Dementia Alzheimers

DSM-5 Neurocognitive Disorders

• Types:
    - Delirium
    - Major Neurocognitive Disorders
    - Mild Neurocognitive Disorders

Clinical Picture of Delirium

• Key Characteristics:
    - Disturbance in attention and awareness
    - Acute onset (from hours to a few days), characterized by a change from baseline and fluctuates with periods of lucidity over a 24-hour day
    - Possible accompanying features:
      - Memory deficit
      - Disorientation
      - Language changes
      - Disturbances in visuospatial ability
      - Delusions and hallucinations (usually visual)
      - Disturbances in sleep-wake pattern

• Physiological Cause:
    - There is a direct physiological cause for the onset of delirium.

Common Causes of Delirium

• Identified Causes:
    - Medications
    - Infections
    - Fluid and electrolyte imbalances
    - Hypoxia/ischemia
    - Brain alterations:
      - Reduction in cerebral functioning or brain metabolism
      - Increased plasma cortisol level
      - Neurotransmitter imbalance
      - Damage to enzyme systems, blood–brain barrier, or cell membranes

Neurocognitive Disorders Overview

• Description:
    - Degenerative, progressive neuropsychiatric disorder that results in:
      - Cognitive impairment
      - Emotional and behavioral changes
      - Physical and functional decline
      - Ultimately leads to death

• Features of Neurocognitive Disorders:
    - Characterized by:
      - Progressive deterioration of cognitive functioning
      - Global impairment of intellect
      - No change in consciousness
      - Acquired condition (not developmental)
      - Difficulties include issues with memory, problem-solving, and complex attention
      - Impacts areas such as orientation, attention, memory, vocabulary, calculation ability, and abstract thinking

Major and Mild Neurocognitive Disorders

• Classification:
    - Mild Neurocognitive Disorder:
      - Does not interfere with Activities of Daily Living (ADLs)
      - Does not necessarily progress
    - Major Neurocognitive Disorder:
      - Interferes with daily functioning and independence

Major Neurocognitive Disorders Types

• Types:
    - Alzheimer's Disease (AD)
    - Frontotemporal dementia
    - Dementia with Lewy bodies
    - Vascular dementia
    - Specifiers include:
      - Traumatic brain injury
      - Substance-induced dementia
      - HIV infection
      - Prion disease
      - Parkinson's disease
      - Huntington's disease

Alzheimer's Disease (AD)

• Prevalence:
    - Accounts for 60% to 80% of all dementias

• Symptoms:
    - Disturbances in executive functioning
    - Aphasia (loss of language ability):
      - Expressive: inability to find words to express ideas
      - Receptive: inability to interpret spoken language
    - Apraxia (loss of purposeful movement)
    - Agnosia (loss of sensory ability to recognize objects or people):
      - Example: inability to name a pencil, watch, or shoe in a Mini-Mental State Examination (MMSE)

Continued Alzheimer's Disease Symptoms

• Sundowning:
    - Tendency for mood deterioration and increased agitation in the late part of the day or at night with fading light

• Memory Impairment:
    - Confabulation: Unconscious creation of stories or answers to maintain self-esteem in place of actual memories
    - Perseveration: Persistent repetition of a word, phrase, or gesture
    - Hyperorality: Tendency to put everything in the mouth and taste and chew
    - Hoarding behavior

Etiology of Alzheimer's Disease

• Risk Factors:
    - Age and family history
    - Cardiovascular disease
    - Social engagement and diet
    - Head injury and traumatic brain injury
    - Hypertension (HTN) and dyslipidemia

• Biological Factors:
    - Oxidative stress and free radicals

Pathological Diagnosis of Alzheimer's Disease

• Hallmarks:
    - Tau proteins and beta-amyloid plaques lead to neurofibrillary tangles
    - Amyloid plaques: Sticky clumps between nerve cells
    - Neurofibrillary tangles: Abnormal collections of protein threads inside nerve cells
    - Result in brain atrophy

Neurotransmitter Implications in Alzheimer's Disease

• Key Neurotransmitters:
    - Acetylcholine:
      - Involved in learning, memory, and mood
      - Decreased production in AD
      - Cholinesterase inhibitors prevent breakdown of acetylcholine
    - Glutamate:
      - Involved in cell signaling, learning, and memory
      - Excess glutamate in AD
      - NMDA antagonists help block some NMDA receptors and reduce excess calcium

Stages of Alzheimer's Disease

• Mild (Early):
    - Symptoms: Forgetfulness, misplacing items, decreased recall, social withdrawal, frustration with self
    - Changes may not be apparent to others

