Delirium & Dementia

Delirium Defined

  • Definition: Delirium is described as an acute confusion; an acute and potentially reversible disturbance of consciousness and cognition triggered by underlying medical or mental illnesses, drug toxicity, and various other causes.

    • Preventability: An estimated 40% of cases are preventable through proactive nursing care that can be modified to prevent the development of delirium.

    • Overlap: Acute confusion may also manifest in patients suffering from depression or dementia.

Delirium: Defining Characteristics

  • Common defining characteristics include:

    • Irritability, anxiety, restlessness

    • Reduced attention span

    • Decreased problem-solving skills

    • Drowsiness due to insomnia

    • Muscle tension

    • Inability to concentrate and focus

    • Decreased ability to perform tasks

Nursing Process - Patient-Centered Care, Safety, Professionalism

  • ADPIE: A structured approach in nursing which includes:

    • Assessment

    • Diagnosis

    • Planning

    • Intervention

    • Evaluation

Delirium: Assessment Criteria

  • Nursing Assessment involves:

    • Disorientation: Manifestation of being improperly oriented to time or place.

    • Inappropriate behavior: Actions that are unsuitable for the context, such as pulling at medical tubes or attempting to get out of bed without permission.

    • Inappropriate communication: This can include incoherence or nonsensical speech.

Delirium Screening Instruments

  • Instruments utilized to assess delirium:

    • Confusion Assessment Method (CAM)

    • CAM-ICU: A modification for intensive care settings.

    • Delirium Rating Scale-revised version (DRS-R-98)

    • References are provided for deeper reading: www.ncbi.nlm.nih.gov; Grover & Kate (2012).

Delirium: Outcome Criteria

  • Expected Outcomes: After a delirium episode, the anticipated outcomes involve:

    • Reduction or resolution of underlying signs & symptoms.

    • Resolution of the underlying illness.

    • Assessment of patient mortality.

Delirium: General Nursing Interventions

  • Care Interventions:

    • Close monitoring and frequent observation of the patient.

    • Regular vital sign assessments.

    • Implementing aspiration and fall precautions.

    • Collaborating with the medical provider for consistent quality care.

    • Ensuring medication is administered safely.

  • Comfort Interventions:

    • Providing a clean and comfortable environment.

    • Reducing sensory stimuli (dim lights, minimize noise).

    • Maintenance of oral care, skin care, and incontinence needs.

    • Assisting with meals for non-NPO patients.

Delirium: Evaluation/Documentation

  • Nursing Process:

    • Evaluate the effectiveness of nursing and medical interventions thoroughly.

    • Document nursing assessments, interventions, evaluations, and patient education meticulously according to facility policy.

Dementia Defined

  • Definition: Dementia encompasses a variety of diseases and conditions characterized by a decline in cognitive abilities such as memory, language, reasoning, and other thinking skills that impede the ability to manage everyday tasks. Memory loss is a primary indicator of dementia.

    • Alzheimer’s Disease is noted as the most prevalent form of dementia.

Dementia Defining Characteristics

  • Major characteristics of dementia include:

    • Forgetfulness

    • Limited social skills

    • Behavioral dyscontrol

    • Impaired thinking abilities disrupting daily functioning.

Dementia: Contributing/Risk Factors

  • Factors influencing dementia risk include:

    • Advancing age

    • Family history

    • Genetic predisposition

    • Head injuries

    • Connection between head and heart health

    • Alcoholism

    • Parkinson’s Disease

Dementia: Assessment Criteria

  • Comprehensive assessments involve:

    • Orientation: Assessment of awareness regarding person, place, time, and situation.

    • Vital Signs: Monitoring temperature, pulse, respirations, blood pressure, O2 saturation, and pain.

    • Measurement of physical parameters: Height, weight, recent weight changes.

    • Mini Mental Status Exam (MMSE): Scoring ranges from 1 to 30, with 30 being excellent and 1 being poor.

    • Appearance: Detailed assessment of grooming, mood, behavior, social skills, sleep patterns, and memory functions.

Dementia: Outcome Criteria

  • Expected Outcomes: For patients diagnosed with dementia include:

    • Preservation of memory and cognitive function for as long as possible.

    • Maintenance of a regular schedule (daily and weekly).

    • Sustaining essential daily living activities (ADLs) such as grooming and toileting.

    • Keeping a stable appetite, sleeping pattern, and behavioral control.

    • Ensuring safety in home environments.

    • Attention to spiritual and religious practices.

    • Regular appointments with primary care providers.

    • Continuous monitoring of disease progression by families and healthcare professionals.

Dementia: General Nursing Interventions

  • A combination of the art and science of nursing is necessary for effective dementia care.

