ex 4 dementia and delirium

what is dementia?

disorder characterized by a decline from the previous level of function in 1 or more cognitive domains

what are the cognitive domains that characterize dementia?

complex attention, executive function, language, learning and memory, perceptual-motor, and social cognition

what does dementia interfere with?

the ability to function and perform daily activities

what does dementia decline not occur with?

the onset of acute confusion such as delirium, or the onset of another major mental problem such as depression - so must rule out these first

what is dementia most commonly caused by?

neurodegenerative conditions that cannot be reversed

what is mixed dementia?

2 or more types of dementia present at the same time

the onset of dementia symptoms depends on

the cause of dementia

neurologic degeneration will occur

gradually and progress over time

vascular dementia will appear

abruptly (stroke)

what may acute or subacute changes that occur over weeks or months indicate?

infectious or metabolic causes of dementia (encephalopathy)

to be diagnosed with dementia, problems such as

judgment, reduced interest in hobbies, repeating questions or stories, forgetting month or year, problems handling finances, difficulty remembering appointments, all must be consistent

a shuffling gait is consistent with

parkinson's

an ataxic gait is consistent with

hydrocephalus

What is Alzheimer's disease?

a type of dementia that is chronic, progressive, irreversible neurodegenerative brain disease

Alzheimer's disease most often affects

ages 65 and older - age is the greatest risk factor

why are women more likely to develop AD than men?

because they live longer

people with a first-degree relative (parent or sibling) with dementia are more likely to

develop AD

what does a clear pattern of inheritance within a family have?

familial AD (FAD) - associated with early onset AD and more rapid disease course

what is closely linked to cardiovascular health?

brain health - anything that increases risk for CVD will increase risk of neurologic problems

how does DM increase risk of developing AD?

insulin resistance interferes with ability to break down amyloid and DM damages small vessels in brain

what changes in the brain structure and function occurs with AD?

amyloid plaques, neurofibrillary tangles, loss of connections between neurons, and neuron death

in AD, where do excess plaques develop first in?

hippocampus - areas used for memory and cognitive function

what will AD attack next?

the cerebral cortex

what is the patho behind AD?

plaques consist of clusters of insoluble deposits of a protein called beta-amyloid and high levels of amyloid causes cell damage and ultimately neuron death

what are neurofibrillary tangles?

abnormal collections of twisted protein threads inside nerve cells

what is the main component of neurofibrillary tangle structures?

tau protein

in AD, what protein is altered?

tau protein

therefore, when tau protein is altered,

the microtubules twist together in helical fashion (like DNA) - forming neurofibrillary tangles

what does loss of connection between neurons and neuron death result in?

structural damage to the brain leading to atrophy

what can the nurse educate caregiver/family to observe for AD?

memory loss that affects job skills, problems with abstract thinking, difficulty doing familiar tasks, poor/decreased judgement, problems with language, misplacing, changes in mood/personality, loss of initiative/motivation

what are initial manifestations of AD?

memory loss, mild disorientation, or trouble with words and numbers

how does memory loss alter with AD?

recent events and short-term memory goes first, remote memory is still intact - with time remote memory will be lost too

in addition to memory problems, patients with AD will experience

unpredictable behaviors , delusions, hallucinations, aphasia, apraxia, visual agnosia, dysgraphia

in late stages of AD, the patient is

unresponsive, incontinent, and needs total care

retrogenesis is

the process in which decline in AD mirrors in reverse order, brain development that occurs from birth - revert back to childhood

mild AD pt will mimic

a teenager

moderate AD pt will mimic

4-7 y/o

severe AD pt will mimic

infant/toddler

what manifestations occur in the mild stage of AD?

short-term memory impairment, loss of initiative/motivation, impatient, slowly loos ability to plan

what manifestations occur in the moderate stage of AD?

memory loss/confusion, trouble organizing/planning, assistance with ADLs, trouble recognizing family/friends, agitation, restlessness, lack of judgement, trouble sleeping, hallucinations, delusions, behavior problems

what manifestations occur in the severe stage of AD?

severe impairment of all cognitive functions, little memory, unable to perform self-care, may be nonverbal, cannot understand words, trouble swallowing, immobility, incontinence

what are the AD stage spectrum?

preclinical AD, mild cognitive impairment, and dementia

in the preclinical stage,

pathologic changes in the brain with no manifestations

what brain changes are seen in preclinical stage of AD?

amyloid buildup and other early neuron changes - no significant symptoms

what is mild cognitive impairment in AD?

state of cognitive function where pt has problems with memory, language, or other essential cognitive functions

in the mild cognitive impairment stage of AD, problems are

severe enough to be noticed by the person having them and by others - can be found on screening tests

because patients in the mild cognitive impairment stage of AD have problems that don't interfere with daily activities, the patient

does not meet the criteria for being diagnosed with dementia

in AD, diagnosis is primarily,

diagnosis of exclusion

what does a definitive diagnosis of AD require?

an examination of brain tissue at autopsy and findings of neurofibrillary tangles and plaques - only definitive after death

in AD, multiple brain structures will

atrophy and volume of brain correlate with neurodegeneration

what is used to determine the progression of AD?

mini-cog, mini mental state exam, Montreal cognitive assessment

what is AD care aim towards?

controlling undesirable manifestations and providing support for family and caregivers

what drug therapy is provided to assists memory and cognition for AD patients?

cholinesterase inhibitors and N-methyl-d-aspartate (NMDA) receptor antagonist

what are examples of cholinesterase inhibitors ?

donepezil (aricept), rivastigmine (exelon), and galantamine (razadyne)

cholinesterase inhibitors will

block cholinesterase, the enzyme that breaks down acetylcholine in the synaptic cleft

what is an example of N-methyl-d-aspartate (NMDA) receptor antagonist ?

memantine (namenda)

N-methyl-d-aspartate (NMDA) receptor antagonist will

protect the brain's nerve cells by blocking the action of glutamate- cells damaged by AD release large amounts of glutamate which attaches to NMDA receptors leading to cellular degeneration

what drug therapy is given for AD associated depression?

