Nursing Care for Older Adults and Neurocognitive Disorders

risk factors

chronic illness, alc and substance abuse, polypharmacy, bereavement and loss, poverty, lack of social support, elder mistreatment

protective factors

marriage effect, education and income, resilience and positive outlook, healthy lifestyle, nutrition, physical activity

interventions to promote wellness

Reduce stigma of mental health treatment, early recognition, monitor medications and polypharmacy, avoid premature institutionalization, social support: transitions, cognitive engagement, lifestyle support, self care enhancement and spiritual support,

communication techniques

focus the person’s attention on the exchange of communication; the older adult may need extra time to begin to process information; fact the person when speaking to him or her; minimize distractions in the room; reduce glare from room lighting by dimming too bright lights; speak slowly and clearly; use short, simple sentences and be prepared to repeat or revise what was said; limit number of topics; ask one question at a time; allow plenty of time for answers; avoid the urge to finish sentences; consider factors such as fatigue and discomfort; postpone if communication is going poorly 

physical assessment when completing mental health assessment

present and past health status, physical examination, abnormal neurologic tests could indicate neuromuscualr problems, chronic illness, nutrition/eating type: amount, type, frequenct, subsyance use, elimination, sleep (pts may sleep more or less when younger, insomnia could indicate depression, interpersonal stress or loneliness), pain: chronic pain contributes to behavior and personality changes/depression

psychological assessment

response to mental health problems: cultural stigma, fear of consequences; do not argue with patient, collateral contacts, educate and use problem solving, MSE

depression distinguished from dementia

worse in AM; maintain ability to complete ADLs; people way more aware of deficits

dementia meds

opiates and synthetic narcotics

psychosis meds

digitalis, L-dopa, reserpine, corticosteroids, barbituates, insoniazid

anxiety meds

decognestanrs, bronchodilators, anticholinergics

depression meds

beta-blockers, chemotherapy drugs, sedative hypnotics

stepwise approach

review current drug, discontinue unnecessary therapy, consider adverse drug events, consider nonpharm approaches, reduce the dose, simplify the dosing schedule, prescribe beneficial therapy

anticholinergic medications effect

xerostomia (dry mouth)→constipation, dehydration

medicated related delirium

a common, reversible cause of acute confusion in older adults, often triggered by anticholinergics, benzos, opioids, and corticosteroids 

BEERS criteria

• Include over 50 medications designated in one of three: 

  • Meds that should always be avoided 

  • Meds that are potentially inappropriate in older adults with particular health conditions or syndromes 

  • Meds that should be used with caution

• Include OTC meds

normal age related changes in cognitive capacity older adults

gradual slowing of speed, reduced multitasking ability, and minor memory issues (occasional word-finding difficulties)

abnormal cognitive changes in older adults that are not age-related

severe memory loss, confusion, language issues, and personality changes

mini mental status exam

offers a quick and simple way to quantify cognitive function and screen for cognitive loss. It tests the individual’s orientation, attention, calculation, recall, language, and motor skills

mini MSE (mood and affect)

depression is common, late onset depression=development of depression or depressive symptoms after 60 years of age 

mini MSE (thought process)

 suspicious and delusional thoughts that characterize dementia

mini MSE (behavioral changes)

irritability, agitation, apathy, and euphoria associated with psychiatric disorders in older adults; psychiatric illness may lead to wandering or aggressive behaviors; apraxia indicates an underlying disease process

mini MSE (stress and coping)

bereavement

risk assessment

depression and/or attempted suicide in the past; family hx of suicide; firearms in the house; abuse of alc or other substances; unusual stress and social isolation; burden to family; chronic medical conditions; suicide rates increase with age 

suicide risk

increases with age (white men over over the age of 85 are at greatest risk of suicide

depression vs dementia

treatable mood disorder (rapid onset and self awareness of deficits)

dementia vs depression

progressive, irreversible neurologiacal decline (gradual memory loss and reduced awareness of cognitive issues)

elder abuse

•  physical, sexual, and emotional abuse, caretaker neglect, financial exploitation and self-neglect; 60+ 

• Call the department of public heath; nurses have duty to report 

neurocognitive disorders

a decline in cognitive function from a previous level of functioning; deficits in domains

• Attention, executive functioning, learning and memory, language, perceptual-motor, social cognition

Delirium

Define= a disorder of acute cognitive impairment that is caused by a medical condition (e.g. infection), substance abuse, or multiple etiologies

Characteristics= server confusion, disorientation, disorganized thinking, hallucinations, and rapid mood swings 

Underlying causes= medical issues, drug interactions,, or environmental stress

Development and Course= an acute, fluctuating disturbance in attention, awareness, and cognition developing over hours to days 

Determination of severity= CAM-S, delirium observation screening scale, and CAM-ICU-7

Associated features= disorganized thinking, memory deficits, emotional instability, vivid hallucinations, and altered sleep-wake cycles 

Nursing Assessment= focus on detecting acute, fluctuating changes in mental status, attention, and consciousness

Nursing Diagnoses= risk for injury, acute confusion, hyperthermia, acute pain, risk for infection, insomnia 

Nursing Interventions=early identification, reorientation, environmental safety, and mitigating underlying causes 

List the most important interventions to eliminate or minimize the risk factors for