• Moderate:
    - Symptoms: Decreased self-care, disorientation to time and place, wandering, pacing, hallucinations or delusions, decreased visual perception leading to accidents, need for supervision, emotional lability

• Severe:
    - Symptoms: Inability to care for self, loss of language use, minimal long-term memory, constant need for complete care

Cognitive Assessment Tools

• Key Tools:
    - Mini-Mental State Examination (MMSE)
    - Dementia Severity Rating Scale
    - Geriatric Depression Scale
    - Memory Impairment Screen
    - Mini-Cog: Includes sections for word recognition, clock drawing, and word recall
    - Functional Assessment Staging Tool (FAST)

Dementia Nursing Assessment/Cues

Biologic Domain:

• Areas to Assess:
    - Past and present health status (comparison to norms)
    - Physical examination and review of systems
    - Vital signs, neurologic status, nutritional status, bladder and bowel function, hygiene, skin integrity, rest and activity, fluid/electrolyte balance, sleep patterns
    - Physical functions, self-care, sleep-wake disturbances, activity and exercise, nutrition, pain

Cues to Assess for Dementia

• Cognitive Cues:
    - Confabulation
    - Perseveration
    - Agraphia (diminished ability to read or write)
    - Hyperorality
    - Aphasia, apraxia, agnosia
    - Sundowning/sundown syndrome

Psychological Cues in Dementia

• Behavioral Symptoms:
    - Suspiciousness, delusions, illusions
    - Hallucinations
    - Mood changes
    - Anxiety
    - Catastrophic reactions

Defense Mechanisms and Behavioral Responses

• Defense Mechanisms:
    - Denial
    - Confabulation
    - Perseveration
    - Avoidance of questions

• Behavioral Responses:
    - Apathy and withdrawal
    - Restlessness, agitation, aggression
    - Aberrant motor behavior
    - Disinhibition
    - Hypersexuality
    - Signs of stress and anxiety

Social Domain Assessment

• Areas to Consider:
    - Functional status
    - Social system and spiritual assessment
    - Legal status (guardianship)
    - Quality of life
    - Primary caregiver support's essential role in the well-being of patients with dementia

Diagnostic Tests

• Recommended Tests:
    - Computed Tomography scan (CT)
    - Positron Emission Tomography (PET)
    - Mental status questionnaires including MMSE
    - Complete physical and neurological examination
    - Comprehensive medical and psychiatric history
    - Review of recent symptoms, medications, and nutritional status

Nursing Diagnoses

• Common Diagnoses:
    - Impaired sleep
    - Risk for injury (wandering)
    - Self-care deficit
    - Anxiety
    - Confusion
    - Impaired verbal communication
    - Hopelessness
    - Caregiver stress
    - Anticipatory grief

Priority Care Issues in Dementia

• Care Priorities:
    - Will change throughout the course of the disorder:
      - Initially in mild stage, focus on delaying cognitive decline
      - In moderate stage, protect from self-harm
      - In late stages, shift to addressing physical needs

Interventions for Confusion or Agitation

• Recommended Actions:
    - Speak clearly, slowly, and directly
    - Avoid approaching from behind; face the patient
    - Utilize para-verbal and nonverbal communication techniques
    - Walk or talk with the patient to alleviate restlessness
    - Use picture albums, music that the person likes, and demonstrate patience

Nursing Interventions in Dementia

• Self-care:
    - Maintain independence as much as possible
    - Ensure oral hygiene

• Nutritional Interventions:
    - Monitor weight, intake, hydration
    - Provide well-balanced meals and observe for swallowing difficulties

• Support bowel and bladder function

• Sleep interventions and managing activity/exercise

• Pain and comfort management: Assess pain carefully, do not rely solely on verbalization of pain

• Implement relaxation techniques

Alzheimer's Disease Medications

• Acetylcholinesterase Inhibitors (AChEIs):
    - Examples: Galantamine (mild to moderate AD), Donepezil, Rivastigmine (PO or transdermal patch)
    - Indications: For mild to moderate AD, used to delay cognitive decline, stabilizing memory, language, and orientation
    - Side Effects: Nausea and vomiting, peaks in 3 months while continuing to delay decline

Continued Medications for Alzheimer's Disease

• NMDA Antagonists:
    - Example: Memantine
    - Action: Modulates N-methyl-D-aspartate (NMDA) receptor activity
    - Benefits: Restores function of damaged nerve cells and reduces abnormal excitatory signals of glutamate
    - Mild side effects: Dizziness, confusion, headaches, constipation

Medications for Behavioral Symptoms

• Off-label Medications:
    - Antipsychotics: May increase mortality risk, use with caution
    - Antidepressants
    - Antianxiety medications
    - Anticonvulsants

