Dementia & Neurological Deficts/Disorders

 Common Causes of Dementia

• Alzheimer's disease:

• Vascular dementia:

• Lewy body dementia:

• Frontotemporal dementia: 

• Mixed dementia:

• Alzheimer's disease: 

• Most common cause of dementia from abnormal buildup of amyloid plaques & neurofibrillary tangles

• Vascular dementia:

• caused by damage to vessels that supply blood to the brain

• Lewy body dementia:

• Lewy bodies are balloon like clumps of protein 

• Frontotemporal dementia: 

• degeneration of these lobes causing changes in behavior, language & personality

• Mixed dementia: 

• Changes occur as a result of 2> types of dementia at the same time

Dementia Statistics and Cause

• Not a normal part of aging

• Affects 15% of older Americans 

• 60% - 80% cases of dementia patients have Alzheimer’s disease (AD)

• Half patients in most long-term care facilities have a form of dementia

  • Due to treatable & untreatable conditions

• Two most common causes

  • Neurodegenerative conditions (60% - 80% of cases)

  • Vascular disorders

  • Other: Infections, inflammatory disease, metabolic & psychiatric disorders

Etiology of Dementia

• Important risk factors

  • Advanced age

  • Family history

• Infectious diseases can result in vascular & neurodegenerative changes leading to dementia

  • Bacterial meningitis 

  • Viral encephalitis

• Dementia caused by treatable conditions can be reversed 

• Prolonged exposure or disease may make dementia irreversible 

Etiology of Dementia: Vascular dementia 

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• ►Loss of cognitive function from brain lesions caused by cardiovascular disease

  • ►Ischemic lesions

  • ►Ischemic–hypoxic lesions

  • ►Hemorrhagic brain lesions

• Results in decreased blood supply from narrowing & blocking of arteries that supply brain

• Can be caused by a single stroke or multiple strokes

Dementia Signs & Symptoms

• Syndrome characterized by dysfunction or loss of 

  • Memory

  • Orientation

  • Attention

  • Language

  • Judgment 

  • Reasoning

Other characteristics 

• Personality changes

• Behavioral problems such as

  • Agitation 

  • Delusions

  • Hallucinations

Onset of Dementia

• Onset of dementia depends on cause

  • Insidious & gradual

  • Abrupt (Vascular dementia tends to be abrupt or progress in a stepwise pattern)

• Classifications

  • Mild

  • Moderate

  • Severe

• Initial symptoms are related to changes in cognitive function

• Family members often report:

  • Memory loss

  • Mild disorientation

  • Trouble with words & numbers

Diagnostic Process of Dementia

• Focused on cause 

  • Reversible or nonreversible 

• Thoroughly evaluate patient history

  • Medical

  • Neurologic

  • Psychologic 

• Mental status testing

• Mini mental state examination (mini cognition health assessment)

  • Commonly used tool

  • Assesses cognitive functioning

Diagnostic Process of Dementia

• Depression often mistaken for dementia & vice versa

• Manifestations of depression (especially in older adults)

  • Sadness

  • Difficulty thinking and concentrating

  • Fatigue

  • Apathy 

  • Feelings of despair

  • Inactivity

Common Diagnostic Studies

• CT scan (Computed Tomography)

• MRI (Magnetic Resonance Imaging)

• To characterize central nervous system (CNS) changes:

  • ►Single-photon emission computed tomography (SPECT)

  • ►Positron emission tomography (PET)

Common Problems of Dementia

• Aphasia

• Apraxia

• Agnosia

• Disturbance in executive functioning

• Aphasia

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• loss or inability to communicate verbally

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• Apraxia

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•  loss the ability to carry out purposeful movement

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• Agnosia

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• inability to recognize or identify objects 

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• Disturbance in executive functioning: 

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• loss of ability to organize, manage, and make decisions

• Inability to carry out basic tasks like bathing, eating, brushing teeth, and other ADL’s

Care of Patients with Dementia

• Provide a safe environment

• Facilitate communication:

  • Use simple language /avoid vague comments

  • Repeat in simple language if not understood/ demonstrate if needed

• Promote cognitive function:

  • Simple activities; empathize & support social activities

  • Dancing / music / board games

  • Person centered & appropriate for age

• Orientation to reality (use life review & reminisce techniques)

• Provide supervision (manage difficult behavior)

• Assist with ADL’s (encourage participation)

Mild Cognitive Impairment (MCI)

• Characteristics

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• Memory deficit (preferably confirmed by another person)

• Abnormal memory for age

• Intact activities of daily living

• Normal general cognitive functioning

• Normal overall thinking and cognitive functioning 

• Ability to perform activities of daily living

• Causes of MCI

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• Stress / Anxiety

• Depression

• Physical illness

Mild Cognitive Impairment (MCI)

• Percentage of patients with MCI who develop Alzheimer's Disease is unknown

• Presently no widely accepted guidelines for treatment due to:

  • ►Insufficient evidence

  • ►Research is being conducted

• Primary treatment consists of ongoing monitoring

Delirium

• An acute, reversible disturbance of mental function characterized by

  • Confusion, disorientation, memory & orientation to time, place, and person

• Rapid onset at night

• Fluctuates, usually worse at night

• Abrupt

• Hours to <1 month

• Sleep pattern often reversed

Parkinson’s Disease

• : a chronic, progressive brain disorder affecting movement & other body systems 

cause of parkinsons disease

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• Unknown: believed to be related to a combination of factors, including genetics & environmental exposure(s). Some research suggests exposure to farming chemicals, Agent Orange, heavy metals, detergents, & solvents may play a role

risk factor of parkinsons disease

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• Anyone could be at risk, but Parkinson's disease affects more men than women. Age is a clear risk factor, as most people develop disease after age 60 

treatment of parkinsons

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• There's no cure for Parkinson’s; medications can help control symptoms. A medical professional can diagnose Parkinson's & provide management to improve symptoms 

Parkinson’s Disease symptoms

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• Symptoms include shaking, stiffness, slow movement, balance problems, masked face and coordination issues. Other symptoms include difficulty walking and talking, mental and behavioral changes, sleep problems, depression, memory difficulties, and fatigue

• Symptoms of End-Stage Parkinson's Disease:

Speaking: softer voice that trails off or loss of communication ability

• Falling & trouble with balance & coordination

• Freezing: sudden, but temporary, inability to move, when you start to walk or change direction. Moving without assistance or a wheelchair

Alzheimer’s Disease (AD)

• Chronic, progressive, degenerative disease of the brain

  • Most common form of dementia

  • 4.5 million Americans suffer from AD

  • Economic cost of caring in the US is at least $100 billion annually

• Burden on patient, family, caregivers, & society as a whole

• Women more likely to develop AD

• Exact etiology is unknown

• Like other forms of dementia

• Age is most important risk factor

  • Early onset

  • Late onset

• Familial Alzheimer's disease history

Alzheimer’s Disease (AD):Beta-Amyloid Plaques build up in parts of the brain used for

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• Memory 

• Cognitive function (Hippocampus) 

• Eventually develops in the cerebral cortex

• Early signs of Alzheimer’s disease

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• Memory loss affecting job skills

• Difficulty performing familiar tasks

• Problems with language

• Disorientation to time & place

• Poor or decrease judgment

• Problems with abstract thinking

• What is a seizure:

• An abrupt onset of an electrical disturbance activity of the brain. A group of neurons fire abnormally resulting  in

  • Motor symptoms of rhythmic jerking

  • Sometimes decreased or loss of LOC 

  • Symptoms & duration vary depending on the location in the brain

• Duration of Seizures:

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• Generally short:30 seconds to 3-4 minutes. Anything longer may be a medical emergency if >5 minutes or breathing stops

• Incidence of seizure

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• Most prevalent in children <10 years of age & in adults >65 years

• More common among males (children)

• Some children with seizures grow out of the condition

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• Generalized seziures

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• widespread electrical activity on both sides of the brain at once

