Chapter 60: Alzheimer's Disease, Dementia, Delirium
Risk factors for dementia
*Aging* is greatest risk factor - FMHx (first degree relative) - *Diabetes* a) Insulin resistance, which causes high blood glucose and in some cases leads to type 2 diabetes, may interfere with the body's ability to break down amyloid, a protein that forms brain plaques in AD b) High blood glucose also produces oxygen-containing molecules that can damage cells, in a process known as oxidative stress c) high blood glucose along with high cholesterol has a role in the atherosclerosis, which contributes to vascular dementia d) microangiopathy, which damages small blood vessels throughout the body, may be causing ongoing damage to blood vessels in the brain and lead to increased risk of cognitive problems - head trauma - Obesity - Smoking - Cardiac dysrhythmias - Hypertension - Hypercholesterolemia - Coronary artery disease
What are some major concerns in Alzheimer's patients?
Behavioral problems (sundowning) Safety (falls, burns, ingesting toxic substance, wandering) Pain management (difficult bc can't always communicate they're in pain) Eating and swallowing difficulties (undernutrition) Oral care (inspect mouth and provide oral care regularly) Infection prevention (UTI, PNA) Skin care (Incontinence, immobility, and undernutrition increase risk of skin breakdown) Elimination problems (Urinary and fecal incontinence, constipation) Caregiver support
Diagnostic Study of delirium
Confusion assessment model (CAM)
Creuta felet-Jakob disease "Mad Cow Disease"
Creuta felet-Jakob disease "Mad Cow Disease" rare and fatal brain disorder caused by a prion protein Earliest symptoms of Creuta felet-Jakob disease "Mad Cow Disease" memory impairment and behavioral changes As Crueta felet -Jakob disease progresses what symptoms become evident mental deterioration, involuntary movements (muscle jerk), weakness in the limbs, blindness, eventually coma
Which patient may face the greatest risk of developing delirium? A) A patient with fibromyalgia whose chronic pain has recently worsened B) A patient with a fracture who has spent the night in the emergency department C) An older patient whose recent computed tomography (CT) shows brain atrophy D) An older patient who takes multiple medications to treat various health problems
D) An older patient who takes multiple medications to treat various health problems Rationale: Polypharmacy is implicated in many cases of delirium, and this phenomenon is especially common among older adults. Brain atrophy, if associated with cognitive changes, is indicative of dementia. Alterations in sleep and environment, as well as pain, may cause delirium, but this is less of a risk than in an older adult who takes multiple medications.
Delirium
Delirium a state of temporary but acute mental confusion, is a common life-threatening and possible preventable syndrome in older adults
In the older adult, what is dementia often confused with?
Depression *Onset* Dementia- Usually insidious Depression- Often coincides with life changes. Often abrupt. *Progression* Dementia- Slow Depression- Variable, rapid to slow but may be uneven. *Duration* Dementia- Years (usually 8-20) Depression- Can be several months to years, especially if not treated. *Thinking* Dementia- Difficulty with abstract thinking, impaired judgment, words difficult to find. Depression- Intact but with apathy, fatigue. May be indecisive. Feels sense of hopelessness. May not want to live. *Perception* Dementia- Misperceptions often present. Delusions and hallucinations. Depression- May deny or be unaware of depression. May have feelings of guilt. *Psychomotor behavior* Dementia- May pace or be hyperactive. As disease progresses, may not be able to perform tasks or movements when asked. Depression- Often withdrawn and hypoactive. *Sleep-wake cycle* Dementia- Sleeps during day. Frequent awakenings at night. Fragmented sleep. Depression- Disturbed, often with early morning awakening.
Onset of Delirium
Develops over 2-3 day period
Is there a definitive diagnostic test for Alzheimer's disease?
NO Diagnosed by exclusion once all other possible conditions causing cognitive impairment have been ruled out A definitive diagnosis of AD usually requires examination of brain tissue and the presence of neurofibrillary tangles and neuritic plaques at autopsy
What is retrogenesis?
