the caregiver is away.
Use respite care services offered by community nursing homes.
Have the patient attend adult day care several days a week.
If the patient is receiving hospice services, respite care can be arranged.
Improve Communication: It is not uncommon for communication among family members to
suffer with the progression of CI in a loved one.
Here are some tips to improve communication:
•
•
•
•
Have a meeting with family members who are not living with the patient and caregiver so
they can better understand the complexity of care.
Keep communication frequent and informal.
If the communication between family members is difficult, a social worker or clergy
member can assist in moderating discussion and keeping family members focused.
Encourage family members to discuss how they feel about having a relative with CI. This
will reduce the stress on family relationships.
Elder Abuse and Neglect
Statistics in the state of Pennsylvania indicate that elderly victims of abuse, neglect, financial
exploitation, and abandonment are usually older women, with 70% being over the age of 75.
Over half of the perpetrators are family members (59%), and another 39% are unrelated to the
victim (Institute on Protective Services, Temple University).
A vulnerable adult is defined as a person who is being mistreated or is in danger of mistreatment
and who, due to age and/or disability, is unable to protect him/herself. If you suspect abuse or
neglect you can contact Adult Protective Services (APS) which provide services to older people
and people with disabilities who are in danger of being mistreated or neglected, are unable to
protect themselves, and have no one to assist them.
National Center on Elder Abuse - http://www.ncea.aoa.gov/ncearoot/Main_Site/index.aspx
Elder abuse - State Resources http://www.ncea.aoa.gov/ncearoot/Main_Site/Find_Help/State_Resources.aspx#state
Pennsylvania: (800) 490-8505
For more information on assessing and dealing with possible abuse and neglect, check out:
http://consultgerirn.org/uploads/File/trythis/try_this_15.pdf
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AdditionalResources
Some caregivers express the desire to have more information about support services that are
available. On the other hand, some caregivers are so overwhelmed that they do not even know to
ask for additional resources. As a nurse anticipating the needs of the patient and caregiver once
they are home, it is a good idea to have some resources handy that you can give the patient and
caregiver upon discharge. This does not have to be a formal process, and the social worker with
whom you are working will likely have access to more information that can be provided.
Here are some additional resources you may find useful:
National Association of Area Agencies on Aging
This agency may be able to provide additional support such as homemaker or chore services,
home delivered hot meals, referrals, and other information on services in the patient’s
community.
http://www.n4a.org/
Benefits Checkup
You can check whether the patient or family member qualify for services here.
http://www.benefitscheckup.org/
Internet resources for Caregivers:
Alzheimer’s Association
The home page for the Alzheimer’s Association, has multiple resources for caregivers that are
applicable to caring for a patient with Alzheimer Disease/Cognitive Impairment. There are
documents that can be down loaded and printed to assist in selecting respite care services and
caregiver stress. Contacts for support groups are available on this site.
http://www.alz.org/
www.nfcacares.org
The home page of the National Family Caregivers Association (NFCA). The NFCA exists to
support family caregivers and advocate for caregivers' needs.
http://www.nfcacares.org/
Family Care America
This web site is managed by Family Care America and was founded to assist corporate America
in supporting employees in caregiving roles. The web site provides resources for finding nursing
care, respite care, home care, durable medical equipment, and elder care attorneys in your area.
http://www.caregiverslibrary.org/home.aspx
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References
ADEAR: Alzheimer’s Disease Education and Referral Center - http://www.alzheimers.org
Algase DL, Sana JM, Beattie E, Beel-Bates CA. Wandering studies: different purposes, different
perspectives. J Gerontol Nurs. Oct 2002;28(10):4, 52; author reply 52.
Alzbrain.org - www.alzbrain.org
Alzheimer’s Association - http://www.alz.org
American Association of Retired Persons - http://www.aarp.org
Cummings, S.M. (1999). Adequacy of discharge plans. Health and Social Work, 24(4). 249-59.
DeBaggio, T. (2002). Losing my mind: An intimate look at life with Alzheimer’s. NY: Free
Press.
Elder abuse http://www.ncea.aoa.gov/ncearoot/Main_Site/Find_Help/State_Resources.aspx#state
Hartford Institute for Geriatric Nursing
a. http://consultgerirn.org/uploads/File/trythis/try_this_d5.pdf (Recognition of Dementia
in Hospitalized Older Adults)
b. http://consultgerirn.org/uploads/File/trythis/try_this_d7.pdf (Communication)
c. http://consultgerirn.org/uploads/File/trythis/try_this_d6.pdf (Wandering)
d. http://consultgerirn.org/uploads/File/trythis/try_this_11_1.pdf (Incontinence - Part 1)
e. http://consultgerirn.org/uploads/File/trythis/try_this_11_2.pdf (Incontinence - Part 2)
f. http://consultgerirn.org/uploads/File/trythis/try_this_d9.pdf (Decision making)
g. http://consultgerirn.org/uploads/File/trythis/try_this_15.pdf (Elder abuse)
Health Link – Medical College of Wisconsin http://healthlink.mcw.edu/article/1031002313.html
Institute on Protective Services - http://www.instituteonps.org/
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Mace, N. L. & Rabins, P. V. (1981). The 36-hour day: a family guide to caring for persons with
Alzheimer’s disease, related dementing illnesses, and memory loss in later life. Baltimore: Johns
Hopkins University Press.
Mittelman, M. S., Epstein, C., & Pierzchala, A. (2003). Counseling the Alzheimer’s Caregiver: A
resource for health care professionals. Chicago: AMA Press.
Naylor, M.D., Stephens, C., Bowles, K., & Bixby, B., (2005) Cognitively impaired older adults,
from hospital to home. American Journal of Nursing, 105(2), 52-62.
Olin JT, Katz IR, Meyers BS, Schneider LS, Lebowitz BD. Provisional diagnostic criteria for
depression of Alzheimer disease: rationale and background. Am J Geriatr Psychiatry. Mar-Apr
2002;10(2):129-141.
Olin JT, Schneider LS, Katz IR, et al. Provisional diagnostic criteria for depression of Alzheimer
disease. Am J Geriatr Psychiatry. Mar-Apr 2002;10(2):125-128.
Strauss, C. J. (2001). Talking to Alzheimer’s. San Francisco: New Harbinger Publications.
University of Pennsylvania’s Alzheimer’s Disease Center - http://www.uphs.upenn.edu/ADC/
U.S. Administration on Aging - http://www.aoa.gov
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IV.EnhancingCareCoordination
The goal of this section is to assist you in enhancing the coordination of care for older adults
with cognitive impairment. Cognitive impairment may be a pre-existing condition, it may be
found on admission during cognitive assessment, or it may develop or worsen during a hospital
stay.
