Class 6: Dementia, Depression, and Suicide

• No decline in wisdom, common sense, judgment, breadth of knowledge etc.

• Slight decline in short term memory

• Slight gradual decline in abstraction, verbal comprehension, spatial orientation, etc.

• Slower processing of information

Cognitive/ intellectual signs of healthy aging: [4]

Dementia

Syndrome of progressive cognitive impairment that affects everyday functioning

• cortex shrivels

• hippocampus shrinks

• ventricles expand

• Reduction in acetylcholine levels

  Reduction in neuronal synapses

  Plaques are formed between neurons                                

  Tangles are formed inside neurons

Neuropathology of Alzheimers: [7]

• memory

• Aphasia

• Visual perception

• Executive function

Cognitive symptoms of alzheimers [4]

1. agitation

2. wandering

3. personality changes

4. hallucinations/dillusions

Behavioral symptoms of Alzheimers: [4]

1. Age

2. Genetics

Risk factors for dementia [2]

1. Healthy Diet

2. Exercise

3. Social engagement

4. Intellectual activity

How risk of dementia can be reduced: [4]

1. early

2. mild-moderate

3. severe

Occurs over a period of years (e.g., 7-10 years from diagnosis to daeaty

Dementia trajectory [3-4 steps]

1. learning and memory

2. thinking and planning

Early development of plaques and tangles of alheimers begin to affect: [2]

1. Cognitive problems start to interfere with work and social life

2. People may begin to have difficulty with language

3. they may experience periods of confusion

Symptoms of mild-moderate Alzheimers: [3]

1. affected people lose their ability to commuicate

2. They have trouble recognizing family and loved ones

3. No longer able to care for themselves

Symptoms of severe Alzheimers: [3]

By exclusion (testing for other things to rule them out)

How is dementia diagnosed?

1. CIs

2. Aricept

3. Exelon

4. NMDA

5. Namenda

Medications that can sow the progression of dementia: [5]

1. personal history and experiences

2. interpersonal interactions

3. environment

How are symptoms of dementia affected outside neuropathology?

1. mitigate disability

2. improve quality of life

3. reduce agitation and disruptive behaviors

A person-centered approach when caring for dementia has proven to: [3]

1. Medications should not be first line of response

2. Focus must be on understanding that by behavioral expressions, a person is communicating DISTRESS most of the time

3. Assess and intervene to reduce possible sources of distress

How to treat behvaioral expressions (that are perceived disruptive) of someone with dementia [3]

1. Communication deficits

2. Pain / discomfort / fatigue

3. sleep disturbances

4. Depression

5. Need for social contact

6. hunger, thirst, need to toilet

7. loss of sense of cotrol

8. misinterpretation of a situation

9. crowded situations and noise

10. many changes to environment / people

11. Being forced to do something / being rushed

12. Fear

13. Restraints

Conditions increasing responsive behaviors in dementia

Personhood approach to care

An approach to care that focuses on understanding the person’s perspective by modifying the environment and enhancing interpersonal interactions. Te focus is not on “doing for” but “partnering with” to control behavior

1. Staying with the resident during the care

2. Altering the pace of care by recognizing the person’s rhythm and adapting to it

3. Focusing care on the person, not the task

Nursing implications for relating well with a person with dementia: [3]

1. Meaningful and enjoyable activities provide cognitive, emotional, and social stimulation

2. Enhance feelings of self-worth, promote a sense of belonging and accomplishment, and encourage expression of feelings and thoughts

Nursing implications for meaningful activity with a person with dementia [2]

1. Maintain or improve function

2. prevent further disability

3. improve mood

Nursing implications for physical activity with a person with dementia

1. support groups

2. day programs

3. social activity groups

4. home care

5. long term care

Community supports that have shown to be helpful while caring for a person with dementia:[5]

Cognitive assessment

Tools are screens for cognitive impairment, estimating the severity of the cognitive impairment. Sensitive to changes over time, can be used to monitor prognosis. NOT DIAGNOSTIC.

1. Mini-state mental exam (MSME)

2. Mini-cog test or Montreal cognitive assessment (MOCA)

Cognitive assessment tools that are brief, standardized measures of mental status: [2]

When the patient is experiencing:

1. Language deficit/barrier

2. hearing /visual impairment

3. anxiety

4. environment distractions

5. inconsistent administration (different people using tools on same individual)

When are cognitive assessment tools less reliable?

Dysphoria

Unhappiness, frustration, agitation or restlessness

Depression presents differently in older adults. Dysphoria is not always a distinguishing feature in old age. Symptoms checklists include items that may be caused by physical illness or bereavement.

Why might diagnostic tools for depression not be a good fit for older adults?

1. psychomotor retardation

2. sleep disturbance

3. physical complaints

4. loss of appetite

5. etc.

Somatic symptoms of depression that are more common in older adults [4]

1. memory complaints

2. slower processing speed

3. executive dysfunction

Cognitive symptoms of depression that are more common in older people [3]

1. Genetic risk factors are less prevalent than factors related to physical illness:

   1. CV disease

   2. Diabetes

   3. neurological disease

   4. medication side effects

2. Sleep disturbance

3. stressful life events

4. isolation

5. socioeconomic stressors

Risk factors for depression in older adults: [8]

ECT (Electroconvulsive therapy or electroshock therapy)

Treatment for depression that is used more commonly in older people and has shown strong efficacy:

1. physical activity

2. social interventions

What has shown to reduce and prevent depression in older people? [2]

• Agitation with no peace

• sleeplessness

• increased somatic complains

• suicide plan

• evidence of putting things in order

• increased verbalization of suicide

• loss of critical support (loss of spouse or caregiver)

Signs and symptoms f older people at higher risk for suicide: [7]

1. older age

2. previous suicide behaviours

3. thoughts of suicide and wanting to die

4. mental illnesses

5. recreational drug misuse

6. medical illnesses

   1. seizure

   2. neurological

   3. cancer

   4. COPD

   5. arthritis

   6. pain

7. Functional impairment

8. social, physical, financial loss

9. negative life events and transitions (ex: move to long term care)

10. Lack of supports/ limited social interaction

Suicide risk factors [10']

•Do you ever go to bed at night and wish you wouldn’t wake up?

•Do you think you would be better off dead?

•Do you have anything to look forward to?

•Would you take your own life?

•Have you ever tried to take your own life?

•Have you considered taking your own life? If yes, how would  you do this? Is there anything stopping you? Do you have the means to do this?

Questions to ask when screening for dementia: [6]

Active suicide

Overdosing on medication, discontinuation of needed medications, jumping, gun, etc.

Passive suicide

Stopping eating, drinking, withdrawing

If detected, depression should always be treated and treatment must be prioritized

Treatment for suicide and suicidal behaviours: