Geriatric Neurology and Mental Health: Aging, Parkinson's, Stroke, Dementia, Delirium, Depression, Anxiety, Substance Abuse
Normal aging: neurological function in older adults
Normal aging changes (not pathological): progression over time in the nervous system
Neuron loss: begins after about age 25; more nerve cells lost as age increases
Neurotransmitters: fewer neurotransmitters available in aging brain
Nerve conduction and reaction time: slower in older adults
Brain atrophy: brain size and neurons decrease with age; space increases on imaging
Plaques: plaques form in nerve cell bodies during aging
Cerebral blood flow: slows somewhat with age
Hippocampus changes: memory retrieval and storage rely on the hippocampus; aging leads to changes there
Activating system changes: sleep-cycle regulation alterations
Sensory decline: receptors decrease in number and sensitivity; cranial nerves show aging-related changes
Vision, hearing, taste, smell, vibratory sensation: often diminished
Temperature sensation: less able to sense temperature changes; environment safety considerations
Balance and postural control: increased risk for postural hypertension and falls; sensitivity to medications that lower blood pressure on standing up
Intellectual maintenance: intellect generally preserved; many argue wisdom and emotional intelligence may improve or stay strong into later years; verbal skills often preserved until around age 70, then vocabulary can decline
Overall nursing task: distinguish normal aging from pathological changes; monitor for differences in presentation and degree
Clinical manifestations linked to normal aging (summary):
Sleep changes: less REM sleep; longer time in stages 1–2; easier to wake; daytime sleepiness may increase
Learning: altered ability to learn new information quickly, though learning is still possible with effort
Memory: storage/retrieval affected via hippocampus; occasional difficulty recalling names or words is common and usually gradual
Vision/hearing changes: sensory deficits impact communication and safety
Taste/smell changes: can influence nutrition; adapt to maintain intake
Postural hypertension and balance issues: greater risk with antihypertensive or diuretic therapies; careful drug management needed
Temperature regulation: environmental safety importance
Cognitive function and intellect: intelligence maintained; some decline in processing speed, but not necessarily loss of intellect
Functional status: slower task performance; need for supports or assistive devices as needed
Red flags requiring further evaluation (nursing alarm signs):
New headaches, new vision changes
Sudden deafness or tinnitus
Rapid mood or personality changes
Altered consciousness or cognition
New clumsiness or unstable gait
Numbness or tingling in extremities or unusual nerve sensations
Parkinson's disease (PD)
Pathophysiology: decreased dopamine in basal ganglia; balance between acetylcholine and dopamine disrupted
Neurotransmitter role: acetylcholine is excitatory; dopamine enables smooth, controlled movement
Classic motor symptoms: resting tremor (often initial), bradykinesia (slowness of initiation), impaired postural reflexes
Typical body presentation: stooped/forward-leaning posture, rigid back, shuffling gait, masked facial expression
Common risk factors: genetic (autosomal dominant defect on chromosome 4) and environmental factors; potential drug/toxin exposure; trauma history
Non-motor features: heat intolerance, constipation, depression; decreased perspiration; dysphagia risk with disease progression
Diagnosis: clinical presentation; no definitive lab test; responds to dopaminergic therapy
Treatments (not curative; symptom management):
Dopaminergic therapy: carbidopa-levodopa (Sinemet) — levodopa precursor to dopamine; carbidopa inhibits peripheral breakdown
Dopamine agonists and anticholinergics to mitigate symptoms and side effects
Catechol O-methyltransferase (COMT) inhibitors to prolong dopamine effect
Surgical options (for selected patients):
Ablation and deep brain stimulation (DBS) reduce aberrant neural activity
Transplantation and stem cell approaches under investigation
Nursing goals and interventions: maintain cognition and function, prevent injuries from impaired movement, minimize falls, safety-focused teaching
Nursing care plan elements:
Active range of motion exercises twice daily
Ambulation with assistive devices (walker/c cane) and PT consult when mobility declines
OT consult for activities of daily living and adaptive devices
Speech/swallow therapy for dysphagia and communication challenges
Nutritional assessment and support; monitor weight and dietary needs
Psychological support; address caregiver burden; community resources
Safety and management emphasis: prevent falls, plan for evolving needs, enable independent function where possible
Cerebrovascular accident (CVA) / Stroke
Types: hemorrhagic stroke (bleed due to vessel rupture or malformation) vs ischemic/thrombotic stroke (clot obstructs blood flow)
Onset pattern: hemorrhagic strokes often have abrupt onset; ischemic strokes may have sudden onset or evolve over minutes to hours
Common presenting symptoms: sudden unilateral facial, arm, or leg numbness or weakness (usually on one side); confusion or trouble speaking; trouble seeing in one or both eyes (hemianopsia); trouble walking, dizziness, loss of coordination; severe headache may occur
Risk factors: advanced age; genetics; African American ethnicity; diabetes; cigarette smoking; heart disease; obesity; physical inactivity; cocaine use; atrial fibrillation (AFib); hypertension (most important modifiable risk factor)
Acute management in hospital: emergency CT scan; continuous monitoring (cardiac and other vitals); labs; possibly EEG; airway protection; head of bed elevated to reduce intracranial pressure (ICP)
Neuro assessment and scales: NIH Stroke Scale or similar tools; assess level of consciousness, orientation, commands, gaze, visual fields, motor function, sensory, language, and cognition
Reperfusion therapy: thrombolytic therapy within a 3-hour window (time is brain); earlier treatment yields better outcomes; later guidelines may vary by stroke type and facility
Medications and interventions:
Anticoagulants or antiplatelets depending on etiology (AFib, clotting risk, etc.)
