Delirium, dementia, Alzheimers

Before assessing, make sure the environment is ___

Quiet and calm

What is the Mini Mental Status Exam (MMSE)?

A set of 11 questions used to check for cognitive impairment.

Identifies problems with: thinking, communication, understanding, memory, attention, and orientation

Grading for MMSE

• 24-30 is normal range

• 20-23 is mild cognitive impairment or mild alzheimer’s

• 10-19 is moderate Alzheimer’s

• 0-9 is severe Alzheimer’s

What is the Mini-Cog assessment?

Assessment that detects cognitive impairment in older adults. Takes 3 minutes to administer.

Process of Mini-Cog

• Tell the patient 3 word, then immediately ask the pt to repeat them

  • if they are unable to repeat them, give them 3 more chances

• Regardless of repetition or not, move onto CDT

• Provide Pt with paper with cirlce drawn, ask them to put all the numbers in the circle and draw hands that indicate the time is 11:10

  • give them 3 minutes to do so

• Ask patient to recall and repeat 3 words from beginning

Grading of Mini-Cog + what it means

• 1 point for each word recalled

• 2 points for a normal clock

• score greater than 3 indicates decreased likelihood of dementia

Grading of CDT

• 1 is perfect

• 2 is minor visual-spatial errors

  • ex. numbers outside circle

• 3 is inaccurate representation of 11:10

  • ex. unable to denote time

• 4 is moderate visual-spatial error, denotation of 11:10 impossible

  • ex. omitted numbers

• 5 is severe disorganization

• 6 is no semblance of a clock

Confusion Assessment Model (CAM)

Differentiates delirium and dementia. Has 4 features.

CAM feature 1 - Acute Onset and fluctuating course

• Assess orientation, ask patient for person/place/time/event

• Ex. their name, date of birth, where they are, and what they are doing at their current location

CAM feature 2 - Attention

• Ask patient to perform specific tasks

  • Ex. Tell months of year backwards

• Observe for difficulty focusing, how distracted they are, if they struggle with keeping track of conversation

CAM feature 3 - Thinking

• Is the patient’s thinking coherent?

• Is their conversation clear, logical, and relevant?

CAM feature 4 - LOC

• is their LOC anything other than alert?

  • Ex. Drowsy, difficult?

• Use last 3 features to help idenfity

Nursing assessments in order of priority

• Safety: Risk for injury/environmental hazards

• Nutrition/Hydration: Assess for malnutrition, difficulty swallowing, aspiration risk, dehydration

• Pain and discomfort: OLD CARTS, what is causing pain, how to help

• Level of cognitive impairment: establish baseline and monitor

• ADLs: Assess independence and necessary help

Nursing interventions in order of priority

• Ensure safety: fall precautions, supervision, safe environment

• Assist with feeding, hydration, prevention of aspiration

• Manage symptoms by redirecting, reorienting, administering medications

• Enhance communication by speaking at a level they understand

• ADLs: assist when necessary

Nursing interventions for Sundowners

• approach calmly, ask if they need anything, redirect

• ensure calm and safe environment

• provide daily routines, remind of time

• offer reassurance and avoid arguing

• allow patient to pace with supervision, set up motion detectors like a bed alarm

What can nurse’s delegate to CNAs?

• Sit with patient

• provide environmental safety

• ask family to help with meds and adls

• use PACET

How long do symptoms of depression have to be present in order to get diagnosed?

2 weeks

If patient is agitated, asses for:

Personal needs, and pain.

No alzheimer’s diagnosis until…

all other disease processes are ruled out