Process where degenerative changes occur in the reverse order in which they were acquired So essentially developmentally age backwards - eventually being unable to sit up without assistance, smile or hold up own head
What is Frontotemporal lobar degeneration (FTLD) ?
Rare disorder caused by shrinking frontal and temporal lobes of the brain - One type of FTLD is Pick's disease May be abnormal microscopic deposits called Pick bodies, but not always - Often misdiagnosed as Alzheimer's and can be misdiagnosed as psychiatric disorder BUT occurs at a younger age than AD (usually 40-70) and there is marked SYMMETRIC LOBAR ATROPHY of the temporal and/or frontal lobes Manifestations: disturbances in behavior (unusual behavior), sleep, personality, and eventually memory
What are some nursing strategies to address difficult behaviors?
Redirection Distraction Reassurance
Drug therapy: Alzheimer's disease *Depression* Treating depression may improve cognitive ability and may help with sleep problems
Selective serotonin reuptake inhibitors (SSRIs) • sertraline (Zoloft) • fluvoxamine (Luvox) • citalopram (Celexa) • fluoxetine (Prozac) Atypical antidepressants • mirtazapine (Remeron) • trazodone (Desyrel)
What is sundowning?
Sundowning is a specific type of agitation Alzheimer's patients can experience Patient becomes more confused and agitated in late afternoon or evening. Cause is unclear. To manage it: Create a quiet, calm environment. Maximize exposure to daylight. Evaluate medications. Limit naps and caffeine. Consult health care provider on drug therapy.
Normal pressure hydrocephalus
uncommon disorder characterized by an obstruction of flow of CSF causing a buildup in the brain Symptoms of Normal pressure hydrocephalus -dementia, urinary incontinence, difficulty walking
Drug therapy: Alzheimer's disease *Sleep disturbances*
zolpidem (Ambien)
Collaborative care: Alzheimer's Disease Collaborative therapy
• Drug therapy for cognitive problems • Behavioral modification • Moderate exercise • Assistance with functional independence • Assistance and support for caregiver
Collaborative care: Alzheimer's Disease Diagnostic
• History and physical examination, including psychologic evaluation • Neuropsychologic testing, including Mini-Cog, Mini-Mental State Examination • Brain imaging tests: CT, MRI, MRS, PET (atrophy, disease progression) • Complete blood count • Electrocardiogram • Serum glucose, creatinine, BUN • Serum levels of vitamins B1, B6, B12 • Thyroid function tests • Liver function tests • Screening for depression
What are the 2 most common causes of dementia?
*Neurodegenerative disorders* - this is insidious and gradual in onset- • Alzheimer's disease • Dementia with Lewy bodies (DLB) • Frontotemporal lobar degeneration (FTLD) • Down syndrome • Amyotrophic lateral sclerosis (ALS) • Parkinson's disease • Huntington's disease *Vascular diseases* - this is abrupt in onset w/stepwise progression- • Vascular (multiinfarct) dementia -Vascular dementia can often be prevented through treatment of risk factors: Hypertension, diabetes, smoking, hypercholesterolemia, dysrhythmias. • Subarachnoid hemorrhage (potentially reversible) • Chronic subdural hematoma (potentially reversible)
What are other causes of dementia?
