CNA: Chapter 19

Cognition

Cognition is the mental process of acquiring, processing, storing, and retrieving information through thought, experience, and the senses

Cognitive impairment

It ranges from mild—where individuals remain independent—to severe, as seen in advanced dementia. Common causes include neurodegenerative diseases, brain injuries, nutritional deficiencies, and medication side effects

Confusion

is the inability to think clearly and logically

GUIDELINES FOR CONFUSION

• DO NOT LEAVE CONFUSED RESIDENT ALONE

• SPEAK IN A LOWER TONE OF VOICE. SPEAK CLEARLY AND SLOWLY

• INTRODUCE YOURSELF EACH TIME YOU SEE THE RESIDENT

• EXPLAIN WHAT YOU ARE GOING TO DO, USING SIMPLE INSTRUCTIONS

• BE PATIENT. DO NOT RUSH THE RESIDENT

• TALK TO THE RESIDENT ABOUT PLANS FOR THE DAY

• PROMOTE SELF-CARE AND INDEPENDENCE

• DO NOT LEAVE CLEANING AGENTS NEARBY THEM

• REPORT OBSERVATIONS TO THE NURSE

Delirium

OCCURS SUDDENLY

is a serious, rapidly developing state of acute confusion that impairs attention, awareness, and thinking ability.

WHEN COMMUNICATING WITH A PERSON WHO IS CONFUSED OR DISORIENTED, THE NURSING ASSISTANT SHOULD:

• KEEP VOICE LOW AND NOT SHOUT

• USE PERSON’S NAME

• USE NONVERBAL BODY LANGUAGE TO AID IN UNDERSTANDING

• TAKE ACTION TO REDUCE DISTRACTIONS IN THE ENVIORNMENT, SUCH AS TURNING DOWN THE TV

• BE GENTLE AND TRY TO DECREASE FEARS

Dementia

is a general term that refers to a serious loss of mental abilities, such as thinking, remembering, reasoning, and communicating

Progressive

A term meaning the condition worsens over time. Symptoms start relatively mild and slowly interfere with broader functions, eventually requiring significant support with daily living

Degeneration:

The continuous, progressive deterioration of cells, tissues, or organs. In the brain, this refers to the death of neurons and loss of synaptic connections

Onset:

The initial appearance of symptoms or the underlying biological beginning of the disease process. This can be insidious, extending over many years before clinical symptoms become apparent

Irreversible

A designation meaning that once neurons or tissues are damaged or lost, they cannot be repaired, replaced, or cured.

Alzheimer’s disease

is a progressive, irreversible brain disorder that slowly destroys memory and thinking skills. It is the most common cause of dementia. While there is no cure, medications and lifestyle adjustments can help manage symptoms and slow its progression

is the most common cause of dementia in elderly

Mild (Early-Stage)Alzheimer’s disease

In this stage, the disease begins to affect daily functioning, though the individual may still be somewhat independent. [1, 2]

• Key Symptoms: Noticeable memory lapses (especially recent events), trouble managing finances, difficulty organizing or planning, and repeating questions. The person may also get lost in familiar places or have difficulty finding the right words.

• Duration: Typically lasts 1 to 2 years

Moderate (Middle-Stage) Alzheimer’s disease

Often the longest phase of the disease, this stage involves deeper damage to the brain, requiring more significant assistance from caregivers. [1, 2]

• Key Symptoms: Pronounced memory loss, including forgetting personal history or well-known facts. Individuals may struggle with personal care like bathing and choosing appropriate clothing. Personality and sleep changes are common, and the person may experience confusion about time, place, or events, alongside potential delusions or paranoia.

• Duration: Can last anywhere from a few years to 10 or more years

Severe (Late-Stage) Alzheimer’s disease

This is the final phase, where cognitive abilities are severely compromised and the individual becomes entirely dependent on others for basic care. [1, 2]

• Key Symptoms: Complete loss of awareness of recent experiences and surroundings. Physical capabilities, including the ability to walk, sit, and eventually swallow, decline. The person may have difficulty communicating and require round-the-clock assistance with all daily activities.