Dementia: Evaluation/Documentation

  • Constant evaluation of nursing interventions is vital as dementia symptoms may fluctuate. Following the nursing process ensures adaptive care in light of those changes.

Types/Subtypes of Dementia

  • Various types or subtypes include but are not limited to:

    • Alzheimer’s Disease

    • Vascular Dementia

    • Frontotemporal Dementia

    • Dementia with Lewy Bodies

    • Parkinson’s Disease Dementia

    • Progressive Supranuclear Palsy

    • Corticobasal Degeneration

    • Wernicke-Korsakoff Syndrome (related to alcohol use)

    • Creutzfeldt-Jakob Disease

    • Pick’s Disease

Reversible Dementias (often termed pseudo-dementia)

  • Factors contributing to potentially reversible dementias include:

    • Depression-induced

    • Medication-induced

    • Alcohol abuse

    • Drug abuse

    • Nutritional deficiencies (such as Vitamins A, C, B-12, and folate)

    • Head trauma

    • Hormonal dysfunction (specifically thyroid issues)

    • Infections

    • Heart disease

    • Brain tumors

    • Environmental toxicity

Irreversible Dementias

  • Types of irreversible dementias include:

    • Alzheimer’s Disease

    • Vascular Dementia

    • Lewy Body Dementia

    • Parkinson’s Dementia

    • Frontotemporal Dementia

    • Huntington’s Dementia

    • Creutzfeldt-Jakob Disease

    • Chronic Traumatic Encephalopathy

    • Pick’s Disease

Alzheimer’s Dementia

  • Incidence: Considered the most frequent cause of dementia in Western societies, with approximately 5.5 million affected in the U.S. and a global prevalence estimated at 24 million.

  • Potential Causes: Associated primarily with the development of beta-amyloid plaques and tau proteins in the brain.

  • Genetics: Higher risk is linked to having first-degree relatives with the disease.

  • Pathophysiology: Damaged neurons result in severed connections and eventual neuron death, contributing to shrinkage of brain tissue.

Discovery of Alzheimer’s Disease

  • Who: Alois Alzheimer, a German psychiatrist and neuropathologist

  • When & Where: First identified in 1906 in Germany.

  • Why: Seen predominantly in older middle-aged patients presenting with senility.

The First Alzheimer’s Patient

  • Who: Auguste Deter, diagnosed at age 51 in 1906.

  • Where: Frankfurt, Germany.

  • What: She displayed irrational behaviors and memory loss.

Alzheimer’s Disease Stages

  • Stages include:

    • Normal functioning

    • Normal age-related forgetfulness

    • Mild cognitive impairment

    • Mild Alzheimer’s Disease

    • Moderate Alzheimer’s Disease

    • Moderately severe Alzheimer’s Disease

    • Severe/end-stage Alzheimer’s Disease

    • Note: Alzheimer’s is a progressive and terminal condition ultimately resulting in death.

Alzheimer’s Disease Assessment

  • Medical Assessment: Utilizes the Alzheimer’s Disease Assessment Scale – Cognitive Subscale (ADAS-Cog), developed in the 1980s to evaluate cognitive dysfunction.

  • Nursing Assessment: Mirrors the comprehensive assessments for dementia, with added emphasis on family interviews.

  • Diagnosis Techniques: Conducted by psychiatrists/neuropsychologists, including brain imaging (MRI, CT, PET scans) to identify brain atrophy and identify enlarged ventricles.

  • Differential Diagnoses: Involves ruling out other conditions that replicate symptoms.

Patient-Centered Care in Alzheimer’s Disease

  • Nursing Process:

    • Planning: Involves social services and addressing physical therapy/occupational therapy needs, dietary requirements, and self-care needs.

    • Interventions:

    • Employing a calm approach.

    • Applying methods of reorientation and remotivation.

    • Utilizing simple, repetitive tasks for engagement.

    • Medications commonly used for treatment include:

    • Antipsychotics: haloperidol, olanzapine, quetiapine, risperidone.

    • Tranquilizers: lorazepam, clonazepam, alprazolam, dronabinol.

    • Sedatives: melatonin, trazodone, mirtazapine, gabapentin, Ambien.

    • Antidepressants: trazodone, mirtazapine, SSRIs.

Remotivation in Dementia

  • Remotivation Therapy (RT): A structured approach designed to enhance engagement for individuals with cognitive impairment. It utilizes sensory stimulation through familiar stimuli to inspire interest, social interaction, and communication skills.

Legal Considerations Surrounding Alzheimer’s Disease

  • Mental Competence: Defined legally as being duly qualified with sufficient capacity.

  • Conservatorship (Property): A judicial appointment to manage the affairs of an individual due to incapacitation.