SSRIs and atypical antidepressants

what are examples of SSRIs (selective serotonin reuptake inhibitors)?

fluoxetine (prozac), sertraline (zoloft), citalopram (celexa)

what are examples of atypical antidepressants?

trazodone, mirtazapine (remeron)

what drug therapy is given for AD behavioral problems?

antipsychotics and benzodiazepines - can be used in caution but benefit must outweigh risks

what is used for last resort when behavior is out of control?

benzodiazepines

what are goals of AD care?

maintain functional ability for as long as possible, maintain safe environment, meet personal care needs, and maintain dignity

what is important to educate in order to decrease risk of cognitive decline?

avoid harmful substances, challenger your mind, exercise regularly, stay socially active, avoid trauma to brain, take care of mental health, treat DM, take care of heart, get enough sleep, get the right fuel

what is nurses first priory for a AD patient in the acute care setting?

providing a safe environment - keep door open, room close to nurses station, and reorient

what does nursing care for AD patients focus on?

decreasing manifestations, preventing harm, and supporting the patient and caregiver throughout the disease process

what should be educated to caregivers?

perform tasks needed to maximize quality of life and safety of patient

what behavioral problems are expressed in AD patients?

receptiveness, delusions, hallucinations, agitation, aggression, wandering, hoarding, sleeping problems, resisting care - not intential and unpredictable

in AD patients, behaviors are often the patients' way of

responding to pain, frustration, temperature extremes, or anxiety

if a AD patient becomes more confused, agitated, hallucinating, what should nurse check for?

changes in VS, urinary and bowel patterns, and pain - could account for behavior problems

for AD patients in acute care, nurses should

redirect, distract, and reassure - play music/tv and be present with patients as they may become more confused in the hospital setting

sundowning is

when the patient becomes more confused and agitated in the late afternoon or evening

what behaviors are related to sundowning?

agitation, aggressivness, wanderinrg, reisistance to redirection, adn increased verbal activity, such as yelling

what are helpful interventions for a patient with sundowning?

create a quiet, calm environment, maximize exposure to daylight by opening binds and turning on lights during the day, evaluate medications to determine if any could case sleep problems, limit naps/caffeine, consult with HCP about drug therapy

when promoting communication with a patient with AD, it is important to

be patient, treat with respect, be gentle, remain calm, give directions using gestures/pictures, simplify tasks, avoid questions, provide reassurance

what is important to not do when communicating with a AD patient?

criticize, argue, correct, rush, hurry, force participation, talk about pt as if they are not there, blame the patient (it is not their fault), do not use "honey or sweetie", overact, try to explain why or rationalize

it is important to help the caregiver asses the home for environmental safety risks and hazards such as

falling, ingesting dangerous substances, wandering, injuring others and self with sharp objects, being burned, and being unable to respond to crisis situations

wondering may be related to

loss of memory or to side effects of medications or expression of physical/emotional need

what are ways to prevent falls?

well-lit walkways, handrails, nonskid mats in shower/tub, remove throw rugs and extension cords, tack down carpet edges

what does pain management rely on?

behavioral cues

patients with severe AD are at high risk for

skin breakdown due to incontinence, immobility, and poor nutrition - frequent position changes

patients with AD may

loose interest in food and decreased ability to feed

what could be done to enhance eating and swallowing for AD patients?

use pureed foods, thickened liquids, and supplements, reminders to chew and swallow food, remove distractions, finger foods and frequent liquids, easy grip utensils

what infections are AD patients at high risk for?

UTI and aspiration pneumonia

what may infection be manifested by for AD patients?

change in behavior, fever, cough, or pain on urination

what may help with AD elimination problems?

schedules toileting

delirium is

temporary state of confusion that develops over days to hours

delirium causes

decreased ability to direct focus, sustain, and shift attention and awareness

what may be present with delirium?

deficits in memory, orientation, language, visuospatial ability, or perception - sleep may be disturbed

what do delirium symptoms represent?

a change from the patients baseline and tend to flucuate throughout the day

what is a main contributing factor of delirium?

impaired cerebral oxidative metabolism - brain gets less oxygen and has problems using it

what neurotransmitter abnormalities may be involved with delirium?

cholinergic deficiency, excess dopamine, increased or decreased serotonin

what is the highest risk factor of delirium?

pre-existing dementia

delirium may be the first symptom of

life-threatening problems such as pneumonia, urosepsis, or meningitis

delirium usually develops

over 2-3 days and last 1-7 days

how is speech with delirium?

rapid, rambiling, and or incoherent

what is a reliable tool for assess delirium?

the confusion assessment method (CAM)

as many cases of delirium are reversible, nursing plays a role in

prevention, recognition, and treatment

how can the nurse eliminate precipitating factors?

discontinue medications, correct fluid and electrolyte disturbances and nutritional deficiencies, abx for suspected infection

what additional nursing care should be done to manage delirium?

reduce environmental stimuli, protect from harm, reassure, reorient, (clocks and calendars may help), remove unnecessary lines