*Toxic, metabolic, or nutritional diseases* • Alcoholism • Thiamine (vitamin B1) deficiency (potentially reversible) • Cobalamin (vitamin B12) deficiency (potentially reversible) • Folate deficiency (potentially reversible) • Hyperthyroidism (potentially reversible) • Hypothyroidism (potentially reversible) *Immunologic diseases or infections* • Multiple sclerosis • Chronic fatigue syndrome • Infections (e.g., Creutzfeldt-Jakob disease) • Acquired immunodeficiency syndrome (AIDS) • Meningitis (potentially reversible) • Encephalitis (potentially reversible) • Neurosyphilis (potentially reversible) • Systemic lupus erythematosus (potentially reversible) *Systemic diseases* • Uremic encephalopathy (potentially reversible) • Dialysis dementia (potentially reversible) • Hepatic encephalopathy (potentially reversible) • Wilson's disease *Trauma* • Head injury (potentially reversible) *Tumors* • Brain tumors (primary) (potentially reversible) • Metastatic tumors (potentially reversible) *Ventricular disorders* • Hydrocephalus (potentially reversible) Drugs (potentially reversible cognitive impairment) • Anticholinergics • phenytoin (Dilantin) • Opioids • Hypnotics • Tranquilizers • Antiparkinsonian drugs • Cardiac drugs: digoxin, methyldopa (Aldomet) • Cocaine • Heroin
Clinical manifestations of Alzheimer's disease
- ↓ Personal hygiene - ↓Concentration and attention - Unpredictable behavior - Delusions and hallucinations - Dysphasia - Apraxia (difficult or impossible to make certain motor movements) - Visual agnosia (inability to process visual sensory information) - Dysgraphia (inability to write, primarily in terms of handwriting, but also in terms of coherence) - Some long-term memory loss - Wandering Late stage: Unable to communicate Cannot perform activities of daily living (ADLs) Patient becomes unresponsive and incontinent.
What are common symptoms reported by family members of patients being diagnosed with dementia?
-Memory loss -Mild disorientation -Trouble with words and/or numbers
What is the difference between delirium and dementia
-the person exhibits sudden cognitive impairment, disorientation or clouded sensorium is likely to have delirium
What are the 10 early warning signs of Alzheimer's disease?
1) Memory loss that affects job skills 2) Difficulty performing familiar tasks 3) Problems with language 4) Disorientation to time and place 5) Poor or decreased judgment 6) Problems with abstract thinking 7) Misplacing things 8) Changes in mood or behavior 9) Changes in personality 10) Loss of initiative
What is the spectrum of Alzheimer's disease?
1) Preclinical AD EARLY INTERVENTION IS THE GOAL - Modify disease before plaques and tangles have formed and symptoms emerge (research is ongoing, current attempts unsuccessful) 2) Mild cognitive impairment (MCI) - Individuals have problems with memory, language, or another essential cognitive function that are severe enough to be noticeable to others and show up on tests, but not severe enough to interfere with activities of daily living. - causes of MCI include: Stress, anxiety, depression, physical illness 3) Dementia (terminal stage of disease)
In planning for the discharge of a client with a cognitive disorder, it is important to assess the client's caregiver support system. Which aspects are the most crucial to assess? Select all that apply. 1. Availability of resources for caregiver support. 2. Ability to provide the level of care and supervision needed by the client. 3. Willingness to transport the client to medical and psychiatric services. 4. Interest in engaging the cognitively disordered family member in reminiscence and games. 5. Willingness to install door alarms and make other safety changes. 6. Understanding the client's abilities and limitations.
1, 2, 3, 5, 6. It is important for a caregiver to have support for herself as well as be able to provide adequate safety, supervision, and medical care to the client. The caregiver must also have realistic expectations of the client, given his abilities and limitations. Reminiscing and engaging the client in games is desirable but not crucial to care.
Transfer data for a client brought by ambulance to the hospital's psychiatric unit from a nursing home indicate that the client has become increasingly confused and disoriented. The client's behavior is found to be the result of cerebral arteriosclerosis. Which of the following behaviors of the nursing staff should positively influence the client's behavior? Select all that apply. 1. Limiting the client's choices. 2. Accepting the client as he is. 3. Allowing the client to do as he wishes. 4. Acting nonchalantly. 5. Explaining to the client what he needs to do step-by-step.
1, 2, 5. Confused clients need fewer choices, acceptance as a person, and step-by-step directions. Allowing the client to do as he wishes can lead to substandard care and the risk of harm. Acting nonchalantly conveys a lack of caring.
The nurse is making a home visit with a client diagnosed with Alzheimer's disease. The client recently started on lorazepam (Ativan) due to increased anxiety. The nurse is cautioning the family about the use of lorazepam (Ativan). The nurse should instruct the family to report which of the following significant side effects to the health care provider? 1. Paradoxical excitement. 2. Headache. 3. Slowing of reflexes. 4. Fatigue.