IDENTIFY PERSONAL ATTITUDES HELPFUL IN CARDING FOR RESIDENTS WITH ALZHEIMER’S DISEASE

• DO NOT TAKE THINGS PERSONALLY

• BE EMPATHETIC

• WORK WITH THE SYMPTOMS AND BEHAVIORS NOTED

• WORK AS A TEAM

• BE AWARE OF THE DIFFICULTIES ASSOCIATED WITH CAREGIVING

• WORK WITH FAMILY MEMBERS

• REMEMBER THE GOALS OF THE CARE PLAN

GUIDELINES: COMMUNICATING WITH RESIDENTS WHO HAVE ALZHEIMER’S DISEASE

• ALWAYS APPROACH FROM THE FRONT, DO NOT STARTLE THE RESIDENT

• SMILE AND LOOK HAPPY TO SEE RESIDENT

• DETERMINE HOW CLOSE THE RESIDENT WANTS U TO BE

• COMMUNICATE IN A CALM AREA WITH LITTLE BACKGROUND AND DISTRACTION

• ALWAYS IDENTIFY SELF, AND USE RESIDENT’S NAME

• SPEAK SLOWLY, USING LOWER TONE OF VOICE THAN NORMAL

• REPEAT YOURSELF, USING THE SAME WORDS AND PHRASES AS OFTEN AS NEEDED

• TALK ABOUT ONLY ONE SUBJECT AT A TIME

• USE SIGNS, PICTURES, GESTURES, OR WRITTEN WORDS TO HELP COMMUNICATE

• BREAK COMPLEX TASKS INTO SMALLER, SIMPLER ONES. GIVE SIMPLE, STEP-BY-STEP INSTRUCTIONS AS NECESSARY

IF THE RESIDENT IS FRIGHTENED OR ANXIOUS

• SPEAK SLOWLY IN A LOW, CALM VOICE

• TRY TO SEE AND HEAR YOURSELF AS THE RESIDENT MIGHT

• USE SIMPLE WORDS AND SHORT SENTENCES

• CHECK YOUR BODY LANGUAGE, MAKE SURE YOU ARE NOT TENSE OR HURRIED

IF THE RESIDENT HAS TROUBLE FINDING WORDS OR NAMES

SUGGEST A WORD THAT SOUNDS CORRECT

IF THE RESIDENT SEEMS NOT TO UNDERSTAND BASIC INSTRUCTIONS OR QUESTIONS

• USE SHORT WORDS AND SENTENCES, ALLOWING THE RESIDENT TIME TO ANSWER

• WATCH FOR NONVERBAL CUES AS THE ABILITY TO TALK LESSENS

• USE SIGNS, PICTURES, GESTURES, OR WRITTEN WORDS

IF THE RESIDENT WANTS TO SAY SOMETHING BUT CANNOT

• ENCOURAGE THE RESIDENT TO POINT, GESTURE, OR ACT IT OUT

• IF THE RESIDENT IS OBVIOUSLY UPSET BUT CANNOT EXPLAIN WHY, OFFER COMFORT WITH A SMILE OR TRY TO DISTRACT HIM. VERBAL COMMUNICATION MAY BE FRUSTRATING

IF THE RESIDENT DOES NOT REMEMBER HOW TO PERFORM BASIC TASKS

BREAK EACH ACTIVITY INTO SIMPLE STEPS

IF THE RESIDENT INSISTS ON DOING SOMETHING THAT IS UNSAFE OR NOT ALLOWED:

REDIRECT ACTIVITIES TOWARD SOMETHING ELSE

IF THE RESIDENT HALLUCINATES (SEES OR HEARS THINGS THAT ARE NOT REALLY HAPPENING) OR IS PARANOID OR ACCUSING

• TRY NOT TO TAKE IT PERSONALLY

• TRY TO REDIRECT THE BEHAVIOR OR IGNORE IT

IF THE RESIDENT IS DEPRESSED OR LONELY

• TAKE TIME ONE-ONE TO ASK HOW HE IS FEELING AND REALLY LISTEN TO THE RESPONSE

• TRY TO INVOLVE THE RESIDENT IN ACTIVITIES.