Enhanced care coordination will improve the transition from hospital care to home management
of older adults with cognitive impairment. In order to coordinate care for an individual with
some form of cognitive impairment, we need to consider his or her individual needs and desires,
as well as the needs and desires of their caregiver. If you can understand these needs and desires
and incorporate them into the discharge plan, care during the transitional period is likely to be
successful.
Using a case study you will apply the knowledge obtained in the first three sections of this webbased training program. The case study format will enable you to integrate information as you
practice in theory (on paper). Practicing in theory will prepare you for the next step, practicing in
reality.
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CaseStudy:Parkinson'sDiseaseDementia
Consider the following Case Study
Mr. J is a 71 year-old male who arrives to the ER by ambulance. He is accompanied by his wife
who is tearful and repeatedly states "I'm sorry...it was my fault." The EMTs found Mr. J lying on
the second floor of his single family home. He was alert but disoriented to place and time. He
was grimacing in pain and yelling "Help me, please!" His wife states that he tripped over the
vacuum cleaner and fell into the nightstand before landing on the floor. Medical history reveals a
six year-history of Parkinson's disease, controlled hypertension, benign prostatic hyperplasia, and
spinal stenosis. Upon examination, Mr. J is agitated, incontinent, and unable to follow simple
commands. He repeatedly states that he has been "kidnapped by the FBI and wants to go home."
1. You are the nurse who receives this patient. Based on the above history, what might be
contributing to Mr. J's clinical presentation? Check all that apply.
a. Shock from questionable hip fracture.
b. Head trauma related to recent fall.
c. Psychosis related to anti-parkinson therapy.
d. Delirium related to an UTI.
e. Adverse effect of pain medication for spinal stenosis.
f. Intoxication.
g. Dementia NOS.
h. Normal Pressure Hydrocephalus (NPH).
i. Cerebrovascular Accident (CVA).
j. Delirium Superimposed on Dementia.
2. You need to collect additional information to complete the admission record. How do you
proceed? Choose the best answer.
a. Only direct your questions to Mr. J and record his responses.
b. Lead Mrs. J in the waiting area and question her only.
c. Direct your questions to Mrs. J and disregard Mr. J's constant interruptions.
d. Question both Mr. and Mrs. J in the same room, and record all responses.
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3. Your next step is to assess Mr. J's pain. What pain scale would you use? Choose the best
answer.
a. A faces pain rating scale.
b. A numerical pain rating scale.
c. A verbal pain rating scale.
Mr. J has been worked up in the ER and diagnosed with a fracture of the proximal femur. Urine
culture was negative. BUN, creatinine, and sodium levels were all elevated. MRI was negative
for CVA, injury, and normal pressure hydrocephalus. Mrs. J revealed that her husband has been
suffering from progressive memory and thinking problems for approximately two years. This
past year has been especially difficult, as he now requires extensive assistance with ADL care
and constant supervision. The two live alone with no other support.
4. Based on the pre-op laboratory tests, what do you think could be going on? Check the best
answer.
a. The results suggest dehydration, which could be exacerbating his existing dementia.
b. The results suggest kidney damage and a nephrology consult should be ordered STAT.
c. The results should be expected because they are normal for a patient with Parkinson's
disease.
5. Dehydration can be a cause of delirium. True or False?
True
False
Twelve hours following admission, Mr. J undergoes an Open Reduction Internal Fixation (ORIF)
of his right hip. While in the recovery room, Mr. J wakes up and pulls out his indwelling
catheter. He is disruptive, agitated, and obviously frightened. The physician orders a medication
to help Mr. J relax, and after three hours, he is transferred to a medical bed.
Mr. J is hospitalized for seven days. His confusion gradually improves with less agitation and
aggression. Delusions have completely resolved and he is now oriented x2 (unable to recall
place). He remains difficult to direct and requires frequent prompting for simple tasks. He has
had limited success with physical therapy for these reasons.
Throughout the week, Mrs. J has demonstrated signs of caregiver burden. She is at the hospital
from early morning to late evening every day, she feeds her husband, and tries to transfer him to
the bathroom. She comes alone and Mr. J has had no other visitors. She comments to you, "I
don't know if I can do this anymore."
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6. Mrs. J asks you if her husband has Alzheimer's disease. What do you say? Check all that
apply.
a. "We need to wait for the test results."
b. "Does your husband have a family history of Alzheimer's disease or any other form of
dementia?"
c. "There are many factors that could be affecting you husband's memory. For instance,
dementia is often seen with Parkinson's disease."
d. "I understand why you would have this concern. There is no evidence that clearly suggests
Alzheimer's disease at this point."
e. "I've seen this time and time again. It definitely looks like Alzheimer's disease."
7. What nonpharmacological measures would help to reduce Mr. J's agitation and aggression?
Check all that apply.
a. Remove unnecessary devices and equipment from the room.
b. Provide as consistent and structured a routine as possible.
c. Play soft, soothing music in his room and limit extraneous noises.
d. Avoid interruptions during sleep. Schedule all tests, vital signs, etc. during waking hours if
possible.
e. Reduce bright lighting by pulling down his shades and only using lights that are required.
f. Allow his wife to bring familiar items from home (i.e. favorite blanket, his own pajamas,
etc.).
8. Keeping in mind Mr. J's mental status, what assessments do you feel are important? Check all
that apply.
a. Orientation
b. Fall risk
c. Pain
d. Vital signs
e. Mood checks
f. Blood glucose levels
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Two days before discharge, you begin speaking with Mrs. J about her husband's transfer to
home. She still appears distraught and asks you to repeat your instructions over and over again.
Mrs. J later reveals that they have no family in the area. She is also finding it difficult to pay the
bills. Although she has an interest in working again, she has no choice but to stay at home with
her husband.
Mr. J returns home, and within five hours, he is visited by the home health nurse. The nurse
performs a comprehensive evaluation and orders daily nursing care for five hours each morning,
and home physical therapy three times a week. The nurse works closely with Mrs. J to
implement available community services. After three weeks, Mrs. J is exhibiting less caregiver
burden and Mr. J's dementia is stable.
9. What can you do to ensure Mrs. J understands the discharge plans? Check all that apply.
a. Write the discharge instructions clearly, use simple language, and provide a copy for Mrs.
J while education is being performed.
b. Encourage Mrs. J to bring along a trusted friend to the discharge planning meetings. It is
always beneficial to have a second set of ears.
c. Hold the discharge planning meetings in a quiet room free of distractions.
d. Ask Mrs. J about her own cognitive status and suggest she take a neuropsychological test.
10. What resources could you suggest to help Mrs. J manage her own psychosocial challenges?
Check all that apply.
a. Services via Area Agency on Aging.
b. Meals on Wheels.
c. Adult day program for Mr. J.
d. Local support group for caregivers.
e. Alternative living options (such as assisted living/nursing home).
11. Caring for someone with dementia is associated with a higher level of stress than caring for
someone with functional impairment from another type of chronic illness. True or False?
True
False
12. What elements constitute a "comprehensive" home nursing evaluation for a patient with
dementia? Check all that apply.
a. Thorough medical history and review of medications.
b. Social history.
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c. Environmental assessment of the home.
d. Discussion of Advanced Directives/Power of Attorney of Healthcare.
e. Visual and hearing assessment.
f. Pain assessment.
g. Past and present alcohol/drug use.
h. Understanding of condition prior to hospitalization.
i. Cerebrovascular Accident (CVA).
j. Nutritional assessment.
k. Sleep/rest assessment.
l. Discussion of treatment goal and development of treatment plan.
13. What interventions can the home care nurse teach Mrs. J to help manage her husband's
dementia in the home? Check all that apply.
a. Use old sheets to restrain him in a chair to reduce wandering and risk of falls.
b. Encourage a regular sleep/wake cycle.
c. Rearrange furniture to allow for wide, open walkways.
d. Ensure regular correspondence with his healthcare providers.
e. Use calendars and clocks for orientation.
f. Keep a consistent, daily routine.
g. Keep lighting low at night.
h. Accept assistance from friends and neighbors.
i. Do not challenge hallucinations or delusions.
j. Keep the doors locked to avoid wandering outside the home.
k. Restrict activities to first floor.
l. Take time for yourself.
Answer Guide: Page 60
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V.BuildingontheFoundation:ManagingMemoryImpairment
You have almost completed this web-based training module. By now you should be an expert at
caring for patients with cognitive impairment and their caregivers. The next time you admit a
patient, you will be on the lookout for neuropsychologic symptoms such as alteration in thinking,
difficulty with speech and language, and poor judgment. If you suspect cognitive impairment,
you will likely enlist the nursing assistant and educate him or her on how best to care for this
patient. You will change your approach to pain management, assessing for nutritional status, fall
prevention, and incontinence, to aid in the patient's adaptation to the hospital environment. As
you prepare the patient for discharge, you will work with the social worker, anticipate the patient
and caregiver's needs, and ensure a smooth transition from hospital to home.
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Appendix
ModuleQuestionsAnswerGuide
Delirium, page 9
Answer: C
Enhancing Care Coordination, pages 54-58
Q1. Answer: all
Q2. Answer: D
Q3. Answer: A
Q4. Answer: A
Q5. Answer: A
Q6. Answer: B, C, D
Q7: Answer: all
Q8: Answer: all
Q9: Answer A, B, C
Q10: Answer: all
Q11: Answer: A
Q12: Answer: all
Q13: Answer: B, C, D, E, F, G, H, I, J, K, L
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Dementia and Delirium Education Modules: Pre-Test/Post-Test
DementiaandDeliriumPre‐Test
1. The universal goal of dementia care is to maximize quality of life. (Points: 1)
True
False
2. The prognosis of hospitalized older adults with delirium is the same as those without delirium.
(Points: 1)
True
False
3. Chronic alcoholism can cause dementia. (Points: 1)
True
False
4. Alcohol withdrawal can cause dementia. (Points: 1)
True
False
5. Depression and anxiety screens are most critical in the early stages of dementia. (Points: 1)
True
False
6. Laboratory and neuroimaging tests are essential components of initial examination and
diagnosis of dementia and delirium. (Points: 1)
True
False
7. The Folstein Mini-Mental State Exam (MMSE) can only be administered by a physician or
psychologist. (Points: 1)
True
False
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Dementia and Delirium Education Modules: Pre-Test/Post-Test
8. Cognitive impairment can lead to reduced food and fluid intake, which can lead to dehydration
and weight loss. (Points: 1)
True
False
9. Which of the following laboratory tests should be ordered during an initial work-up for
dementia vs. delirium? Choose the best answer. (Points: 1)
a. Blood chemistry
b. Complete blood count (CBC)
c. Thyroid studies
d. Vitamin B12
e. All of the above
10. How would you respond to a patient's wife who says, "The doctor said my husband has
dementia, what does that mean?" (Points: 1)
a. Dementia is a normal part of the aging process. It is to be expected for someone your
husband's age.
b. Dementia is a complex medical condition. It suggests that your husband is experiencing a
rapid decline in his memory and other cognitive functions.
c. This most likely means he has Alzheimer's disease. He will gradually lose his ability to
think, communicate, and care for himself.
d. There are many potential causes of dementia. Some are reversible and some are not. His
medical history, symptom presentation, and most recent blood and imaging tests will help
us get a better sense of his diagnosis.
11. The most common type of dementia is: (Points: 1)
a. Vascular dementia
b. Lewy Body dementia
c. Alzheimer's disease
d. Frontotemporal dementia
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Dementia and Delirium Education Modules: Pre-Test/Post-Test
12. You have a patient who carries a diagnosis of Alzheimer's disease. You find him wandering
in the halls after you have asked him several times to remain in bed. The night nurse who gave
you report this morning said that he was awake several times during the night ringing his call
bell, and when she went into his room, he was tangled in his IV line. When she tried to untangle
the line, he hit her arm and said "stop touching me, you don't even know me." What stage of
Alzheimer's disease do you think he is experiencing? (Points: 1)
a. Mild stage
b. Moderate stage
c. Severe stage
d. Profound stage
13. Which of the following is NOT a typical characteristic of frontotemporal dementia? (Points:
1)
a. Uninhibited socially inappropriate behavior
b. Inappropriate sexual behavior
c. Compulsive oral and eating fixation
d. Age of onset is 75 years or older
14. You can identify that your patient is at risk for delirium in the hospital because she has which
of the following? (Points: 1)
a. Pre-existing depression
b. Other comorbid conditions such as anemia or heart disease
c. Pre-existing cognitive impairment
d. Advanced age
e. All of the above
15. Which of the following pairs is matched correctly? (Points: 1)
a. Apraxia: Difficulty with language
b. Agnosia: Difficulty with balance
c. Aphasia: Difficulty with language
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Dementia and Delirium Education Modules: Pre-Test/Post-Test
d. Apraxia: Difficulty identifying objects
16. The hallmark characteristic of Lewy Body dementia is: (Points: 1)
a. Visual hallucinations
b. Frequent falls
c. Sudden physical agitation
d. Slowly progressive language disturbance
17. Mrs. McMinn is a 70 year-old woman admitted for rule out stroke after a fall while shopping.
You think she is developing vascular dementia because you have observed: (Points: 1)
a. Verbal aggression
b. Abrupt onset of memory and cognitive changes
c. Auditory hallucinations
d. Misplacing personal items
18. Which of the following is NOT true of polypharmacy? (Points: 1)
a. Polypharmacy refers to the number of medications as well as the chemical combination
of those medications.
b. Only drugs such as sedative-hypnotics and narcotics can cause polypharmacy.
c. Polypharmacy can occur with the use of over the counter and herbal medications.
d. The effects of polypharmacy can happen at any time, they do not have to happen at the
moment when the patient takes the new medication.