Lipid-lowering agents and antihypertensives for long-term secondary prevention
Indirect vascular procedures (carotid endarterectomy or extracranial bypass) and brain surgery for certain conditions (aneurysms, malformations, intracranial bleeding)
Acute nursing interventions: keep head elevated, monitor vitals, turn and ROM every 2 hours, encourage use of unaffected arm for ADLs, ensure swallow safety and resumption of oral intake after swallow study
Speech and language concerns: aphasia types (receptive vs expressive); visual field deficits (hemianopia); adapt patient/family education to language abilities
Outcomes and family/community planning: stroke prevention education, access to resources, and long-term rehabilitation planning
Priority considerations: safety and prevention of secondary injury; test-tasks often emphasize safety as the highest priority in acute care
Mental health and substance use in older adults
Depression in older adults: prevalent; 20–25% of adults aged 55+ have a mental health disorder (depression is especially common)
Causes and contributing factors: chronic illnesses, aging-related losses (bereavement, relocation, retirement), changes in social roles and income, societal undervaluation of older adults; medications may contribute to depression
Screening and assessment: Geriatric Depression Scale (GDS-15); 15 yes/no questions; scores >5 suggest depression requiring further evaluation
Key signs: fatigue, constipation, psychomotor retardation, persistent depressed mood, anhedonia, low energy, social withdrawal, neglect of hygiene or self-care, somatic complaints; altered cognition common in depression and can mimic dementia
Treatment considerations: prefer SSRIs over tricyclic antidepressants (TCAs) due to anticholinergic side effects and safety concerns in older adults; avoid combining SSRIs with St. John’s wort; consider psychotherapy and nonpharmacologic approaches (acupuncture, guided imagery, light therapy, sleep, exercise, nutrition)
Start low, go slow: gradual dosing and small increases to minimize side effects and falls risk; expect SSRIs to take ~2 weeks or more to show effect
Suicide risk: high among older adults; ~29% of suicide deaths occur in older adults; highest risk in men aged 85+ and older white men; risk factors include bereavement, chronic illness, social isolation, and retirement
Suicide risk assessment and response: use structured tools (e.g., National Institute of Mental Health resources) to assess frequency of thoughts, plan, past attempts, symptoms, social support; determine disposition (emergency psychiatric evaluation, inpatient care, or nonurgent follow-up); safety planning and no-suicide contracts when appropriate
Alcohol use in older adults: SMAST-G screening; two or more positive responses suggests an alcohol problem; recommended limits typically not more than one standard drink per day for older adults; withdrawal management and potential interactions with medications required; benzodiazepines for alcohol withdrawal can be dangerous in older adults
Anxiety in caregivers and patients: coaching and coping strategies; relaxation and deep breathing; modify perceptions of stress; psychotherapy and nonpharmacological approaches preferred; meds should be a last resort in older adults due to safety concerns
Substance abuse in older adults: not rare; may involve prescription opioids and other substances; increased risk of falls, cognitive impairment, self-neglect; discuss strategies for safe medication use and monitoring; do not overlook prescription misuse and social factors that sustain abuse
Delirium vs dementia (two “d’s”) and nursing care
Delirium: acute, abrupt global cognitive impairment with fluctuating mental status; may be worse at night; disorganized thinking; inattention; altered alertness; can include agitation or hypoactivity; hallucinations common in hospital settings
Causes of delirium: drugs, electrolyte and acid-base imbalances, oxygen delivery/deficiency (hypoxia), hypothyroidism, infections, bladder/bowel retention, hypoglycemia/hyperglycemia, sleep deprivation, sensory deprivation or overstimulation, environmental factors, ICU-related factors
Assessment and criteria: Hartford Institute criteria (common nursing tool) look for: acute change in mental status; agitation or lethargy; fluctuating or altered level of consciousness; memory impairment or disorganized thinking; inattentiveness; change in behavior; criteria usually require multiple signs; delirium is a medical emergency and must be addressed promptly
Management principles: identify and treat the underlying cause (medication changes, electrolytes, oxygenation, infection, catheter-related issues, hypothyroidism, etc.); minimize stimuli and provide orientation; reassurance and consistent care; limit restraints and sedating medications; use antipsychotics like haloperidol only as a last resort due to safety concerns in older adults
