Geriatric Chapter 28: Delirium and Dementia

Possible Causes of delirium

Fluids and electrolytes: dehydration, fluid and electrolyte imbalance, hypo- and hypercalcemia, and hypo- and hyperglycemia

Conditions: CHF, decreased cardiac function (HTN), decreased respiratory or renal function, hypothyroidism, CNS disturbances

Misc.: emotional stress, trauma, toxic substances (medications: anesthesia, narcotics {oxycodone}) and pain

Signs and Symptoms of delirium

Rapid and altered LOC; decreased arousal

Disorientation (A&O status), worsened memory, altered attention span, meaningless chatter, labile mood

Hypervigilance, mild drowsiness, semi-comatose status

Hallucinations (visual) and illusions (misinterpreting caregivers as police guards)

Delirium Interventions in the Acute Stage

Establishing medical stability

Minimizing stimulation

-consistency in care

-prevention of harm to self and others

Dementia

Irreversible, progressive impairment in cognitive function, affecting: 

-Memory, orientation, judgement. reasoning, attention, language, and problem-solving

Caused by damage or injury to the brain

Causes of Dementia

Damage to brain tissue due to Alzheimer’s or other degenerative diseases, circulatory problems, lack of oxygen, infection, trauma, hydrocephalus, tumor: alcoholism, etc. 

Onset of Dementia

Slow; moths to years before symptoms are evident

Mental Status of Dementia

Poor short- and long-terms memory, disoriented, confused, difficulty finding proper words to use, impaired judgement, problems with arithmetic and problem-solving, personality changes

Level of Consciousness (Alertness)

Delirium: Changed, can be highly agitated or very dull

Dementia: Normal

Behavior

Delirium: Can be hyperactive, be less active than normal, or fluctuate between both extremes

Dementia: Inappropriate; may be unsteady on feet, have difficulty with coordinated movements

Recovery

Delirium: Disease can be reversed and normal mental status recovered if cause is treated promptly

Dementia: Progression of disease may be solved but disease cannot be reversed; usually continues to worsen

Alzheimer’s Disease

Most common form of dementia

Changes in the brain

• Neuritic plaques containing beta-amyloid protein

• Neurofibrillary tangles in the cortex

-Loss or degeneration of neurons and synapses

-Changes in neurotransmitter systems

Possible causes of AD

Genetics (chromosomal abnormalities)

Environmental factors'

Free radicals

High levels of aluminum and mercury in brain cells and low zinc levels

Slow-acting virus

Alzheimer’s Disease

Symptoms develop gradually and progress at different rates among individuals

Staging: Global Deterioration Scale/Functional Assessment Staging (GDS/FAST)

Early disease changes (greatest risk for self harm): Depression, anxiety, writing sticky notes to compensate, structuring routines, simplifying responsibilities

Diagnosis: symptoms, MRI, cognitive function testing, neuro exams

Treatment/Management for AD

No current treatment to prevent/cure AD

Clinical trials in place with NIH to improve function and slow disease progression

Antioxidants, anti-inflammatory agents, folic acid, vitamins B6 and B12, and gene therapy

donepezil (Aricept) , memantine (Namenda)

-Slows progression of disease… NOT a cure

Vascular Dementia

Related to small cerebral infarctions, causing damage to brain tissue

Damage can be diffused or localized; onset more rapid with predictable disease progression

Risk Factors: smoking, HTN, hyperlipidemia, inactivity, Hx of stroke or cardiovascular disease

Frontotemporal Dementia (Pick’s Disease)

Characterized by neuronal atrophy affecting the frontal lobes of the brain rather than by neurofibrillary tangles and plaques as in Alzheimer’s disease

-Appearance of behavioral rather than cognitive abnormalities in the early stage

-Early cognitive changes include impairment of abstract thinking and speech and language skills rather than poor memory

Lew Body Dementia

Presence of Lewy body substance in cerebral cortex

-Lewy bodies are clumps of protein that form in the brain, causing problems with brain function including memory, movement, thinking skills, mood, behavior

Fluctuations in mental status, decompensate rapidly when experiencing a medical condition, idiosyncratic reactions to cholinergic-type medications (sedative, antipsychotic)

Creutzfeldt-Jakob Disease

Rapid onset and progression, causing dementia and death

Characterized by severe neurological impairment that accompanies the dementia

May occur spontaneously, be inherited, or transmitted by contact with infected tissue (transplant or eating contaminated meat)

Symptoms: psychotic behavior, heightened emotional lability, memory impairment, loss of muscular function, muscle spasms, seizures, and visual disturbances

Wernicke-Korsakoff Syndrome

Due to the lack of thiamine (vitamin B1)

-Wernicke encephalopathy

• Acute neurological condition 

• Confusion, vision changes, ataxia

-Korsakoff syndrome

• Chronic long-lasting stage

• Memory disorder

Caring for Persons with Dementia: Ensuring patient safety

-Problems related to poor judgement and misperceptions

-Consistent, structured environment

-Items to trigger memory

-Controlled environment

-Wandering behavior

-Prevention of abuse

Sundowner Syndrome

Individuals with cognitive impairments may experience a nocturnal confusion. Some of the factors that increase the risk of this condition include unfamiliar environments, disturbed sleep patterns, use of physical restraints, sensory overload, sensory deprivation, or changes in the circadian rhythm

Nursing management of Sundowners

Placing familiar objects and photos in the person’s room

Providing physical activity opportunities in the afternoon for energy expenditure

Adjusting lighting to prevent the room from becoming dark in the evening

Keeping a night-light on throughout the night

Having frequent interactions with the patient

Using to touch to provide human contact and calm the patient

Ensuring the environmental temperature is within a comfortable range for the person

Controlling noise and traffic flow in the evening

Ensuring the person’s basic needs are met

Caring for Persons with Dementia: Promoting therapy and activity

-Reality orientation (daily groups or reminding patient who he or she is during every interaction)

-Listening to music, support animal, touching various textures or objects to stimulate the brain

Caring for Persons with Dementia: Modify communication techniques

-Short sentences with one idea or instruction

*calm manner using adult tone and avoid sarcasm

-Offering simple decision opportunities

-Avoid arguments (distractions)

-Observe nonverbal expressions and behaviors

Caring for Persons with Dementia: Supporting the patient’s family

-Consideration of physical, emotional, and socioeconomic burdens of caregiving

-Review/educate basic care techniques

-Help prepare for feeling that may accompany the role of caregiver

-Confabulation