1. Although all of the side effects listed are possible with Ativan, paradoxical excitement is cause for immediate discontinuation of the medication. (Paradoxical excitement is the opposite reaction to Ativan than is expected.) The other side effects tend to be minor and usually are transient.
When developing the plan of care for a client with Alzheimer's disease who is experiencing moderate impairment, which of the following types of care should the nurse expect to include? 1. Prompting and guiding activities of daily living. 2. Managing a medication schedule. 3. Constant supervision and total care. 4. Supervision of risky activities such as shaving.
1. Considerable assistance is associated with moderate impairment when the client cannot make decisions but can follow directions. Managing medications is needed even in mild impairment. Constant care is needed in the terminal phase, when the client cannot follow directions. Supervision of shaving is appropriate with mild impairment— that is, when the client still has motor function but lacks judgment about safety issues.
In addition to developing over a period of hours or days, the nurse should assess delirium as distinguishable by which of the following characteristics? 1. Disturbances in cognition and consciousness that fluctuate during the day. 2. The failure to identify objects despite intact sensory functions. 3. Significant impairment in social or occupational functioning over time. 4. Memory impairment to the degree of being called amnesia.
1. Fluctuating symptoms are characteristic of delirium. The failure to identify objects despite intact sensory functions, significant impairment in social or occupational functioning over time, and memory impairment to the degree
A client with early dementia exhibits disturbances in her mental awareness and orientation to reality. The nurse should expect to assess a loss of ability in which of the following other areas? 1. Speech. 2. Judgment. 3. Endurance. 4. Balance.
2. Clients with chronic cognitive disorders experience defects in memory orientation and intellectual functions, such as judgment and discrimination. Loss of other abilities, such as speech, endurance, and balance, is less typical.
A nurse on the Geropsychiatric unit receives a call from the son of a recently discharged client. He reports that his father just got a prescription for memantine (Namenda) to take "on top of his donepezil (Aricept)." The son then asks, "Why does he have to take extra medicine?" The nurse should tell the son: 1. "Maybe the Aricept alone isn't improving his dementia fast enough or well enough." 2. "Namenda and Aricept are commonly used together to slow the progression of dementia." 3. "Namenda is more effective than Aricept. Your father will be tapered off the Aricept." 4. "Aricept has a short half-life and Namenda has a long half-life. They work well together."
2. The 2 medications are commonly given together. -Neither medicine will improve dementia, but may slow the progression. Neither medicine is more effective than the other; they act differently in the brain. Both medicines have a half-life of 60 or more hours.
Which of the following is essential when caring for a client who is experiencing delirium? 1. Controlling behavioral symptoms with low-dose psychotropics. 2. Identifying the underlying causative condition or illness. 3. Manipulating the environment to increase orientation. 4. Decreasing or discontinuing all previously prescribed medications.
2. To institute measures to correct the underlying causative condition or illness. Controlling behavioral symptoms with low-dose psychotropics, manipulating the environment, and decreasing or discontinuing all medications may be dangerous to the client's health.
A client is experiencing agnosia as a result of vascular dementia. She is staring at dinner and utensils without trying to eat. Which intervention should the nurse attempt first? 1. Pick up the fork and feed the client slowly. 2. Say, "It's time for you to start eating your dinner." 3. Hand the fork to the client and say, "Use this fork to eat your green beans." 4. Save the client's dinner until her family comes in to feed her.
3. Agnosia is the lack of recognition of objects and their purpose. The nurse should inform the client about the fork and what to do with it. Feeding the client does not address the agnosia or give the client specific directions. It should only be attempted if identifying the fork and explaining what to do with it is ineffective. Waiting for the family to care for the client is not appropriate unless identifying the fork and explaining or feeding the client are not successful.