19. What is the biggest risk factor for developing delirium? (Points: 1)
a. Family history of delirium
b. Acute illness
c. Advanced age
d. Pre-existing dementia
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Dementia and Delirium Education Modules: Pre-Test/Post-Test
20. Which of the following is a consequence of untreated Delirium Superimposed on Dementia
(DSD)? (Points: 1)
a. Prolonged length of stay
b. Permanent functional decline
c. Increased use of chemical and physical restraints
d. All of the above
21. Which statement best describes the CAM (Confusion Assessment Method)? (Points: 1)
a. The CAM is a four-item test where patients are asked to look at pictures and describe
what they see. If they describe two incorrectly, they are considered to have delirium.
b. The CAM is a 10-item questionnaire administered to a caregiver that asks questions
around cognitive function at home, ability to bathe and use the bathroom, and sleep
patterns.
c. The CAM is a four-item algorithm that enables clinicians to quickly and accurately
identify delirium in hospitalized older adults. Patients are identified as positive for
delirium if three of the four following elements are present as reported by caregivers
(acute onset and fluctuating course, altered level of consciousness, disorganized thinking,
and inattention).
d. The CAM is an instrument completed by the nurse that asks questions about observed
behavior of the patient. Based on the nurse's observations, it will be determined whether
or not the patient has delirium.
22. You think your patient may have some memory and thinking problems, and you want to use
a tool to assess his ability with recall, orientation, registration, language, short-term memory, and
calculation. What tool will you use? (Points: 1)
a. Delirium Rating Scale-Revised-98 (DRS-98)
b. Intelligence Quotient Test (IQ)
c. Lawton's Instrumental Activities of Daily Living
d. Mini-Mental State Exam (MMSE)
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23. Functional impairment (i.e.: difficulty driving, paying bills, cooking) is often an early sign of
dementia. (Points: 1)
True
False
24. We know that elderly patients with cognitive impairment do not experience pain as much as
younger patients do because they do not complain about it as much. (Points: 1)
True
False
25. Patients with memory and thinking problems sometimes act inappropriately given the current
situation because of their insight and judgment. (Points : 1)
True
False
26. Suicidal ideation is common in the acutely ill older adult with cognitive impairment. (Points:
1)
True
False
27. If a patient with cognitive impairment experiences a visual hallucination, it must mean he or
she is crazy. (Points: 1)
True
False
28. Mrs. Williams is an 82 year-old woman with COPD admitted for shortness of breath. She
lives in an assisted living facility with her sister, who is 75 years old. She is normally
independent with activities of daily living, but right now she cannot walk without "losing her
breath." Her sister states that Mrs. Williams has become forgetful lately, and often asks the same
questions over and over. She has also had some "accidents" and does not want to leave the house
for fear of wetting herself in public. Based on your assessment so far, which of the following
scenarios is LEAST LIKELY for Mrs. Williams? (Points: 1)
a. She is at risk to fall because she is experiencing an exacerbation of chronic illness and
has signs of memory impairment.
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b. She is at risk for incontinence in the hospital, because she is already experiencing some
incontinence in the community and is in a new environment.
c. She is at risk for delirium, but will probably respond well to frequent reorientation and
decreased environmental stimuli.
d. She is at risk for delirium, but will probably respond well to soft restraints, which will
remind her not to pull out her IV.
29. You are caring for Mr. Mathias, a 79 year-old man who was admitted last night for chest
pain. He has a history of "prostate problems" and "recent memory problems" according to his
wife, who is 76 years old. He is on strict bed rest, and has had 3 episodes of incontinence since
admission, because he can't figure out how to use the urinal. You realize that he is at risk for
urinary tract infections, so how will you instruct the nursing assistant to help you recognize early
signs and symptoms? (Points: 1)
a. Tell her to remind Mr. Mathias every two hours or so how to use the urinal, and check his
bed sheets frequently for episodes of incontinence, because he may be embarrassed to tell
you.
b. Tell her to be on the lookout for foul smelling, dark colored urine and report it to you,
even if the patient is not complaining of any pain on urination.
c. Tell her to firmly request that Mr. Mathias follow the nurse's instructions that were given
four hours ago on how to use the urinal and then ring the call bell to let someone know it
needs to be emptied.
d. Answers A and B.
30. You are caring for Mrs. Peabody, who is second day s/p hip replacement, and has been noted
with some memory and thinking problems. The nursing assistant comes to you and says, "Mrs.
Peabody had an episode of incontinence, but I can't clean her up because she is holding the side
rail tightly and will not let go to turn to the side. When I tried to tell her she was wet, she just
clenched her eyes closed. I don't think she likes me very much." What is the most likely
explanation for Mrs. Peabody's behavior? (Points: 1)
a. She does not like the nursing assistant, so she is refusing care.
b. She is experiencing pain, but is having difficulty verbalizing her feelings.
c. She would rather sleep than be cleaned up.
d. None of the above.
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31. Which of the following is NOT an age-related change that you may encounter during your
physical exam? (Points: 1)
a. The elderly can experience hypotension with sudden position changes, leading to
dizziness and falls.
b. The elderly may experience a blunting of symptoms for problems related to the
gastrointestinal system, making early warning signs difficult to detect.
c. The elderly experience dementia or memory and thinking problems as a normal agerelated change.
d. The elderly experience a delay in the signal telling them to void and decreased bladder
capacity, which can lead to incontinence.
32. When assessing a patient's neuropsychologic status, what are some key areas on which to
focus? (Points: 1)
a. Activity level
b. Emotional state
c. Speech and language abilities
d. All of the above
33. You go into Mr. Morris' room to take his blood pressure, and he says to you, "If my wife
comes to visit, tell her I'm not here. If you let her come in this room, she will surely kill me. I
know she is out to get me." Mr. Morris is most likely experiencing: (Points: 1)
a. Depression
b. A delusion
c. Obsessive behavior
d. Suicidal ideation
34. Poor hearing or vision can contribute to a patient misinterpreting environmental stimuli.
(Points: 1)
True
False
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35. When dealing with a patient that exhibits aggressive behavior, always confront the patient
immediately. (Points: 1)
True
False
36. Patients with aphasia have difficulty understanding and/or using verbal language to
communicate. (Points: 1)
True
False
37. People with memory and thinking problems always need assistance with basic Activities of
Daily Living. (Points: 1)
True
False
38. Patients with cognitive impairment do not have the capacity to express their health care
preferences. (Points: 1)
True
False
39. Which of the following is characterized by unrealistic beliefs, such as suspicion? (Points: 1)
a. Hallucinations
b. Delusions
c. Paranoia
d. None of the above
40. Which of the following is NOT true of capacity? (Points: 1)
a. Capacity can vary depending on the complexity of the decision.
b. Capacity must be determined by the psychiatrist, and cannot be changed once it is
documented.
c. Capacity is a clinical decision; it is not a question of competency.
d. People with some memory and thinking problems can still have capacity.