Parkinson's Disease Overview

• Description:
    - Chronic, progressive, insidious neurodegenerative disease characterized by insufficient dopamine and an imbalance between dopamine and acetylcholine

Cardinal Features of Parkinson's Disease

• Motor Symptoms:
    - Tremor:
      - Described as pill-rolling, recognized most notably when at rest; considered least debilitating because it decreases during purposeful activity
      - Initially starts unilaterally, progresses to contralateral over the years
    - Muscle Rigidity:
      - Increased resistance to passive range of motion (PROM) demonstrating a jerky quality
      - Also begins unilaterally and spreads contralaterally
    - Bradykinesia:
      - Generalized slowness of movement, often the major cause of disability in PD patients
      - Often described as weakness, incoordination, or tiredness

Later Symptoms of Parkinson's Disease

• Postural Instability:
    - Symptoms include trouble with balance, increased risk of falls, and a positive "pull test"

Nonmotor and Neuropsychiatric Features of Parkinson's Disease

• Recognition:
    - PD is now recognized as a complex disorder that includes non-motor manifestations:
      - Cognitive dysfunction and dementia
      - Psychoses and hallucinations
      - Mood disorders
      - Olfactory dysfunction (may appear before motor symptoms)
      - Sleep disturbances

• Autonomic Dysfunction:
    - Symptoms include orthostasis, constipation, dysphagia, diaphoresis, urinary difficulties, and sexual dysfunction

• Pain/Sensory Disorders:
    - Affects areas like face, abdomen, genitals, joints; study shows 97% report non-motor symptoms with an average of 8 symptoms per patient

Characteristic Appearance of PD

• Notable features:
    - Blank facial expression
    - Forward tilt to posture
    - Slow, monotonous, slurred speech
    - Tremor and short, shuffling gait

Micrographia in Parkinson's Disease

• Definition:
    - Progressive shrinking of handwriting observed in PD patients
    - Demonstrative Example:
      - Before and after images of a sentence show notable changes in handwriting size and clarity

Diagnosis of Parkinson's Disease

• Criteria:
    - No specific diagnostic tests available; diagnosis based on clinical history and features
    - Requires presence of at least 2 or 3 signs of the classic triad
    - Confirmation achieved by a positive response to antiparkinsonian drugs

Pharmacologic Treatments for Parkinson's Disease

• Objective:
    - No cure, focus is primarily on symptom relief
    - Treatment aimed at correcting neurotransmitter imbalances, either by enhancing dopamine release or antagonizing cholinergic arterial effects

Levodopa for Symptomatic Relief

• Description:
    - Most effective drug for symptomatic PD, especially for bradykinesia
    - Notable Side Effects:
      - Various potential side effects reported
      - Motor fluctuations may develop over years: “On-off phenomenon”
    - Combination Treatments:
      - Includes dopamine agonists used in monotherapy or combination with other agents
      - Anticholinergics may also be used

On-Off Phenomenon

• Overview:
    - An invariable consequence of long-term Levodopa administration
    - "On" period: mobile; "Off" period: immobile
    - Initially, wearing off occurs at end of dosing intervals; becomes unpredictable over time
    - Management Strategies:
      - Reduce inter-dose intervals, use controlled-release medications, avoid high protein meals

Surgical Treatments for Parkinson's Disease

• Common Procedure:
    - Deep Brain Stimulation (DBS):
      - Most common surgical treatment for advanced PD
      - Adjusts to control symptoms and is reversible

Nursing Care in Parkinson's Disease

• Recommended Nursing Care:
    - Allow extra time for responses and activities of daily living (ADLs)
    - Collaborate with occupational therapy (OT)
    - Provide emotional support and administer medications promptly while monitoring side effects
    - Implement interventions to prevent complications of immobility:
      - Address constipation, contractures, skin breakdown
    - Collaborate with physical therapy: Encourage physical exercise

Additional Nursing Care Considerations

• Collaborate with Speech Pathologist:
    - Address issues of dysphagia and hypophonia

• Collaborate with Dietician:
    - Ensure balanced, high-caloric, and high-fiber diet, with fluid intake and bite-sized meal recommendations

• Assess for mental health issues:
    - Depression, anxiety, and sleep disturbances are common complaints

Patient Guidance for Freezing Episodes

• Recommendations for Patients Experiencing Freezing:
    - Consciously think about stepping over imaginary or real lines on the floor
    - Drop rice kernels and step over them
    - Rock from side to side and lift toes when stepping
    - Take one step backward and two steps forward
    - Remove tripping hazards like rugs at home

Psychosocial Support for Caregivers

• Importance:
    - Assess caregiver burden as the disease progresses
    - Encourage involvement in local support groups for both patients and caregivers.