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• Focal Seizures (partial) seizures

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• electrical discharge from one side in a limited area of the brain

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• Recurrent Seizures: 

• due to brain disorder known as Epilepsy

• Specific Types of seizures:

• Tonic-clonic (grand mal):

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• general body stiffening, rhythmic jerking of limbs, loss of consciousness, loss of bladder and bowel control

• Specific Types of seizures:

• Clonic

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• spasms of face, neck or arm muscles

• Specific Types of seizures:

• Tonic

• brief spasms of arms, legs or trunk often during sleep 

Seizure Disorders

• Atonic

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• sudden loss of muscle tone, also called drop seizures

Seizure Disorder

• Myoclonic

• muscle  spasms  that resemble the sensation of a shock

Seizure Disorders:

• Absence (petit mal):

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• brief disconnection, such as a blank stare, eyes rolling back

Seizure Disorders

• Potential complications:

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• Respiratory depression or arrest

• Tongue biting, bleeding, avulsion (tear away from normal position)

• Social stigma, withdrawal, isolation

• Impact on family, stress, and fear of recurring episodes

• Medications can have side effects: rash, GI upset, blood disorders

• Some types of epilepsy can lead to underemployment, learning disabilities, & memory lapses

Seizure Disorders

Common Causes 

• Epilepsy

• Brain tumor, Brain injury (concussion, hematoma, edema), Stroke

• Low O2 at birth

• Meningitis, encephalitis (infection)

• Genetic Conditions (tuberous sclerosis)

• Formation of the brain after birth

• Unknown cause?

Common Triggers

Seizure Disorders

• Sleep deprivation

• Stress, illness, hormonal fluctuations (puberty/menstruation)

• High rapid onset of fever (esp. children)

• Alcohol/drug withdrawal or mood-altering substances

• Drug interactions

• Rapid flashing bright lights or certain visual patterns

• Low serum Na+, Ca+, Mg, glucose

• Vit B6 deficiency

• Drug interactions with seizure medications or missed dose

Seizure Disorders

• Nursing Assessment:

  • ►Assess for triggers & risk factors

  • ►Assess airway during a seizure

  • ►Observe nystagmus (rapid eye movement from side to side), drooling, confusion, motor activity, and breathing quality

  • ►Monitor post seizure behavior: muscle tone, strength ability to speak, memory and orientation

Seizure Disorders: Safety Measures

• Precautions for known history of seizures:

  • Be prepared with padded side rails, headboard and footboards of beds

  • Keep bed rails raised & bed in low position

  • Place oral / nasal suction equipment ready as well as an airway 

  • Have O2 ready in the event it is needed for a prolonged seizure

  • Educate family on summoning assistance 

  • Assign a room close / or within view of the nursing station

Seizure Disorders: Safety Measures

• Precautions during a seizure:

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• If an aura occurs prior to a seizure, place the patient in bed (if possible) or on the floor with head cushioned 

• Provide privacy

• Place patient on their side & stay with them

• Do not attempt to open the mouth: can cause injury to the patient or you as the nurse

• Do not attempt to restrain

• Loosen restrictive clothing

• Care of a patient cannot be delegated due to ongoing assessments and interventions that may be required (medication administration, first aid, airway management)

Seizure Disorders: Safety Measures: care of the patient after teh seziuire

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• Keep patient on their side & suction if needed

• Reorient & reassure following the event. Assist with care to address any incontinence

• Examine for injuries & keep stimulation to a minimum (low lights and noise), and no food or drink until they are fully conscious and alert

• Monitor VS and mental status every 15 minutes x 2 hours

• Observe post seizure behavior, muscle tone, ability to speak, memory and orientation

• Document characteristics of the seizure

• Note first symptoms & progression of the seizure

• Manage oral secretions as needed

Patient Education for Prevention Strategies 

• Get sufficient rest & eat a healthy diet

• Avoid triggers (video games, bright / flashing lights)

• Take prescribed medications 

• Avoid excess alcohol & drugs that interact with seizure medications

• Research a seizure dog trained to alert to seizures