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41. Which of the following is true of caregivers? (Points: 1)
a. The majority of caregivers are spouses, primarily wives.
b. Caregivers experience high levels of depression.
c. The patient's delusions and agitation contribute to emotional distress in caregivers.
d. All of the above.
42. You are the caregiver for Mr. M, who was discharged from the hospital last week after an
episode of acute delirium, which was found to be caused by pneumonia. Once the pneumonia
was cleared, it was discovered that Mr. M has some memory and thinking problems. You are
taking him to his follow-up appointment at the pulmonologist's office. Which of the following
actions would be LEAST helpful in ensuring a successful visit? (Points: 1)
a. Make a list of health care concerns ahead of time and bring it to the visit.
b. Make a list of all the health care providers the patient sees and give a copy to the
pulmonologist.
c. Send Mr. M into the exam room alone, and tell him to remember everything the doctor
says so he can tell you in the car ride home.
d. Bring all of the medications the patient is taking, so the doctor can see them first hand.
43. Mr. P is about to be discharged, and you ask his wife if she has any further questions about
the instructions you provided. Mrs. P states that she is already getting frustrated because she tried
to explain the new medications to Mr. P, and he keeps asking her the same questions over and
over, or changes the topic completely. How would you advise Mrs. P to deal with these
communication difficulties? (Points: 1)
a. Just ignore him and tell him to take the pills you give him.
b. Raise your voice, that way he'll know not to ask the same question again.
c. Minimize distractions and use simple words and short sentences.
d. Give up because there is no way she can help Mr. P to understand his medications.
Dementia and Delirium Pre-Test Answer Guide: Pages 71-72
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DementiaandDeliriumPre‐TestAnswerGuide
Q1. True
Q2. False
Q3. True
Q4. True
Q5. True
Q6. True
Q7: False
Q8: True
Q9: Answer E
Q10: Answer: D
Q11: Answer: C
Q12: Answer: B
Q13: Answer: D
Q14: Answer: E
Q15: Answer: C
Q16: Answer: A
Q17: Answer: B
Q18: Answer: B
Q19: Answer: D
Q20: Answer: D
Q21: Answer: C
Q22: Answer: D
Q23: True
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Q24: False
Q25: True
Q26: True
Q27: False
Q28: Answer: D
Q29: Answer D
Q30: Answer: B
Q31: Answer: C
Q32: Answer: D
Q33: Answer: B
Q34: True
Q35: False
Q36: True
Q37: False
Q38: False
Q39: Answer: C
Q40: Answer: B
Q41: Answer: D
Q42: Answer: C
Q43: Answer: C
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UnderstandingCognitiveImpairment‐ProficiencyQuestions
1. The universal goal of dementia care is to maximize quality of life. (Points: 1)
True
False
2. The prognosis of hospitalized older adults with delirium is the same as those without delirium.
(Points: 1)
True
False
3. Chronic alcoholism can cause dementia. (Points: 1)
True
False
4. Alcohol withdrawal can cause delirium. (Points: 1)
True
False
5. Depression and anxiety screens are most critical in the early stages of dementia. (Points: 1)
True
False
6. Laboratory and neuroimaging tests are essential components of initial examination and
diagnosis of dementia and delirium. (Points: 1)
True
False
7. The Folstein Mini-Mental State Examination (MMSE) can only be administered by a
physician or psychologist. (Points: 1)
True
False
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8. Cognitive impairment can lead to reduced food and fluid intake, which can lead to dehydration
and weight loss. (Points: 1)
True
False
9. Which of the following laboratory tests should be ordered during an initial work-up for
dementia vs. delirium? Check the best answer. (Points: 1)
a. Blood Chemistry
b. Complete blood count (CBC)
c. Thyroid studies
d. Vitamin B12
e. All of the above
10. How would you respond to a patient’s wife who says, “The doctor said my husband has
dementia; what does this mean?” (Points: 1)
a. Dementia is a normal part of the aging process. It is to be expected for someone your
husband’s age.
b. Dementia is a complex medical condition. It suggests that your husband is experiencing
a rapid decline in his memory and other cognitive functions.
c. This most likely means that he has early Alzheimer’s disease. He will gradually lose his
ability to think, communicate, and care for himself.
d. There are many potential causes of dementia. Some are reversible and some are not. His
medical history, symptom presentation and recent blood and imaging tests will help us
get a better sense of his exact diagnosis.
11. The most common type of dementia is: (Points: 1)
a. Vascular dementia
b. Lewy body dementia
c. Alzheimer’s disease
d. Frontotemporal dementia
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12. You have a patient who carries a diagnosis of Alzheimer’s disease. You find him
wandering in the halls after you have asked him several times to remain in bed. The night nurse
who gave you report this morning said that he was awake several times during the night ringing
his call bell, and when she went into his room, he was tangled in his IV line. When she tried to
untangle the line, he hit her arm and said “stop touching me, you don’t even know me.” What
stage of Alzheimer’s disease do you think he is experiencing? (Points : 1)
a. Mild stage
b. Moderate stage
c. Severe stage
d. Profound stage
13. Which of the following is NOT a typical characteristic of Frontotemporal dementia? (Points:
1)
a. Uninhibited and socially inappropriate behavior
b. Inappropriate sexual behavior
c. Compulsive oral and eating fixation
d. Age of onset is 75 years or older
14. You can identify that your patient is at risk for delirium in the hospital because she has which
of the following? (Points: 1)
a. Pre-existing depression
b. Other comorbid conditions such as anemia or heart disease
c. Pre-existing cognitive impairment
d. Advanced age
e. All of the above
15. Which of the following pairs are matched correctly? (Points: 1)
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a. Apraxia: difficulty with language
b. Agnosia: difficulty with balance
c. Aphasia: difficulty with language
d. Apraxia: difficulty identifying objects
16. The hallmark characteristic of Lewy Body Dementia is: (Points: 1)
a. Visual hallucinations
b. Frequent falls
c. Sudden physical agitation
d. Slowly progressive language disturbance
17. Mrs. McMinn is a 70 year old woman admitted for rule out stroke after a fall while shopping.
You think she is developing Vascular Dementia because you have observed: (Points: 1)
a. Verbal aggression
b. Abrupt onset of memory and cognitive changes
c. Auditory hallucinations
d. Misplacing personal items
18. Which of the following is NOT true of polypharmacy? (Points: 1)
a. Polypharmacy refers to the number of medications as well as the chemical combination
of those medications.
b. Only drugs such as sedative-hypnotics and narcotics can cause polypharmacy.
c. Polypharmacy can occur with the use of over the counter and herbal medications.
d. The effects of polypharmacy can happen at any time, they do not have to happen at the
moment when the patient takes a new medication.
