dementia and delirium

dementia

s a disorder that is characterized by impairment of cognition, typically involving memory and at least one other cognitive domain (language, visuospatial- connection/sequencing, executive function)

dementia presentation

Difficulty in:

 Retaining new information

 Handling complex tasks

 Reasoning

 Spatial ability and orientation

 Language

 Behavior

causes of dementia

 Alzheimer Disease

 Dementia with Lewy Bodies

 Frontotemporal Dementia

 Parkinson Disease Dementia

 Less common neurodegenerative disorders (eg. Huntington Disease)

 Non-neurodegenerative dementia (Vascular dementia)

PATHOPHYSIOLOGY ALZHEIMER DISEASE

Accumulation of beta-amyloid plaques and neurofibrillary tangles distributed throughout the brain which degenerates neurons and synapses leading to atrophy of the cerebral cortex

Alzheimer's disease

A neurodegenerative disorder of uncertain cause and pathogenesis that primarily affect older adults and is the most common cause of dementia

alzheimer’s disease cardinal symptoms

• memory impairment

• declarative episodic memory

declarative episodic memory

memory of events occurring at a particular time and place is usually profoundly affected

DEMENTIA WITH LEWY BODIES

 Produces a gradual, progressive decline in cognitive abilities with motor parkinsonism

 Rapid Eye Movement sleep behavior disorder

 Visual hallucinations

 Fluctuations in level of alertness

 Prominent visuospatial dysfunction

 Manifests parkinsonism and cognitive decline contemporaneously

FRONTOTEMPORAL DEMENTIA

Damage to the frontal and temporal lobes of the brain

FRONTOTEMPORAL DEMENTIA symptoms

• Unusual behaviors

• Emotional problems

• Communication difficulties

• Difficulty with work

• Difficulty walking

• Occurs at a younger age (45-60)

manifestations of parkinson disease

visual hallucinations and delusions

Huntington disease

inherited progressive neurodegenerative disorder characterized by choreifrom movements, psychiatric problems, and dementia

cause of huntington

caused by trinucleotide repeat in the huntingtin (HTT) gene and inherited in an sutosomal dominant pattern

Cure for Huntington disease

no known cure, treatment is symptomatic and remains supportive

vascular dementia

any dementia that is primarily caused by cerebrovascular disease or impaired cerebral blood flow or in which cerebrovascular disease or impaired cerebral blood flow is a contributing causative factor.

Approximately 35 percent of dementia cases are attributable to a combination of nine potentially modifiable risk factors:

• low educational attainment

• midlife Htn

• midlife obesity

• hearing loss

• late-life depression

• diabetes

• physical inactivity smoking

• social isolation

dementia goal

to preserve function and autonomy for as long as possible and to maintain quality of life for both the patient and the caregivers

COMMUNICATION CHALLENGES IN DEMENTIA

 Expressing themselves

 Difficulty in finding words

 Difficulty remembering the names of people &/or objects

 Substitute words with similar sounds (wrong for ring)

 Substitute words with related meaning (wedding for ring; music thing for piano)

 Describe the object they cannot name (it’s a thing that goes around for

ring)

 Difficulty communicating the whole thought, but can communicate words within the thought (bus-home for “I’m concern about missing the bus that takes me home” or

 Rambling thoughts

 Use of curse words

MONTREAL COGNITIVE ASSESSMENT score for severe cognitive impairment.

<10

delirium

• clinical syndrome caused by a medical condition, substance intoxication or withdrawal or medication side effect that is

• characterized by a disturbance of consciousness with reduced ability to focus, sustain or shift attention

DELIRIUM – CHARACTERIZED BY:

• Disturbance in attention

• The disturbance develops over a short period of time

• An additional disturbance in cognition

• Disturbances are not better explained by another preexisting, evolving or established neurocognitive disorder

• The disturbance is caused by a medical condition, substance intoxication or withdrawal or medication side effect

delirium presentation

Loss of mental clarity

 Distractibility (patient’s flow of thoughts)

 May appear drowsy, lethargic, semicomatose- more advanced cases

Or

 Hypervigilance seen more in cases of alcohol or sedative drug withdrawal

 Change in cognition – memory loss, disorientation, difficulty with language and speech

 Hallucinations – visual, auditory or somatosensory

 Language difficulties – e.g. lose ability to write or to speak a second language

prevention and nursing care for delirium

 Orientation protocols – clock, calendar windows, verbally reorienting patient

 Cognitive stimulation – provide activities such as regular visits. Don’t overstimulate, especially at night.

 Sleep – avoid procedure during sleeping ; reduce night-time noise

 Early mobilization and minimal use of physical restraints

Withdrawal delirium

a rapid-onset, fluctuating disturbance of attention and cognition, sometimes with hallucinations, in the presence of alcohol withdrawal

when does withdrawal delirium typically begin?

72 - 96 h after the patient’s last drink

severe manifestations of withdrawal delirium

agitation and signs of extreme autonomic hyperactivity, including fever, severe tachycardia, hypertension, and drenching sweats

Moderate and severe withdrawal symptom of alcohol withdrawal

hallucination, seizures or delirium tremens

communication interventions in persons with delirium

 Keep conversations basic and one topic at a time

 Talk in a calm, soothing voice

 Give them time to respond

 Remind them of where they are and what is happening

 Avoid asking to many questions

 If having a hallucination, do not argue with them or try to correct them. Instead acknowledge their feelings and calmly reassure them

behavior interventions in persons with delirium

 Have someone stay in the room with the patient

 Have a regular and night routine

 Keep the room quiet and calm

 Make sure they’re comfortable

 Well nourished and hydrated

 Sensory items available

 Re-orient

Identify if it is a quality of delirium or dementia: Onset is rapid (within hours to a day or two)

delirium

Identify if it is a quality of delirium or dementia: Onset of minor symptoms that progress over years

dementia

Identify if it is a quality of delirium or dementia: Ability to stay focused is impaired

delirium

Identify if it is a quality of delirium or dementia: Remains alert in early stages

dementia

Identify if it is a quality of delirium or dementia: Symptoms can come and go several times in a day

delirium

Identify if it is a quality of delirium or dementia: Memory and thinking skills stay at a constant level

dementia

factors that increase baseline vulnerability

• underlying brain disorders (eg. dementia)

• advance age

• sensory impairment

factors that precipitate the disturbance

• polypharmacy (especially psychoactive drugs)

• infection

• dehydration

• immobility (including restraint use)

• malnutrition

• use of bladder catheters

• drugs that precipitate delirium (anticholinergics, benzodiazepines, narcotics in high doses)

prevention and nursing care

1. use of visual and hearing aids for patients with these impairments

2. monitor medications (benzodiazepines)

3. avoid and treat medical complications (dehydration, hypoxemia, infections).

4. manage pain