Dementia co-occurring with delirium: delirium often superimposed on dementia; do not assume delirium is simply a manifestation of baseline dementia; obtain history and observe for changes; educate families and involve them in care planning
Nursing practice points: environment optimization (calm, well-lit, predictable routines); involve family; provide 24-hour sitter if needed; prioritize safety and reorientation; document delirium status per unit protocol
Dementia and Alzheimer’s disease (AD)
Dementia overview: progressive, irreversible cognitive deterioration with personality changes and functional decline; DSM-5 defines major neurocognitive disorder as dementia; mild neurocognitive disorder (MCI) is cognitive decline not yet affecting ADLs/IADLs
Common etiologies: dementia is a syndrome with multiple diseases causing it; Alzheimer’s disease accounts for 60–80% of dementia cases; Lewy body dementia (5–10%); vascular dementia (5–10%); frontotemporal dementia (FTD) (5–10%); other diseases such as AIDS and Parkinson’s may contribute
Alzheimer’s disease pathology: beta-amyloid plaques and tau tangles damage neurons and disrupt neurotransmission; plaques are amyloid beta fragments; tau proteins stabilize neurons but become tangled in AD
Common dementia progression patterns: Alzheimer’s disease tends to show a gradual, steady decline; vascular dementia often shows a stepwise decline after each cerebrovascular event
Frontotemporal dementia (FTD): earlier onset (often <60); affects frontal lobes; early behavioral changes or language impairment; different from AD in initial symptomatology
Lewy body dementia (LBD): alpha-synuclein inclusions (Lewy bodies); parkinsonian symptoms along with cognitive fluctuations and early visual hallucinations; often overlaps with Parkinson’s disease symptoms
Other causes and mimics: depression, drugs, vitamin/mineral deficiencies, thyroid disorders, metabolic issues, infections, exposure to toxins; reversible conditions must be ruled out before confirming dementia
Risk factors for AD and dementia (modifiable and non-modifiable):
Non-modifiable: age, family history, ApoE4 allele (two copies confer higher risk; up to ~10x baseline risk) 10\times; early-onset dementia linked to strong family history/genetics
Modifiable risk factors (Lancet Commission 2020): reduced incidence of dementia by addressing multiple factors; key factors include 40\% risk reduction if addressed collectively: less education, hearing loss, hypertension, physical inactivity, diabetes, obesity, low social contact, depression, tobacco, head injury, and potentially excessive alcohol
Prevention and screening: primary care uses MMSE, MoCA, or Mini-Cog; screening alone is not diagnostic; family observations are crucial and should be weighed alongside screening tests; if abnormal, refer to neuropsychology, neurologist, or geriatrician for comprehensive evaluation; imaging (CT/MRI) and labs to evaluate reversible causes
Diagnosis advances: traditional lumbar puncture (cerebrospinal fluid beta-amyloid and tau) and PET scans; newer blood-based tests measuring amyloid/tau ratios show promise for Alzheimer’s-specific diagnosis; these tests may guide prognosis and treatment decisions in the future
Stages and assessment tools for dementia: use scales such as the Alzheimer’s Association staging (1–4), Global Deterioration Scale (one to seven), MMSE (higher is better), and Allen scale (higher score indicates better function in some scales); clinicians should know which scale is being used when interpreting results
Mild cognitive impairment (MCI): cognitive decline not severe enough to interfere with daily activities; can progress to dementia or remain stable
Treatments and emerging therapies for AD:
Symptom management: cholinesterase inhibitors (e.g., donepezil) and memantine to modulate glutamate activity; these do not cure AD but can slow symptoms in some individuals
Disease-modifying therapies (recent advances): monoclonal antibodies that target amyloid plaques, such as
Leqembi (lecanemab)
Donanemab
Other agents (e.g., aducanumab) discussed in the literature; these therapies can slow cognitive decline by approximately 25\%-30\% over 18\text{ months} but carry risks of amyloid-related imaging abnormalities (ARIA) and require regular MRIs and monitoring
Administration and monitoring: IV infusions every two weeks (then potential subcutaneous maintenance later); frequent MRI surveillance (e.g., every 4 weeks during active treatment) due to ARIA risk; cost and insurance coverage remain significant barriers in many settings