19. What is the biggest risk factor for developing delirium? (Points: 1)
a. Family history of delirium in the hospital
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b. Acute illness
c. Advanced age
d. Pre-existing dementia
20. Which of the following is a consequence of untreated Delirium Superimposed on Dementia
(DSD)? (Points: 1)
a. Prolonged length of stay
b. Permanent functional decline
c. Increased use of chemical and physical restraints
d. All of the above
21. Which statement best describes the CAM (Confusion Assessment Method)? (Points: 1)
a. CAM is a four-item test where patients are asked to look at pictures and describe what
they see. If they describe two incorrectly, they are considered to have delirium.
b. The CAM is a 10 item questionnaire administered to caregivers that asks questions
around cognitive function at home, ability to bathe and use the bathroom, and sleep
patterns.
c. CAM is a four-item algorithm that enables clinicians to quickly and accurately identify
delirium in hospitalized older adults. Patients are identified as positive for delirium if
three of the four following elements are present as reported by caregivers (acute onset
and fluctuating course, altered level of consciousness, disorganized thinking, and
inattention).
d. CAM is an instrument completed by the nurse that asks questions about observed
behavior of the patient. Based on the nurse’s observations, it will be determined whether
or not the patient has delirium.
22. You think your patient may have some memory and thinking problems, and you want to use
a tool to assess his ability with recall, orientation, registration, language, short-term memory, and
calculation. What tool will you use? (Points: 1)
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a. Delirium Rating Scale-Revise-98 (DRS-98)
b. Intelligence Quotient Test (IQ)
c. Lawton’s Instrumental Activities of Daily Living
d. Mini-Mental State Exam (MMSE)
Understanding Cognitive Impairment - Proficiency Questions - Answer Guide: Page 79
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UnderstandingCognitiveImpairment‐AnswerGuide
Q1. True
Q2. False
Q3. True
Q4. True
Q5. True
Q6. True
Q7: False
Q8: True
Q9: Answer E
Q10: Answer: D
Q11: Answer: C
Q12: Answer: B
Q13: Answer: D
Q14: Answer: E
Q15: Answer: C
Q16: Answer: A
Q17: Answer: B
Q18: Answer: B
Q19: Answer: D
Q20: Answer: D
Q21: Answer: C
Q22: Answer: D
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AssessingPatientRiskforCognitiveImpairment‐ProficiencyQuestions
1. Functional impairment (i.e. difficulty driving, paying bills, cooking) is often an early sign of
dementia. (Points: 1)
True
False
2. We know that elderly patients with cognitive impairment do not experience pain as much as
younger patients do because they do not complain about it as much. (Points: 1)
True
False
3. Patients with memory and thinking problems sometimes act inappropriately given the current
situation because they lack insight and judgment. (Points: 1)
True
False
4. Suicidal ideation is common in the acutely ill older adult with cognitive impairment. (Points:
1)
True
False
5. If a patient with cognitive impairment experiences a visual hallucination, it must mean he or
she is crazy. (Points: 1)
True
False
6. Mrs. Williams is an 82 year old woman with COPD admitted for shortness of breath. She lives
in an assisted living facility with her sister, who is 75 years old. She is normally independent
with activities of daily living, but right now she cannot walk without “losing her breath.” Her
sister states that Mrs. Williams has become forgetful lately, and often asks the same questions
over and over. She has also had some “accidents” and does not want to leave the house for fear
of wetting herself in public. Based on your assessment so far, which of the following scenarios is
LEAST LIKELY for Mrs. Williams? (Points: 1)
a. She is at risk to fall because she is experiencing an exacerbation of chronic illness and
has signs of memory impairment.
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b. She is at risk for incontinence in the hospital, because she is already experiencing some
incontinence in the community and is in a new environment.
c. She is at risk for delirium, but will probably respond well to frequent reorientation and
decreased environmental stimuli.
d. She is at risk for delirium, but will probably respond well to soft restraints, which will
remind her not to pull out her IV.
7. You are caring for Mr. Mathias, a 79 year old man who was admitted last night for chest pain.
He has a history of “prostate problems” and “recent memory problems” according to his wife,
who is 76 years old. He is on strict bed rest, and has had 3 episodes of incontinence since
admission, because he can’t figure out how to use the urinal. You realize that he is at risk for
urinary tract infections, so how will you instruct the nursing assistant to help you recognize early
signs and symptoms? (Points: 1)
a. Tell her to remind Mr. Mathias every 2 hours or so how to use the urinal, and check his
bed sheets frequently for episodes of incontinence, because he may be embarrassed to tell
you.
b. Tell her to be on the lookout for foul smelling dark colored urine and report it to you,
even if the patient is not complaining of any pain on urination.
c. Tell her to firmly request that Mr. Mathias follow the nurse’s instructions that were given
4 hours ago on how to use the urinal and then ring the call bell to let someone know it
needs to be emptied.
d. Answers A and B.
8. You are caring for Mrs. Peabody, who is second day s/p hip replacement, and has been noted
with some memory and thinking problems. The nursing assistant comes to you and says, “Mrs.
Peabody had an episode of incontinence, but I can’t clean her up because she is holding the side
rail tightly and will not let go to turn to the side. When I tried to tell her she was wet, she just
clenched her eyes closed. I don’t think she likes me very much.” What is the most likely
explanation for Mrs. Peabody’s behavior? (Points: 1)
a. She does not like the nursing assistant, so she is refusing care.
b. She is experiencing pain, but is having difficulty verbalizing her feelings.
c. She would rather sleep than be cleaned up.
d. None of the above.
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9. Which of the following is NOT an age-related change that you may encounter during your
physical exam? (Points: 1)
a. The elderly can experience hypotension with sudden position changes, leading to
dizziness and falls.
b. The elderly may experience a blunting of symptoms for problems related to the
gastrointestinal system, making early warning signs difficult to detect.
c. The elderly experience dementia or memory and thinking problems as a normal agerelated change.
d. The elderly experience a delay in the signal telling them to void and decreased bladder
capacity, which can lead to incontinence.