  • Guardianship (Clinical & Property): A legal method to protect individuals unable to manage their well-being due to incapacity.

Important Legal Terms for Cognitively Impaired Individuals

  • Health Care Proxy: A document appointing an agent to make healthcare decisions for a patient when they are unable.

  • MOLST Form: Stands for Medical Order for Life-Sustaining Treatment, an initiative for end-of-life medical decision-making, used in several states.

Depression Defined

  • Definition: Clinical depression is diagnosed when a person experiences persistent feelings of sadness or anxiety, as well as loss of interest in typical activities coinciding with five or more of the following symptoms for a minimum of two consecutive weeks:

    • Changes in appetite resulting in significant weight change not related to dieting.

    • Insomnia or excessive sleep.

    • Increased restlessness or irritability.

    • Loss of energy or augmented fatigue.

    • Feelings of worthlessness or inappropriate guilt.

    • Difficulty in concentration, thought processes, or decision-making.

  • Demographics: Clinical depression appears to affect women twice as frequently as men. Approximately one in four women and one in ten men will encounter depression in their lifetime.

  • Treatability: Depression is well-treated; about 80-90% of treated individuals report significant improvement, with nearly all gaining some relief from symptoms.

Depression: Defining Characteristics

  • Mnemonic: IN SAD CAGES describes:

    • Interest reduced

    • Negative thoughts

    • Sleep disturbance

    • Appetite change

    • Decreased confidence

    • Concentration reduced

    • Affect blunt/flat

    • Guilt

    • Energy reduced

    • Suicidal ideas

Depression in the Elderly

  • Elderly individuals may manifest depressive symptoms alongside delirium, dementia, and other health complications. Hence, comprehensive medical assessments are crucial to arriving at accurate diagnoses.

Differentiating Delirium, Dementia, and Depression

Delirium

  • Causes: Physiological triggers.

  • Onset: Acute.

  • Course: Varies with underlying causes.

  • Alertness: Exhibits intermittent sleepiness or lethargy.

  • Memory Loss: Temporary due to confusion.

  • Thinking Process: Disorganized; may include hallucinations and illusions.

  • Responses: Inappropriate or bizarre responses to questions.

  • Language: Dysarthric, pressured speech; loud or softly spoken; hypophonic.

  • Sleep Patterns: Disrupted.

  • Reversibility: Possible with resolution of the underlying health issue.

Dementia

  • Causes: Physiological factors.

  • Onset: Chronic and gradual; insidious.

  • Course: Progressive over time.

  • Alertness: Typically normal.

  • Memory Loss: Impairment in both recent and remote memory; recent memory loss is often the first sign.

  • Thinking Process: Challenges with abstraction and vocabulary, especially nouns; difficulty with judgment and insight.

  • Responses: Inappropriate or confabulatory.

  • Language: Often incoherent or rambling speech; difficulties with vocabulary.

  • Sleep Patterns: Fragmented.

  • Reversibility: Generally irreversible; progressive.

Depression

  • Causes: Linked to loss or stress.

  • Onset: Can be acute or chronic; specific to events.

  • Course: Varies based on underlying causes.

  • Alertness: Typically decreased.

  • Memory Issues: More forgetfulness than outright memory loss.

  • Thinking Process: Issues with concentration.

  • Responses: Often apathetic.

  • Language: Intentional speech is slow and hypophonic.

  • Sleep Patterns: Difficulties falling asleep; may sleep excessively during the day; early morning awakenings are common.

  • Reversibility: Generally high potential for improvement with proper treatment adherence.

Depression Nursing Process - Patient-Centered Care & Safety

  • Assessment: Examine mood, affection, behavior, appetite, sleep patterns, energy levels, and vital signs alongside physical measurements.

  • Nursing Diagnosis: May involve diagnoses such as Depression, Self-care Deficit, Altered Nutrition, and Altered Sleep Pattern.

  • Planning: Develop a care plan which encourages family involvement, establishes a peaceful setting, and maintains a consistent routine.

  • Interventions: Includes medication administration, fact-checking support for Electroconvulsive Therapy (ECT), assistance with ADLs, and emotional support.

  • Evaluation: Ensuring the completion of interventions, following up on the Nursing Plan of Care, and medical treatment plan details.

  • Documentation: Precise records in Nursing Notes and specifications regarding the Process Interventions and Treatment Plan.

  • Teaching: Advise on medication and treatment plans, encourage adherence, and discuss relapse prevention methods.

  • Re-evaluation: Continuous monitoring to ensure the best quality of life for the patient.

Disturbed Thought Processes: Summary

  • Delirium: Acute and temporary cognitive disruption.

  • Dementia: Chronic and permanent cognitive decline.

  • Depression: Symptoms can be either acute/temporary or chronic.