Nonpharmacologic approaches for dementia care: cognitive stimulation therapy, communication therapies, behavioral therapy to limit triggers, reality orientation, validation therapy, reminiscence therapy; safety planning; establishing regular routines; balancing independence with caregiver support; simple, stage-appropriate communication; meaningful activities to improve quality of life
Neuropsychiatric symptoms in dementia: common behaviors include resisting care, repetitive actions, delusions, sexual disinhibition, wandering, suspiciousness; management requires a person-centered approach and may include diverting attention, environmental adjustments, and boundary-setting; antipsychotics carry higher mortality and should be used cautiously as a last resort
Sexual disinhibition: common in dementia; set clear boundaries and maintain professional boundaries; acknowledge feelings but keep care focused on medical needs
Wandering and agitation: use distraction, safety measures, and engaging activities; explain to family and staff the importance of reducing triggers and enhancing routines
Communication strategies: keep messages simple; tailor to the person’s stage; involve family; use reminiscence and validation approaches to reduce distress
Caregiver support and ethics: emphasize a balance between independence and dependence, supporting caregivers to reduce burnout; involve community resources and patient safety planning; consider ethical issues around autonomy, consent, and quality of life
Diagnostic and assessment tools (summary)
Screening instruments in primary care: MMSE, MoCA, and Mini-Cog; high scores do not rule out MCI or early dementia; family observations are equally important
Neuropsychology referral: detailed testing by a neuropsychologist or neurologist can differentiate mild cognitive impairment from dementia and identify reversible factors
Imaging and labs: CT or MRI to identify stroke, tumors, or hydrocephalus; labs to rule out reversible causes (thyroid function, vitamin deficiencies, infections, metabolic disorders)
Biomarkers and diagnostics (emerging): blood-based amyloid/tau measures; CSF biomarkers; PET imaging for amyloid/tau; potential for earlier and more accessible diagnosis, with implications for treatment
Staging and progression evaluation: use multiple scales; recognize that scores can vary by education and baseline functioning; family input remains critical for accurate staging and monitoring
Practical and ethical implications for nursing practice
Early identification and safety: prioritize safety in all neurological and cognitive issues; assess for risk of falls, aspiration, and functional decline; implement prevention measures
Interdisciplinary care: collaborate with PT/OT, speech-language pathology, nutrition, social work, and bereavement/caregiver support services
Patient-centered care: tailor care plans to the patient’s goals and stage of disease; respect preferences while ensuring safety and quality of life
Education and resources: connect families with community resources, respite care, adult day services, home health, and legal services; discuss advance care planning when appropriate
Ethical considerations: balance autonomy with safety in dementia care; manage behavioral symptoms with least restrictive approaches; avoid unnecessary aggressive pharmacologic interventions
Quick reference: key numbers and terms (LaTeX-ready)
Onset age for neuron loss: after 25 years
Time window for thrombolysis in acute stroke: 3\ hours
Alzheimer’s disease prevalence among dementia patients: 60\%-80\%
Lewy body dementia prevalence: 5\%-10\%
Vascular dementia prevalence: 5\%-10\%
Frontotemporal dementia prevalence: 5\%-10\%
Modifiable risk factors reduction potential (Lancet Commission 2020): 40\% reduction in dementia incidence when addressed
ApoE4 allele risk: two copies increase risk by about 10\times baseline
Monoclonal antibodies for Alzheimer's (emerging): approximate reduction in cognitive decline 25\%-30\% over 18\text{ months}; ARIA risk; frequent MRI monitoring
Geriatric Depression Scale (GDS-15) threshold: score > 5 suggests depression requiring further evaluation
Alcohol screening (SMAST-G): two or more “Yes” answers indicates an alcohol problem
Suicide statistics: older adults account for about 29\% of suicide deaths; highest in men 85+; risk factors include bereavement, illness, isolation, retirement
End of notes
Describe effects of aging on nervous system
Normal Physiological Changes:
Neuron loss: begins after about age 25 and increases with age.
Neurotransmitters: fewer available in the aging brain.
Nerve conduction and reaction time: slower in older adults.
Brain atrophy: decrease in brain size and neuron count; space increases on imaging.
Plaques: form in nerve cell bodies.
Cerebral blood flow: slows somewhat.