IF THE RESIDENT REPEATEDLY ASKS TO GO HOME

• ASK THE RESIDENT TO TELL YOU WHAT HIS WAS LIKE AND HOW HE FELT BEING THERE

IF THE RESIDENT IS VERBALLY ABUSIVE OR USES BAD LLANGUAGE

DONT TAKE PERSONALLY

IF THE RESIDENT HAS LOST MOST VERBAL SKILLS

USE YOUR NONVERBAL BODY LANGUAGE, SMILE

WHAT ARE GENERAL PRINCIPLES THAT WILL HELP RESIDENTS WITH PERSONAL CARE

• develop a routine and stick to it

• promote self-care

• take care of themselves, both mentally and physically

IF THE RESIDENT HAS TROUBLE BATHING

• BE FLEXIBLE WHEN ABOUT TO BATHE A RESIDENT. THEY MAY NOT ALWAYS BE IN THE MOOD

IF THE RESIDENT HAS PROBLEMS WITH GROOMING AND DRESSING

• HELP WITH GROOMING TO HELP RESIDENTS FEEL ATTRACTIVE AND DIGNIFIED

• ENCOURAGE RESIDENT TO PICK CLOTHES

• BREAK THE TASK DOWN INTO SIMPLE STEPS

IF THE RESIDNET HAS PROBLEMS WITH ELIMINATION

• ENCOURAGE FLUIDS

• MARK THE BATHROOOM WITH A SIGN

IF THE RESIDENT HAS PROBLEMS WITH NUTRITION

• encourage nutritious food

TO PROMOTE THE RESIDENT’S MENTAL AND EMOTIONAL HEALTH

• MAINTAIN SELF-ESTEEM BY ENCOURAGING INDEPENDNECE IN ADLS

• SHARE IN ENJOYABLE ACTIVITIES, SUCH AS LOOKING AT PICTURES, TALKING, AND REMINSCING

• REWARD POSITIVE AND INDEPENDENT BEHAVIOR WITH SMILES AND WARM TOUCHES

Agitation

is a state of severe restlessness, irritability, and mental distress accompanied by unintentional, purposeless physical movements

trigger

is a mechanical lever that activates a device (such as a firearm), or an external stimulus that initiates a reaction, emotional response, or process.

Sundowning

(or "sundown syndrome") is a state of increased confusion, anxiety, and agitation that commonly affects individuals with Alzheimer's disease and other forms of dementia. It typically begins in the late afternoon and continues into the night as daylight fades

HOW TO HANDLE SUNDOWNING

• PLAY SOFT MUSIC

• PROVIDE SNACKS

• GIVE A SOOTHING BACK MASSAGE

• DISTRACT THE RESIDENT WITH A SIMPLE, CALM ACTIVITY

• AVOID STRESSFUL SITUATIONS

Catastrophic reactions

is an extreme, disproportionate emotional or physical outburst triggered when a person feels completely overwhelmed or unable to cope with a situation.

Violent behavior

IF A RESIDENT IS VIOLENT, THE NA SHOULD:

• CALL FOR HELP IF NEEDED

• BLOCK BLOWS BUT NEVER HIT BACK

• NEVER TRY TO RESTRAIN THE RESIDENT

• STEP OUT OF REACH AND STAY CALM

• NOT LEAVE THE RESIDENT ALONE

• TRY TO REMOVE TRIGGERS

• USE THE SAME TECHNIQUES TO CALM RESIDENT AS FOR AGITATION

PACING

WALKING BACK AND FORTH IN THE SAME AREA

WANDERING

WALKING AIMLESSLY

CAUSES OF PACING AND WANDERING

• restlessness

• hunger

• disorientation

• incontinence

• constipation

• pain

• forgetting how or where to sit

• too much daytime napping

• need for exercise

IF THE RESIDENT PACES OR WANDERS, THE NA SHOULD:

• REMOVE CAUSES FOR IT WHEN POSSIBLE

• LET RESIDENTS PACE OR WANDER IN A SAFE AND SECURE (LOCKED) AREA WHERE STAFF CAN KEEP AN EYE ON THEM

• REDIRECT ATTENTION TO SOMETHING THE RESIDENT ENJOYS SUCH AS TAKING A WALK TOGETHER

• MARK ROOMS WITH SIGNS OR PICTURES, SUCH AS STOP SIGNS

• REPORT TO THE NURSE IMMEDIATELY IF A NURSE ELOPES OR WANDERS FROM A PROTECTED AREA

Hallucinations

a resident who sees, hears, smells, tastes, or feels things that are not there

Delusions

believes things that are not true

Depression

people who become withdrawn, isolated, lack energy, and stop eating or doing things they used to enjoy may be depressed

causes of depression

• loss of independence

• inabiliy to cope

• feelings of failure ot fear

• reality of facing a progressive, degenerative illness

• chemical imbalance

IF THE NA NOTICES THAT A RESIDENT IS DEPRESSED

• REPORT SIGNS OF DEPRESSION TO THE NURSE IMMEDIATELY

• OBSERVE FOR TRIGGERS THAT CAUSE CHANGES IN MOOD

• ENOURAGE INDEPENDENCE, SELF-CARE, AND ACTIVITY

• LISTEN TO RESIDENTS IF THEY WANT TO SHARE THEIR FEELINGS OR TALK ABOUT THEIR MOOD

• FIND WAYS TO ENCOURAGE SOCIAL INTERACTION

PERSERVATION OR REPETITIVE PHRASING

Perseveration is the involuntary, uncontrollable repetition of a word, phrase, thought, or action long after it is appropriate or the stimulus has ended. Unlike intentional repetition to achieve a goal, it happens because the brain "gets stuck" and struggles to shift attention to a new topic or task. [1, 2, 3, 4]

Why It Happens

Perseveration typically stems from neurological or psychological factors: [1, 2, 3]

• Brain Injury: Damage to the frontal lobe (which controls inhibition and task-switching) can leave a person unable to stop an automatic response. [1, 2]

• Cognitive Disorders: It is a common symptom in conditions like dementia, Alzheimer's disease

DISRUPTIVENESS

ANYTHING THAT DISTURBS OTHERS, SUCH AS YELLING, BANGING ON FURNITURE, AND SLAMMING DOORS

INAPPROPRIATE SOCIAL BEHAVIOR

MAY INCLUDE CURSING, NAME-CALLING, OR YELLING

INAPROPRIATE SEXUAL BEHAVIOR

SUCH AS REMOVING CLOTHING OR TOUCHING ONE’S OWN GENITALS IN PUBLIC, TOR TRYING TO TOUCH OTHERS CAN DISTURB OR EMBARASS THOSE AROUND THEM

Hoarding

is collecting and putting things away in a guarded way

Rummaging

is going through drawers, closets, or personal items that belong to oneself or other people

Sleep disturbances

• MAKE SURE THE RESIDENT GETS MODERATE EXERCISE THROUGHOUT THE DAY

• ALLOW THE RESIDENT TO SPEND SOME TIME EACH DAY IN NATURAL SUNLIGHT IF POSSIBLE

• SUSPICION

Validating therapy

means giving value to or approving

(for example, play along if a resident is saying hes going out to a restaruant with his wife, who passed away many years ago)

Reminascence therapy

involves discussing or reliving past events, typically guided by sensory prompts like old photographs, favorite songs, or familiar scents. It aims to stimulate long-term memory, boost mood, reduce anxiety, and foster emotional connections, particularly for individuals experiencing dementia or depression

Music therapy

is the evidence-based use of music by credentialed professionals to achieve individualized goals, such as reducing stress, managing pain, and improving motor function. It is tailored for people of all ages and abilities, and no prior musical background is required to participate