10. When assessing the patient’s neuropsychologic status, what are some key areas on which to
focus? (Points: 1)
a. Activity level
b. Emotional State
c. Speech and language abilities
d. All of the above
11. You go into Mr. Morris’ room to take his blood pressure, and he says to you, “If my wife
comes to visit, tell her I’m not here. If you let her come in this room, she will surely kill me. I
know she is out to get me.” Mr. Morris is most likely experiencing: (Points: 1)
a. Depression
b. A delusion
c. Obsessive behavior
d. Suicidal ideation
Assessing Patient Risk for Cognitive Impairment - Proficiency Questions - Answer Guide: Page
83
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Dementia and Delirium Education Modules: Post-test by section
AssessingPatientRiskforCognitiveImpairment‐AnswerGuide
Q1. True
Q2. False
Q3. True
Q4. True
Q5. False
Q6. Answer: D
Q7: Answer: D
Q8: Answer: B
Q9: Answer C
Q10: Answer: D
Q11: Answer: B
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HospitaltoHome:EducatingandSupportingPatientandFamily‐Proficiency
Questions
1. Poor hearing or vision can contribute to a patient misinterpreting environmental stimuli.
(Points: 1)
True
False
2. When dealing with a patient that exhibits aggressive behaviors, always confront the patient
immediately. (Points: 1)
True
False
3. Patients with aphasia have difficulty understanding and/or using verbal language to
communicate. (Points: 1)
True
False
4. People with memory and thinking problems always need assistance with basic Activities of
Daily Living. (Points: 1)
True
False
5. Patients with cognitive impairment do not have the capacity to express their health care
preferences. (Points: 1)
True
False
6. Which of the following is characterized by unrealistic beliefs, such as suspicion? (Points: 1)
a. Hallucinations
b. Delusions
c. Paranoia
d. None of the above
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7. Which of the following is NOT true of capacity? (Points: 1)
a. Capacity can vary depending on the complexity of the decision.
b. Capacity must be determined by a psychiatrist, and cannot be changed once it is
documented.
c. Capacity is a clinical decision; it is not a question of competency.
d. People with some memory and thinking problems can still have capacity.
8. Which of the following is true of caregivers? (Points: 1)
a. The majority of caregivers are spouses, primarily wives
b. Caregivers experience high levels of depression
c. The patient’s delusions and agitation contribute to emotional distress in caregivers
d. All of the above
9. You are the caregiver for Mr. M, who was discharged from the hospital last week after an
episode of acute delirium, which was found to be caused by pneumonia. Once the pneumonia
was cleared, it was discovered that Mr. M has some memory and thinking problems. You are
taking him to his follow-up appointment at the pulmonologist’s office. Which of the following
actions would be LEAST helpful in ensuring a successful visit? (Points: 1)
a. Make a list of health care concerns ahead of time and bring it to the visit.
b. Make a list of all the health care providers the patient sees and give a copy to the
pulmonologist.
c. Send Mr. M into the exam room alone, and tell him to remember everything the doctor
says so he can tell you in the car ride home.
d. Bring all of the medications the patient is taking so the doctor can see them first hand.
10. Mr. P is about to be discharged, and you ask his wife if she has any further questions about
the instructions you provided. Mrs. P states that she is already getting frustrated because she tried
to explain the new medications to Mr. P, and he keeps asking her the same questions over and
over, or changes the topic completely. How would you advise Mrs. P to deal with these
communication difficulties? (Points: 1)
a. Just ignore him and tell him to take the pills you give him
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b. Raise your voice, that way he’ll know not to ask the same question again
c. Minimize distractions and use simple words and short sentences
d. Give up because there is no way she can help Mr. P to understand his medications
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HospitaltoHome:EducatingandSupportingPatientandFamily‐Answer
Guide
Q1. True
Q2. False
Q3. True
Q4. False
Q5. False
Q6. Answer: C
Q7: Answer: B
Q8: Answer: D
Q9: Answer: C
Q10: Answer: C
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BuildingontheFoundation:ManagingMemoryImpairment‐Imagine
If...ThinkingOutsidetheBox
Mrs. M is a 64 year-old female who resides in a single-family home with her husband, daughter,
son-in-law, and four-year old grandson. She is employed as a receptionist at their church where
she works 20 hours a week. She reduced her hours to part-time three months ago due to “mental
exhaustion” with several near car accidents, diminished motivation, and difficulty remembering
names and phone numbers. Her husband and daughter have become concerned as she frequently
repeats herself and is easily frustrated and angered by her grandson. They convinced her to seek
medical evaluation after she forgot to turn off the stove and her grandson received second-degree
burns on both hands.
Mrs. M’s Medical Profile
• DOB: 12/5/40
• Race: African American
• PMH: Hypothyroidism
• Hypertension
• Hypercholestremia
• Family History of:
o Hypertension (mother and father)
o Ovarian cancer (mother)
o Osteoarthritis (mother and maternal grandmother)
o CVA (maternal grandfather)
o Alzheimer's disease (paternal grandfather)
o Lung cancer (paternal grandmother)
• Medications: Levothyroxine 50mcg qd
• Hydrochlorothiazide 50mg qd
• ASA 81 mg qd
• Multivitamin
Scoring review completed by experts to determine application of what was learned in the
modules.
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1. Mrs. M is evaluated by her primary care physician, Dr. Harvest. Physical examination is
unremarkable with the exception of a MMSE score of 22. Dr. Harvest decides to refer her to a
memory disorder specialist at the University of Pennsylvania. (Points: 1)
1) Imagine you are Dr. Harvest. What tests would you order? What is the significance of
her medical profile? How would you explain the purpose of the memory disorder referral
to Mrs. M and her family?
2) Imagine you are Mrs. M. What would you be thinking? How would you be feeling?
What would you want from your healthcare provider at this stage?
2. Mrs. M is evaluated three weeks later by the memory disorder specialist, Dr. Crest, and
diagnosed with early Alzheimer’s disease. Jane, a nurse in Dr. Crest’s office, provides education
to Mrs. M, her husband, and daughter. Mrs. M is started on donepezil 5mg at bedtime with
directions to increase the dose to 10mg after one month. She is scheduled for follow-up
evaluations every six months. (Points: 1)
1) Imagine you are Jane. What topics would you include in your initial education of
Alzheimer’s disease? How would you raise the issue of long-term care planning?
2) Imagine you are Mrs. M’s daughter. What would you be thinking? How would you be
feeling? What would you want from your mother’s healthcare provider at this stage?
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3. Mrs. M resigns from her position at the church approximately five months after diagnosis. She
spends the next seven months sitting in a chair, watching television, and declines all social
invitations. She has lost 15 lbs. since baseline and rarely shares meals with her family. She
suffers from severe insomnia at night, which causes her to sleep intermittently throughout the
day. Mr. M raises concerns about the drastic change in his wife’s personality at their next visit
with Dr. Crest. She is started on citalopram. Her MMSE score is 20. (Points: 1)
1) Imagine you are Dr. Crest. How would you assess Mrs. M’s mood with respect to her
cognitive deficits? What criteria would you use to diagnosis depression? Would you say
her cognition is stable based on her MMSE score?
2) Imagine you are Mrs. M. What would you be thinking? How would you be feeling?