Hippocampus changes: affects memory retrieval and storage.
Activating system changes: alters sleep-cycle regulation.
Sensory decline: receptors decrease in number and sensitivity; cranial nerves show aging-related changes; vision, hearing, taste, smell, vibratory sensation often diminished.
Temperature sensation: reduced ability to sense temperature changes, implying environmental safety considerations.
Balance and postural control: increased risk for postural hypotension and falls; sensitivity to blood pressure-lowering medications.
Intellectual maintenance: generally preserved; wisdom and emotional intelligence may improve or stay strong; verbal skills often preserved until around age 70, then vocabulary can decline.
Clinical Manifestations Linked to Normal Aging (Summary):
Sleep changes: less REM sleep; longer time in stages 1–2; easier to wake; increased daytime sleepiness.
Learning: altered ability to learn new information quickly, though still possible with effort.
Memory: storage/retrieval affected via hippocampus; occasional difficulty recalling names or words is common and usually gradual.
Vision/hearing changes: sensory deficits impact communication and safety.
Taste/smell changes: can influence nutrition; adapt to maintain intake.
Postural hypotension and balance issues: greater risk with antihypertensive or diuretic therapies; careful drug management needed.
Temperature regulation: environmental safety importance.
Cognitive function and intellect: intelligence maintained; some decline in processing speed, but not necessarily loss of intellect.
Functional status: slower task performance; potential need for supports or assistive devices.
List risk factors for neurologic problems in older adults
Parkinson's Disease (PD):
Genetic (autosomal dominant defect on chromosome 4).
Environmental factors; potential drug/toxin exposure; trauma history.
Cerebrovascular Accident (CVA) / Stroke:
Non-modifiable: advanced age, genetics, African American ethnicity.
Modifiable: diabetes, cigarette smoking, heart disease, obesity, physical inactivity, cocaine use, atrial fibrillation (AFib), hypertension (most important modifiable risk factor).
Alzheimer’s Disease (AD) and Dementia:
Non-modifiable: age, family history, ApoE4 allele (two copies confer higher risk; up to \sim10\times baseline risk); early-onset dementia linked to strong family history/genetics.
Modifiable (Lancet Commission 2020): reduced incidence of dementia by addressing multiple factors; key factors include 40\% risk reduction if addressed collectively: less education, hearing loss, hypertension, physical inactivity, diabetes, obesity, low social contact, depression, tobacco, head injury, and potentially excessive alcohol.
Describe measures to promote neurologic health, promote independence, and reduce risk of injury in older adults
General Nursing Actions:
Distinguish normal aging from pathological changes; monitor for differences in presentation and degree.
Prioritize safety in all neurological and cognitive issues; assess for risk of falls, aspiration, and functional decline; implement prevention measures.
Interdisciplinary care: collaborate with PT/OT, speech-language pathology, nutrition, social work, and bereavement/caregiver support services.
Patient-centered care: tailor care plans to the patient’s goals and stage of disease; respect preferences while ensuring safety and quality of life.
Education and resources: connect families with community resources, respite care, adult day services, home health, and legal services; discuss advance care planning when appropriate.
Ethical considerations: balance autonomy with safety in dementia care; manage behavioral symptoms with least restrictive approaches; avoid unnecessary aggressive pharmacologic interventions.
Parkinson's Disease Interventions:
Maintain cognition and function, prevent injuries from impaired movement, minimize falls, safety-focused teaching.
Nursing care plan elements: active range of motion exercises twice daily; ambulation with assistive devices (walker/cane) and PT consult when mobility declines; OT consult for activities of daily living and adaptive devices; speech/swallow therapy for dysphagia and communication challenges; nutritional assessment and support; monitor weight and dietary needs; psychological support; address caregiver burden; community resources.
Safety and management emphasis: prevent falls, plan for evolving needs, enable independent function where possible.
Stroke Prevention:
Stroke prevention education.
Acute nursing interventions: keep head elevated, monitor vitals, turn and ROM every 2 hours, encourage use of unaffected arm for ADLs, ensure swallow safety and resumption of oral intake after swallow study.
Priority considerations: safety and prevention of secondary injury; test-tasks often emphasize safety as the highest priority in acute care.
Dementia and Alzheimer’s Disease Nonpharmacologic Approaches (also promoting mental health):
Cognitive stimulation therapy, communication therapies, behavioral therapy to limit triggers, reality orientation, validation therapy, reminiscence therapy.
Safety planning; establishing regular routines; balancing independence with caregiver support.
Simple, stage-appropriate communication; meaningful activities to improve quality of life.
