Dementia, delirium, alzheimers

Class Learning Outcomes

• Delirium vs. Dementia: The ability to compare and contrast the two conditions.

• Disease Management: Describe the pathophysiology, clinical manifestations, and nursing management of Alzheimer’s disease, delirium, and dementia.

• Drug Therapy: Review medication options for managing Alzheimer’s disease, delirium, and dementia.

• Nursing Process: Utilize the nursing process as a framework for providing care to patients suffering from Alzheimer’s disease, delirium, and dementia.

Introduction and Epidemiology

• Prevalence of Alzheimer’s Disease (AD):     * Alzheimer's disease is the most common form of dementia.     * In $2016$, an estimated $5.2 \text{ million}$ Americans aged $65$ and older had Alzheimer's disease.     * By $2050$, the prevalence is expected to reach $13.8 \text{ million}$.     * This projection for $2050$ includes $7 \text{ million}$ people aged $85$ and older.

Understanding Delirium

• Definition: Delirium is a serious disturbance in mental abilities resulting in confused thinking and reduced environmental awareness.

• Onset: Usually rapid, appearing within hours or a few days.

• Contributing Factors: Delirium can often be traced to specific causes, including:     * Severe or chronic illness.     * Changes in metabolic balance (e.g., low sodium).     * Medication side effects or interactions.     * Infections.     * Surgery.     * Alcohol or drug intoxication or withdrawal.

• Clinical Presentation: The symptoms of delirium and dementia can be similar, necessitating careful differentiation.

Types of Delirium

• Hyperactive Delirium: The most easily recognized type. Symptoms include:     * Restlessness (e.g., pacing).     * Agitation.     * Rapid mood changes.     * Hallucinations.     * Refusal to cooperate with medical care.

• Hypoactive Delirium: Symptoms include:     * Inactivity or reduced motor activity.     * Sluggishness.     * Abnormal drowsiness.     * Appearing to be in a daze.

• Mixed Delirium: Includes both hyperactive and hypoactive signs and symptoms. The patient may switch back and forth quickly between these states.

Understanding Dementia

• Onset and Progression: Symptoms are subtle in onset with a slow, progressive decline in memory and thinking skills. This is caused by the gradual dysfunction and loss of brain cells.

• Primary Causes:     * Alzheimer’s Disease: The most common cause, accounting for $70\%$ of all dementia cases.     * Non-Alzheimer’s Causes: These include degenerative, vascular, neoplastic, demyelinating, infectious, inflammatory, toxic, metabolic, and psychiatric disorders.

Comparison of Delirium vs. Dementia

• Onset:     * Delirium: Sudden, with a definite beginning point.     * Dementia: Slow and gradual, with an uncertain beginning point.

• Duration:     * Delirium: Days to weeks (though it may be longer).     * Dementia: Usually permanent.

• Underlying Cause:     * Delirium: Almost always another condition (e.g., infection, dehydration, drug use/withdrawal).     * Dementia: Usually a chronic brain disorder (e.g., Alzheimer's, Lewy body dementia, vascular dementia).

• Course:     * Delirium: Usually reversible.     * Dementia: Slowly progressive.

• Nighttime Effect:     * Delirium: Almost always worse at night.     * Dementia: Often worse at night.

• Attention:     * Delirium: Greatly impaired.     * Dementia: Unimpaired until the disease becomes severe.

• Level of Consciousness:     * Delirium: Variably impaired.     * Dementia: Unimpaired until the disease becomes severe.

• Orientation to Time and Place:     * Delirium: Varies.     * Dementia: Impaired.

• Language Use:     * Delirium: Slow, often incoherent, and inappropriate.     * Dementia: Sometimes difficulty finding the right word.

• Memory:     * Delirium: Varies.     * Dementia: Lost, especially for recent events.

Characteristics of Alzheimer’s Disease

• Definition: A progressive brain disorder that gradually destroys memory, reasoning, judgment, communication, the ability to learn, and the ability to carry out daily activities.

• Reversibility: It is the most common cause of irreversible dementia.

• Behavioral Changes: As the disease progresses, individuals may experience changes in personality and behavior, including:     * Anxiety.     * Suspiciousness.     * Agitation.     * Delusions or hallucinations.

• Individual Variation: Each person progresses through the disease process differently.

Degenerative Changes and Pathophysiology in AD

• General Concepts:     * Also known as senile dementia.     * A chronic, progressive, degenerative disorder affecting $4.5 \text{ million}$ people in the U.S.     * It is not a normal part of the aging process.     * It is the sixth leading cause of death.     * It affects half of all individuals aged $85$ and older.

• Types of AD:     * Familial/Early onset.     * Sporadic/Late onset.

• Pathophysiological Markers:     * Neurofibrillary Tangles: Involving Tau protein.     * Senile Plaques: Involving $b$-amyloid protein ($\text{amyloid, Ab}$).     * Oxidative Stress: Research suggests this plays a significant role in the disease process.     * Other features: Inflammation, neuronal atrophy, and influence from genetic and environmental factors.

Clinical Manifestations and Diagnosis of AD

• General Manifestations:     * Global cognitive decline.     * Behavioral changes.     * Eventual loss of function.

• Severity: Based on stage and progression; AD is classified into seven stages.

• Initial Symptoms:     * Memory loss.     * Confusion.     * Restlessness and mood swings.     * Difficulty interpreting visual information.

• Diagnostic Tools:     * History and Physical Exam: Foundational assessment.     * Neurologic Evaluation: Assessing mental status, communication, memory, comprehension, math skills, reasoning, balance, and visual/motor coordination.     * Imaging: Brain scan, MRI, and CT scan are used to rule out other diseases.     * Definitive Diagnosis: Can only be made at autopsy.

Nursing Management and Symptomatic Care

• Core Nursing Goals:     * Cognitive Function: Support remaining cognitive abilities.     * Safety: Promote physical safety and general health status.     * Independence: Promote independence in self-care activities for as long as possible.     * Psychological Support: Reduce anxiety and agitation; improve communication.     * Social/Personal Needs: Provide for socialization and intimacy needs.     * Nutrition and Rest: Promote adequate nutrition and balanced activity and rest.     * Care Transitions: Support home, community, and transitional care.     * Goal of Care: Maximize the patient's quality of life.

Medication Management for Memory in AD

• Goal of Therapy:     * Slow memory and cognition loss.     * Delay the onset of the disease.     * Bring about slight improvements in cognition and function.

• Drug Classes: Two main classes of drugs are approved to treat Alzheimer’s: Cholinesterase Inhibitors and N-Methyl-D-Aspartate (NMDA) Receptor Antagonists.

Cholinesterase Inhibitors

• Indications: Prescribed for mild to moderate Alzheimer’s disease.

• Mechanism of Action: They prevent the breakdown of acetylcholine, a brain chemical important for memory and thinking.     * As the disease progresses, the brain produces less acetylcholine, which may cause these drugs to lose their efficacy.

• Specific Medications:     * Razadyne® (galantamine).     * Exelon® (rivastigmine).     * Aricept® (donepezil).

• Clinical Considerations: No published study directly compares these three drugs. A patient may respond better to one than the others.

N-Methyl-D-Aspartate (NMDA) Antagonist

• Indications: Prescribed for moderate to severe Alzheimer’s disease.

• Medication: Namenda® (memantine).

• Mechanism of Action: Regulates glutamate. Excessive glutamate can lead to brain cell death.

• Main Effect: Decreases symptoms, potentially allowing patients to maintain daily functions slightly longer.

• Combination Therapies:     * NMDA antagonists work differently from cholinesterase inhibitors and can be prescribed together.     * Namzaric®: A combination of Namenda® and Aricept®.     * The FDA has also approved Aricept® and the Exelon® patch for moderate to severe stages.

Evaluation of Pharmacologic Therapy

• Cognitive Enhancers: Both drug classes show modest efficacy in preserving function.

• Adverse Effects: Practitioners must monitor for side effects, particularly gastrointestinal effects associated with cholinesterase inhibitors.

• Discontinuation: Should be considered when dementia reaches an advanced stage where the initial intended purpose of the drugs is no longer achievable.

Medications for Behavioral Symptoms

• Other Pharmacologic Therapies:     * Antidepressants.     * Anti-anxiety agents.     * Antipsychotics.

Future Research Directions

• Insulin Resistance: Researchers are studying the effects of insulin on brain cell function and its potential link to AD. A trial is currently testing an insulin nasal spray.

• Heart-Head Connection: Growing evidence links brain health to heart and blood vessel health.     * AD risk increases with conditions that damage the heart or arteries.     * Key risk conditions: High blood pressure, heart disease, stroke, diabetes, and high cholesterol.