Delirium= frequent orientation, optimizing sleep-hygiene, implementing early mobilization, ensuring sensory aids, managing pain, minimizing environmental noise/lights and encouraging family presence 

Dementia

Define= characterized by chronic cognitive impairments and is differentiated by underlying cause, not by symptom patterns. Dementia can be further classified as cortical or subcortical to denote the location of the underlying pathology 

Characteristics= memory loss, communication difficulties, impaired judgement, and cognitive decline 

Development and Course (early signs)= forgets recently learned information and unable to recall later; difficulty with everyday tasks like preparing a meal; problems with language, substitute unusual words; disoriented to time and place, confused in own neighborhood; poor judgement, may dress inappropriately for weather; problems with abstract thinking; misplacing objects by putting them in unusual places; dramatic changes in personality; loss of initiative (early onset= before age 65; late onset= after age 65)

Risk factors= older age, female, gentics/family hx, people with down syndrome, fewer years of education, head trauma/brain injury, metabolic syndrome, infections (HIV, HSV)

Determination of severity= assessed by cognitive function and daily living abilities 

Symptoms based on severity (mild, moderate, severe)

• Mild= loss of memory, language difficulties, mood swings, personality changes, diminished judgement, apathy 

• Moderate= inability to retain new information; behavioral, personality changes; increasing long-term memory loss; wandering, agitation, aggression, confusion; requires assistance w/ ADL

• Severe= gait and motor disturbances; bedridden; unable to perform ADL; incontinence; requires long-term care placement 

Associated features= memory loss, communication difficulties, visual/spatial deficits, reduced executive function, movement issues, personality changes, mood disturbances, psychosis, behavioral disturbances 

aphasia

• language disorder caused by brain damage (commonly stroke or injury) that impairs speaking, understanding, reading, and writing, often causing frustration and social isolation 

  • Nursing assessment: evaluate expressive (speaking) and receptive (understanding) language skills 

  • Nursing diagnosis= impaired verbal communication

  • Nursing interventions=reducing environmental noise, speaking slowly in short sentences, using visual aids, allowing ample time for response 

apraxia

•  neurological disorder characterized by the inability to perform learned, purposeful movements despite having the desire and physical capability to do so 

  • Nursing assessment=focus on identifying deficits in motor planning

  • Nursing diagnosis=risk for impaired physical mobility, self care deficit, and impaired verbal communication

  • Nursing Interventions= enhancing communication, safety, and independence through structured, consistent, and sensory-rich approaches 

agnosia

• rare neurological disorder characterized by the inability to recognize familiar objects, people, sounds, or smells despite having intact sensory faculties 

  • Nursing assessment= evaluating a pt’s inability to recognize objects, sounds, or faces despite intact sensory faculties 

  • Nursing diagnosis= disturbed sensory perception, risk for injury, self-care deficit, and impaired environmental interpretation syndrome 

  • Nursing interventions= compensatory strategies, safety, and enhancing sensory input to help pts recognize objects, faces, or sounds 

suicide risk

increased in older adults

interventions for agitated, anxious, confused patient

calm environment, gentle communication, validate feelings, employing distraction (music, activities), establishing routines, and managing pain or discomfort

guidelines

physical activity to reduce for cognitive decline in older adults (WHO)

recommendations

promote tobacco cessation; reduce harmful drinking; help pts lose excess weight in midlife; encourage a healthy diet (Mediterranean style diet can reduce dementia risk); cognitive training; social participation and support are important throughout life; HTN, diabetes, and depression should be managed 

different types of dementia

• Vascular Dementia

• Parkinson Disease

• Huntington Disease

• Frontotemperoal neurocognitive Disorder

• Neurocogntive Disorder with Lewy Bodies

Vascular Dementia

• 2nd most common; caused by conditions that block or reduce blood flow to the brain 

• Symptoms usually appear more suddenly than AD 

Parkinson Disease

75% of people with PD develop dementia; may have overlapping pathology with AD

Huntington Disease

Genetically transmitted autosomal dominant disorder; frontal dementia=caused in behavior and personality, decreased attention 

Frontotemporal Neurocognitive Disorder

 similar to AD, but has distinct patterns of brain atrophy and neuropathology 

Neurocognitive Disorder with Lewy Bodies

• Creutzfeldt-Jakob disease, a rare, rapidly fatal, brain disorder 

• Mad cow disease, a bovine disorder 

• Progressive cognitive decline with visual hallucinations, REM sleep disorder, and spontaneous parkinsonism characterize dementia, symptoms fluctuate and may resemble delirium

Sundown Syndrome

impacts memory, thinking, personality, reasoning, behavior, and mood often occurring later in the day; prevalent among individuals with dementia

Sundown Syndome etiology

• Impaired circadian rhythm, environmental (e.g. limited sunlight or overstimulation), physical illness or infection, chronic pain

• Possible degeneration of the suprachiasmatic nucleus of the hypothalamus and decreased production of melatonin

dementia mild severity

loss of memory, language difficulties, mood swings, personality changes, diminished judgement, apathy

dementia moderate severity

inability to retain new information; behavioral, personality changes; increasing long-term memory loss; wandering, agitation, aggression, confusion; requires assistance w/ ADL

dementia severe severity

gait and motor disturbances; bedridden; unable to perform ADL; incontinence; requires long-term care placement