Identify signs and symptoms of neurologic disorders in older adults
Red Flags Requiring Further Evaluation (Nursing Alarm Signs):
New headaches, new vision changes.
Sudden deafness or tinnitus.
Rapid mood or personality changes.
Altered consciousness or cognition.
New clumsiness or unstable gait.
Numbness or tingling in extremities or unusual nerve sensations.
Parkinson's Disease (PD) Symptoms:
Classic motor symptoms: resting tremor (often initial), bradykinesia (slowness of initiation), impaired postural reflexes.
Typical body presentation: stooped/forward-leaning posture, rigid back, shuffling gait, masked facial expression.
Non-motor features: heat intolerance, constipation, depression; decreased perspiration; dysphagia risk with disease progression.
Cerebrovascular Accident (CVA) / Stroke Symptoms:
Common presenting symptoms: sudden unilateral facial, arm, or leg numbness or weakness (usually on one side); confusion or trouble speaking; trouble seeing in one or both eyes (hemianopsia); trouble walking, dizziness, loss of coordination; severe headache may occur.
Dementia Symptoms:
Progressive, irreversible cognitive deterioration with personality changes and functional decline; memory impairment, disorganized thinking, inattentiveness, change in behavior.
Frontotemporal dementia (FTD): earlier onset (often <60); affects frontal lobes; early behavioral changes or language impairment.
Lewy body dementia (LBD): parkinsonian symptoms along with cognitive fluctuations and early visual hallucinations (due to alpha-synuclein inclusions/Lewy bodies).
Neuropsychiatric symptoms: resisting care, repetitive actions, delusions, sexual disinhibition, wandering, suspiciousness.
Delirium Symptoms:
Acute, abrupt global cognitive impairment with fluctuating mental status; may be worse at night; disorganized thinking; inattention; altered alertness; can include agitation or hypoactivity; hallucinations common in hospital settings.
Describe symptoms, unique features and nursing care for patients with Parkinson’s disease, transient ischemic attacks, and cerebrovascular accidents in older adults
Parkinson's Disease (PD):
Symptoms: Resting tremor, bradykinesia, impaired postural reflexes, stooped/forward-leaning posture, rigid back, shuffling gait, masked facial expression, non-motor features like heat intolerance, constipation, and depression; dysphagia risk with progression.
Pathophysiology: Decreased dopamine in basal ganglia; balance between acetylcholine (excitatory) and dopamine (smooth movement) disrupted.
Treatments (symptom management): Dopaminergic therapy (carbidopa-levodopa), dopamine agonists, anticholinergics, Catechol O-methyltransferase (COMT) inhibitors. Surgical options include ablation and deep brain stimulation (DBS).
Nursing Care: Maintain cognition and function, prevent injuries from impaired movement, minimize falls, safety-focused teaching. Implement active range of motion exercises, ambulation with assistive devices, and consults for PT, OT, speech/swallow therapy. Provide nutritional assessment and support, psychological support, and address caregiver burden.
Transient Ischemic Attacks (TIA):
While not detailed as a separate section in the notes, TIAs are considered mini-strokes with temporary symptoms that resolve. They share common risk factors with CVA/Stroke and are often a warning sign for a future stroke. Nursing care focuses on identifying risk factors and implementing stroke prevention strategies as outlined under CVA management.
Cerebrovascular Accident (CVA) / Stroke:
Types: Hemorrhagic stroke (bleed) vs Ischemic/Thrombotic stroke (clot).
Onset: Hemorrhagic strokes often have abrupt onset; ischemic strokes may have sudden onset or evolve over minutes to hours.
Common Presenting Symptoms: Sudden unilateral facial, arm, or leg numbness or weakness; confusion or trouble speaking; trouble seeing in one or both eyes (hemianopsia); trouble walking, dizziness, loss of coordination; severe headache may occur.
Risk Factors: Advanced age, genetics, African American ethnicity, diabetes, cigarette smoking, heart disease, obesity, physical inactivity, cocaine use, atrial fibrillation (AFib), hypertension (most important modifiable risk factor).
Acute Management in Hospital: Emergency CT scan; continuous monitoring (cardiac and other vitals); labs; possibly EEG; airway protection; head of bed elevated to reduce intracranial pressure (ICP).
Neuro Assessment: NIH Stroke Scale or similar tools; assess level of consciousness, orientation, commands, gaze, visual fields, motor function, sensory, language, and cognition.
Reperfusion Therapy: Thrombolytic therapy within a 3\ hour window (time is brain); earlier treatment yields better outcomes, though guidelines may vary.