What would you want from your healthcare provider at this stage?
4. Mrs. M’s mood is stable over the next year, however her cognition has demonstrated marked
decline. She enjoys reminiscing about the past yet cannot recall what she ate for breakfast. She
commonly loses her purse, shoes, and even money. She can no longer pay the bills, prepare
meals, or administer her own medications. She is able to perform ADLs with little assistance,
however her outfits are often bizarre and inappropriate. Mr. M requested early retirement from
his company in order to provide 24-hour supervision and maintain their home. He frequently
calls Jane at Dr. Crest’s office to report “she’s not getting better!” (Points: 1)
1) Imagine you are Jane. How would you counsel Mr. M? What would you teach him
about AD progression/prognosis? What are possible reasons that past educational efforts
have failed?
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2) Imagine you are Mr. M. What would you be thinking? How would you be feeling?
What would you want from your wife’s healthcare provider at this stage?
5. Approximately two years later, Mrs. M begins to demonstrate unusual behaviors, such as
talking to herself, urinating in the bed, and increased agitation. She insists that she is late for
work every morning and attempts to walk out the front door. She frequently lashes out at her
grandson, who is now afraid to be alone with “Nanny." Her husband is beginning to describe
symptoms of caregiver burden and states “I just want my wife back." They present to Dr. Crest
for a six month evaluation. Her MMSE score is 14. (Points: 1)
1) Imagine you are Dr. Crest. What medications would you start or stop? What nonpharmacological strategies would you recommend? What would you teach the family
about the cause and management of psychosis in AD? What community resources would
you suggest?
2) Imagine you are Mr. M. What would you be thinking? How would you be feeling?
What would you want from your wife’s healthcare provider at this stage?
6. Mrs. M is enrolled in an adult day program, which she attends three times a week. This has
provided some relief of caregiver burden for Mr. M, however the cost is becoming an issue for
their limited income. Over the next year, Mrs. M’s behavioral disturbances progress, and she is
now incontinent of bladder and sometimes bowel. Nights are most difficult as she wanders
throughout the house and falls several times a week. She often wakes up her family by turning on
all of the televisions in the home. Mrs. M’s daughter and son-in-law are beginning to
contemplate moving into their own home.
One particular night, Mr. M is awakened by loud sobs coming out of his wife’s bedroom. He
finds her in the fetal position on the floor holding her right arm. She is able to point to her chest
but cannot describe specific symptoms. Their daughter calls 9-1-1 and she is taken to the local
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ER. Echocardiogram is negative for a myocardial infarction and symptoms are relived with
nitroglycerine, suggesting angina. She is admitted and has an angiography the next day, which
shows an 80% blockage of two arteries. Three days later, she successfully undergoes an
angioplasty. Mrs. M’s daughter is at the hospital everyday with her father and frequently
complains that the nursing staff is ignoring her mother’s persistent moans and groans. (Points: 1)
1) Imagine you are the nurse caring for Mrs. M at the hospital. What specific nursing
strategies would you employ for this patient with dementia during her post-op care? How
would you manage her behavioral disturbances? How would you manage her pain?
2) Imagine you are Mrs. M’s daughter. What would you be thinking? How would you be
feeling? What would you want from your mother’s healthcare provider at this stage?
7. Mrs. M is ready for discharge after a six day stay and the social worker begins talking to Mrs.
M and her family about various discharge options. Mr. M comments that he is not yet ready for
his wife to return home, and they all agree on a temporary admission to a dual rehab
facility/nursing home. (Points: 1)
1) Imagine you are the social worker. What specific long-term care issues would you
discuss with the family at this stage of the disease?
2) Imagine you are Mr. M. What would you be thinking? How would you be feeling?
What would you want from your wife’s healthcare provider at this stage?
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8. Mrs. M’s transition to the rehab facility is rather seamless and she adjusts well to her new
environment. After five days however, Mr. M receives a phone call stating that Mrs. M is
extremely agitated, aggressive and more confused than usual. They were forced to restrain her
for one hour that afternoon after she hit three staff members and could not be managed. Mr. M
agrees to send his wife back to the local ER. She is found to have a urinary tract infection and is
prescribed antibiotic therapy. She returns to the rehab facility that same day. (Points: 1)
1) Imagine you are a nurse caring for Mrs. M at the rehab facility. What considerations
should be made when restraining a patient with dementia? What factors could have led to
her urinary tract infection? What preventive measures would you put in place to avoid
future urinary tract infections for this patient with dementia?
2) Imagine you are Mrs. M. What would you be thinking? How would you be feeling?
What would you want from your healthcare provider at this stage?
9. The antibiotic works well and Mrs. M returns to baseline after three days. She is prescribed
physical and occupational therapy at the rehab facility. The nurses enforce a very strict routine
for Mrs. M, and encourage her to participate with her ADL care. She attends daily social
activities, and especially enjoys reminiscing and music groups. She requires frequent prompting
and orienting, but can be left unsupervised for short durations of time while watching television
or sitting in her room. She is visited everyday by her husband however, her daughter refuses to
see her in an “old person home." (Points: 1)
1) Imagine you are the physical, occupation or activity therapist. How would you
encourage Mrs. M’s participation? What communication techniques would you use to
promote understanding? Why are these activities important?
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2) Imagine you are Mrs. M’s daughter. What would you be thinking? How would you be
feeling? What would you want from your mother’s healthcare provider at this stage?
10. Mrs. M’s Medicare coverage for rehab expires after 100 days. The social worker and nursing
staff begin talking to Mr. M about possible placement options for his wife. After deep
consideration, he chooses to have her return home. The social worker puts Mr. M in contact with
the Area Agency on Aging and home health assistance is set up free of cost through their Waver
program. Mary, the assigned home health aide, goes out to the house three times a week for three
hours each day to assist with ADLs and other necessary care. Mrs. M is already scheduled to
return to the nursing home for a week while Mr. M attends a family reunion over the summer.
(Points: 1)
1) Imagine you are Mary. What strategies would you teach the family to ensure a safe
and effective home environment for Mrs. M?
2) Imagine you are Mr. M. What would you be thinking? How would you be feeling?
What would you want from your wife’s healthcare provider at this stage?
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11. Mrs. M is now considered to be in the middle to late stages of Alzheimer’s disease, yet is
appropriately managed in the home. She continues to be followed by Dr. Crest and her MMSE
score is eight. Her family is coping well with the daily challenges presented by her disease. They
recently met with an attorney that specializes in elder law and estate planning. Mrs. M’s daughter
has come to terms with her mother’s prognosis, although she continues to experience anxiety
about her own risk of Alzheimer’s. She joins her father for a monthly AD support group and
plans on starting a scrapbook of her mother’s pictures and keepsakes for her son. (Points: 1)
Do you have any final thoughts?
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