Delirium & Dementia Lecture Notes

I. Delirium & Dementia

A. Definitions

Delirium
  - A sudden, temporary change in thinking and awareness.
  - Usually caused by a medical problem (e.g., infection, medications, dehydration).
  - It is reversible when the underlying cause is treated.
Dementia
  - A slow, long-term decline in memory and thinking.
  - Caused by damage to brain cells.
  - It can be reversible or irreversible, depending on the cause.

B. Defining Characteristics

Delirium
  - Sudden onset (hours–days)
  - Fluctuates during the day
  - Trouble focusing
  - Possible hallucinations or confusion
  - Considered a medical emergency
Dementia
  - Slow onset (months–years)
  - Steady decline
  - Memory loss
  - Poor judgment
  - Personality changes

C. Contributing / Risk Factors

Delirium
  - Infection (e.g., UTI, pneumonia)
  - Changes in medications
  - Dehydration
  - Surgery/anesthesia
  - Electrolyte imbalance
Dementia
  - Age
  - Family history
  - Stroke
  - Head injury
  - Chronic diseases (e.g., hypertension, diabetes)

D. Assessment Criteria

Nurses assess the following:
  - Level of consciousness
  - Orientation (person, place, time)
  - Memory
  - Behavior changes
  - Vital signs
  - Lab results (indicating infection, electrolytes, etc.)
  - Medication list
Tools for assessment:
  - CAM (Confusion Assessment Method)
  - Mini-Cog
  - MMSE (Mini-Mental State Examination)

E. Outcome Criteria

The client should achieve the following outcomes:
  - Remain safe
  - Improved orientation
  - Reduced confusion
  - Stable vital signs
  - Family understands the condition
  - Basic needs met (hydration, nutrition, sleep)

F. General Nursing Interventions

Nursing interventions should include:
  - Providing a calm, quiet environment
  - Using clocks, calendars, and simple reminders
  - Keeping a consistent routine
  - Encouraging hydration and nutrition
  - Gently reorienting the patient
  - Ensuring safety (e.g., bed alarms, fall precautions)
  - Involving family
  - Monitoring medications

G. Evaluation / Documentation

Nurses should document:
  - Changes in mental status
  - Responses to interventions
  - Safety concerns
  - Family teaching
  - Progress toward goals

H. Dementia as a Disturbed Thought Process

Definition: A chronic decline in memory, reasoning, and behavior caused by brain cell damage.
Diagnosis Based on:
  - Patient history
  - Cognitive testing
  - Brain imaging
  - Lab tests to rule out reversible causes
Types of Dementia
  - Reversible Dementias: Improve when the cause is treated, including:
    - Vitamin B12 deficiency
    - Thyroid disorders
    - Medication toxicity
    - Depression (often referred to as "pseudodementia")
    - Normal pressure hydrocephalus
  - Irreversible Dementias: Do not improve, including:
    - Alzheimer's disease
    - Vascular dementia
    - Lewy body dementia
    - Frontotemporal dementia
Alzheimer's Disease (AD)
  - Incidence:
    - Most common cause of dementia.
    - Risk increases significantly after age 65.
  - Causes (Theories):
    - Presence of beta-amyloid plaques
    - Formation of neurofibrillary tangles
    - Genetic factor: APOE-4 gene
    - Inflammation processes
    - Oxidative stress
  - Pathophysiology:
    - Brain cells cease to communicate with one another.
    - Accumulation of plaques and tangles occurs.
    - Over time, the brain shrinks.
    - Results in a gradual decline in memory and thinking.
  - Stages of Alzheimer’s:
    - Early Stage:
      - Mild forgetfulness
      - Misplacing items
      - Difficulty with complex tasks
    - Middle Stage:
      - Increased confusion
      - Wandering
      - Notable personality changes
      - Requires help with Activities of Daily Living (ADLs)
    - Late Stage:
      - Inability to communicate
      - Bedridden condition
      - Requires total care

I. Assessment / Diagnostic Process

Assessment and diagnostic measures for dementia include:
  - Cognitive tests (e.g., MMSE, Mini-Cog)
  - Brain scans (e.g., CT/MRI)
  - Rule out any reversible causes
  - Conducting a family interview for history and context

J. Differentiation: Dementia vs. Delirium vs. Depression

Feature	Dementia	Delirium	Depression
Onset	Slow	Sudden	Weeks–months
Course	Steady decline	Fluctuates	Improves with treatment
Attention	Normal early	Poor	Normal
Mood	Variable	Fearful	Sad, withdrawn
Reversible?	No	Yes	Yes

K. Planning Nursing Goals

The nursing goals when dealing with dementia patients should include:
  - Maintaining safety
  - Supporting memory
  - Promoting independence
  - Reducing anxiety
  - Supporting caregivers

L. Interventions (including Re-motivation)

Effective nursing interventions include:
  - Use of simple instructions
  - Providing a structured routine
  - Labeling objects in the patient's room
  - Encouraging familiar activities
  - Utilizing music, photos, and reminiscence therapies
  - Re-motivation: Encouraging participation in meaningful tasks
  - Promoting physical activity
  - Maintaining hydration and nutrition

M. Medications

Common medications include:
  - Cholinesterase inhibitors: (e.g., donepezil, rivastigmine)
  - NMDA antagonist: (e.g., memantine)
  - Purpose: These medications aim to slow the decline of cognitive function but do not cure the disease.

N. Evaluation / Reassessment

Reassessment focuses on:
  - Determining if the client is safe
  - Assessing whether behaviors are improving
  - Evaluating family coping mechanisms
  - Checking if medications are effective

O. Legal Considerations

Important legal aspects include:
  - Advance directives
  - Power of attorney for medical and financial decisions
  - Guardianship arrangements
  - Safety concerns regarding driving and finances

II. Competence vs. Incompetence

Mental Competence
- Defined as the ability to understand information and make decisions about health, finances, and daily life choices.
Incompetence
- A legal term declared by a court, indicating a person cannot make safe decisions.

III. Guardianship (Clinical & Property)

Clinical Guardianship:
- A court-appointed individual who makes health-care decisions for clients who cannot understand medical information.
Property Guardianship / Conservatorship:
- A court-appointed individual manages the client’s finances, property, and bills, protecting the client from financial harm.

V. Social Isolation

A. Definition

Social isolation refers to a lack of meaningful contact with others.

B. Defining Characteristics

Common characteristics include:
  - Loneliness
  - Withdrawal
  - Depression
  - Lack of support

C. Contributing / Risk Factors

Factors contributing to social isolation include:
  - Living alone
  - Loss of spouse
  - Mobility problems
  - Hearing/vision loss
  - Cognitive decline

D. Assessment Criteria

Nurses assess the following:
  - Social support
  - Daily activities
  - Mood
  - Access to transportation
  - Community involvement

E. Outcome Criteria

Desired outcomes include:
  - Increased social interaction
  - Improved mood
  - Participation in activities
  - Reduced loneliness

F. Nursing Interventions

Interventions to reduce social isolation involve:
  - Encouraging group activities
  - Teaching communication strategies
  - Connecting the client with community resources
  - Promoting physical activity
  - Involving family members

G. Evaluation / Documentation

Evaluation should focus on:
  - Improvement in social interaction
  - Client attendance at activities
  - Improvement in mood

H. Community-Based Strategies

Strategies for community involvement include:
  1. Senior centers / Councils on Aging
  2. Foster grandparent programs
  3. Geriatric day care:
    - Medical: health monitoring, therapy
    - Social: activities, meals, companionship

I. Alternative Living Arrangements

Options for living arrangements include:
  - Independent senior housing
  - Assisted living
  - Adult foster homes
  - Memory-care units
  - Skilled nursing facilities