Medications and Interventions: Anticoagulants or antiplatelets depending on etiology; lipid-lowering agents and antihypertensives for long-term secondary prevention. Indirect vascular procedures (carotid endarterectomy or extracranial bypass) and brain surgery for certain conditions (aneurysms, malformations, intracranial bleeding).
Acute Nursing Interventions: Keep head elevated, monitor vitals, turn and ROM every 2 hours, encourage use of unaffected arm for ADLs, ensure swallow safety and resumption of oral intake after swallow study.
Speech and Language Concerns: Aphasia types (receptive vs expressive); visual field deficits (hemianopia); adapt patient/family education to language abilities.
Outcomes and Planning: Stroke prevention education, access to resources, and long-term rehabilitation planning. Safety and prevention of secondary injury are highest priorities.
List measures that promote mental health for older adults
For Depression: Psychotherapy and nonpharmacologic approaches (acupuncture, guided imagery, light therapy, sleep, exercise, nutrition).
For Anxiety: Coaching and coping strategies; relaxation and deep breathing; modify perceptions of stress; psychotherapy and nonpharmacological approaches preferred.
For Dementia: Cognitive stimulation therapy, communication therapies, behavioral therapy to limit triggers, reality orientation, validation therapy, reminiscence therapy; promoting meaningful activities.
Describe symptoms and care for an older adult with depression
Symptoms: Fatigue, constipation, psychomotor retardation, persistent depressed mood, anhedonia, low energy, social withdrawal, neglect of hygiene or self-care, somatic complaints. Altered cognition is common and can mimic dementia.
Causes and Contributing Factors: Chronic illnesses, aging-related losses (bereavement, relocation, retirement), changes in social roles and income, societal undervaluation of older adults; certain medications may contribute.
Screening: Geriatric Depression Scale (GDS-15); scores > 5 suggest depression requiring further evaluation.
Treatment Considerations and Care:
Prefer SSRIs over tricyclic antidepressants (TCAs) due to anticholinergic side effects and safety concerns in older adults.
Avoid combining SSRIs with St. John’s wort.
Consider psychotherapy and nonpharmacologic approaches (acupuncture, guided imagery, light therapy, sleep, exercise, nutrition).
"Start low, go slow" with gradual dosing and small increases to minimize side effects and falls risk.
Expect SSRIs to take \sim2\ weeks or more to show effect.
Identify indications of suicidal thoughts in older adults
Suicide Risk Factors:
High among older adults, accounting for \sim29\% of suicide deaths.
Highest risk in men aged 85+ and older white men.
Specific risk factors include bereavement, chronic illness, social isolation, and retirement.
Assessment and Response:
Use structured tools (e.g., National Institute of Mental Health resources) to assess frequency of thoughts, plan, past attempts, symptoms, and social support.
Determine disposition (emergency psychiatric evaluation, inpatient care, or nonurgent follow-up).
Implement safety planning and no-suicide contracts when appropriate.
Describe interventions to reduce anxiety in older adults
Coaching and coping strategies.
Relaxation and deep breathing techniques.
Modifying perceptions of stress.
Psychotherapy and nonpharmacological approaches are preferred.
Medications should be a last resort in older adults due to safety concerns.
Discuss signs of substance abuse in older adults. Identify nursing actions to manage disruptive behavior associated with mental health conditions in older adults
Signs of Substance Abuse:
Alcohol Use: SMAST-G screening; two or more positive responses suggests an alcohol problem. Recommended limits typically not more than one standard drink per day for older adults.
General Substance Abuse: Not rare; may involve prescription opioids and other substances; increased risk of falls, cognitive impairment, self-neglect.
Nursing Actions for Substance Abuse:
Withdrawal management and attention to potential interactions with medications (for alcohol withdrawal, benzodiazepines can be dangerous in older adults).
Discuss strategies for safe medication use and monitoring; do not overlook prescription misuse and social factors that sustain abuse.
Managing Disruptive Behavior Associated with Mental Health Conditions (e.g., in Dementia):
Common behaviors include resisting care, repetitive actions, delusions, sexual disinhibition, wandering, and suspiciousness.
Management requires a person-centered approach and may include diverting attention, environmental adjustments, and boundary-setting.
Antipsychotics carry higher mortality and should be used cautiously as a last resort.
For sexual disinhibition: Set clear and professional boundaries; acknowledge feelings but keep care focused on medical needs.
For wandering and agitation: Use distraction, safety measures, and engaging activities; explain to family and staff the importance of reducing triggers and enhancing routines.
Utilize communication strategies: Keep messages simple; tailor to the person’s stage; involve family; use reminiscence and validation approaches to reduce distress.
Differentiate delirium from dementia
Delirium:
Acute, abrupt global cognitive impairment with fluctuating mental status; may be worse at night.
Characterized by disorganized thinking, inattention, altered alertness; can include agitation or hypoactivity.
Hallucinations are common, especially in hospital settings.
Dementia:
Progressive, irreversible cognitive deterioration with personality changes and functional decline.
DSM-5 defines major neurocognitive disorder as dementia; mild neurocognitive disorder (MCI) is cognitive decline not yet affecting ADLs/IADLs.
Key distinction: Delirium is acute and fluctuating, while dementia is progressive and irreversible.
Co-occurring Conditions:
Delirium often superimposed on dementia; do not assume delirium is simply a manifestation of baseline dementia. Obtain history and observe for changes; educate families and involve them in care planning.
Identify factors that cause delirium
Drugs (medication changes, polypharmacy).
Electrolyte and acid-base imbalances.
Oxygen delivery/deficiency (hypoxia).
Hypothyroidism.
Infections (e.g., UTIs, pneumonia).
Bladder/bowel retention.
Hypoglycemia/hyperglycemia.
Sleep deprivation.
Sensory deprivation or overstimulation.
Environmental factors (unfamiliar surroundings, ICU).
Describe characteristics, symptoms, and management of dementia
Characteristics and Symptoms:
Progressive, irreversible cognitive deterioration with personality changes and functional decline.
Memory impairment, disorganized thinking, inattentiveness, and changes in behavior (e.g., resisting care, repetitive actions, delusions, wandering, suspiciousness).
Management (Nonpharmacologic Approaches):
Cognitive stimulation therapy, communication therapies, behavioral therapy to limit triggers, reality orientation, validation therapy, reminiscence therapy.
Safety planning; establishing regular routines; balancing independence with caregiver support; simple, stage-appropriate communication; meaningful activities to improve quality of life.
Management (Pharmacologic Approaches for Alzheimer's Disease):
Symptom management: Cholinesterase inhibitors (e.g., donepezil) and memantine to modulate glutamate activity; these can slow symptoms but do not cure AD.
Disease-modifying therapies (recent advances): Monoclonal antibodies targeting amyloid plaques, such as Leqembi (lecanemab) and Donanemab.
These therapies can slow cognitive decline by approximately 25\%-30\% over 18\text{ months} but carry risks of amyloid-related imaging abnormalities (ARIA) and require frequent MRI surveillance (e.g., every 4 weeks during active treatment).
Administration typically involves IV infusions every two weeks.
List causes of dementia. Outline nursing considerations for older adults with dementia
Causes of Dementia (Etiologies):
Alzheimer’s disease: Accounts for 60\%-80\% of dementia cases; characterized by beta-amyloid plaques and tau tangles.
Lewy body dementia (LBD): 5\%-10\% of cases; involves alpha-synuclein inclusions (Lewy bodies), parkinsonian symptoms, cognitive fluctuations, and early visual hallucinations.
Vascular dementia: 5\%-10\% of cases; often shows a stepwise decline after each cerebrovascular event.
Frontotemporal dementia (FTD): 5\%-10\% of cases; earlier onset (often <60); affects frontal lobes, leading to early behavioral changes or language impairment.
Other diseases: AIDS and Parkinson’s disease may contribute.
Other causes and mimics (reversible conditions to be ruled out): Depression, drugs, vitamin/mineral deficiencies, thyroid disorders, metabolic issues, infections, exposure to toxins.
Nursing Considerations for Older Adults with Dementia:
Environment Optimization: Create a calm, well-lit, and predictable routine-based environment.
Family Involvement: Involve family in care planning and provide education; offer a 24-hour sitter if needed.
Safety and Reorientation: Prioritize patient safety, assess for fall/aspiration risk, and provide consistent reorientation.
Documentation: Document delirium status according to unit protocol, especially when superimposed on dementia.
Support and Resources: Emphasize balancing independence with caregiver support to reduce burnout; connect families with community resources like respite care, adult day services, home health, and legal services; discuss advance care planning.
Behavioral Management: Manage neuropsychiatric symptoms (e.g., resisting care, wandering, agitation, sexual disinhibition) with a person-centered approach, diversion, environmental adjustments, and boundary-setting. Use antipsychotics cautiously as a last resort due to higher mortality risk.
Communication: Use simple messages, tailor communication to the person’s stage, involve family, and employ reminiscence and validation approaches to reduce distress.
Ethical Considerations: Balance autonomy with safety; manage behavioral symptoms with the least restrictive approaches; avoid unnecessary aggressive pharmacologic interventions.