The physician orders risperidone (Risperdal) for a client with Alzheimer's disease. The nurse anticipates administering this medication to help decrease which of the following behaviors? 1. Sleep disturbances. 2. Concomitant depression. 3. Agitation and assaultiveness. 4. Confusion and withdrawal.
3. Antipsychotics are most effective with agitation and assaultiveness. Antipsychotics have little effect on sleep disturbances, concomitant depression, or confusion and withdrawal.
When communicating with the client who is experiencing dementia and exhibiting decreased attention and increased confusion, which of the following interventions should the nurse employ as the first step? 1. Using gentle touch to convey empathy. 2. Rephrasing questions the client doesn't understand. 3. Eliminating distracting stimuli such as turning off the television. 4. Asking the client to go for a walk while talking.
3. Competing and excessive stimuli lead to sensory overload and confusion. Therefore, the nurse should first eliminate any distracting stimuli. After this is accomplished, then using touch and rephrasing questions are appropriate. Going for a walk while talking has little benefit on attention and confusion.
The nurse observes a client in a group who is reminiscing about his past. Which effect should the nurse expect reminiscing to have on the client's functioning in the hospital? 1. Increase the client's confusion and disorientation. 2. Cause the client to become sad. 3. Decrease the client's feelings of isolation and loneliness. 4. Keep the client from participating in therapeutic activities.
3. Reminiscing can help reduce depression in an elderly client and lessens feelings of isolation and loneliness. Reminiscing encourages a focus on positive memories and accomplishments as well as shared memories with other clients. An increase in confusion and disorientation is most likely the result of other cognitive and situational factors, such as loss of short-term memory, not reminiscing. The client will not likely become sad because reminiscing helps the client connect with positive memories. Keeping the client from participating in therapeutic activities is less likely with reminiscing.
When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant? 1. Allow the client to go to bed four to five times during the day. 2. Test the cognitive functioning of the client several times a day. 3. Provide reality orientation even if the memory loss is severe. 4. Maintain consistency in environment, routine, and caregivers.
4. Change increases stress. Therefore, the most important and relevant suggestion is to maintain consistency in the client's environment, routine, and caregivers. Although rest periods are important, going to bed interferes with the sleep-wake cycle. Rest in a recliner chair is more useful. Testing cognitive functioning and reality orientation are not likely to be successful and may increase stress if memory loss is severe.
An elderly woman's husband died. When her brother arrives for the funeral, he notices her short-term memory problems and occasional disorientation. A few weeks later, she calls him to say that her husband just died. She says, "I didn't know he was so sick. Why did he die now?" She also complains of not sleeping, urinary frequency and burning, and seeing rats in the kitchen. A home care nurse is sent to evaluate her situation and finds the woman reclusive and passive, but pleasant. The nurse calls the woman's primary care physician to discuss the client's situation and background, and give his assessment and recommendations. The nurse concludes that the woman: 1. Is experiencing the onset of Alzheimer's disease. 2. Is having trouble adjusting to living alone without her husband. 3. Is having delayed grieving related to her Alzheimer's disease. 4. Is experiencing delirium and a UTI.
4. Delirium is commonly due to a medical condition such as a UTI in the elderly. Delirium often involves memory problems, disorientation, and hallucinations. It develops rather quickly. There is not enough data to suggest Alzheimer's disease especially given the quick onset of symptoms. Delayed grieving and adjusting to being alone are unlikely to cause hallucinations.
What is dementia?
A syndrome characterized by dysfunction or loss of: -Memory -Orientation -Attention -Language -Judgment -Reasoning -Personality changes -Behavioral problems *60-80% of patients with dementia have Alzheimer's disease (AD)* and they are often lumped together
Although he has been told that ginkgo biloba will probably have no effect, a 58-year-old man with early stage Alzheimer's disease insists on taking the herb because he believes it will slow the disease progression. Which statement, if made by the patient to the nurse, indicates understanding about the side effects of ginkgo? A) "Ginkgo may increase the risk of bruising." B) "Ginkgo may cause leg pain while walking." C) "It is not safe to suddenly stop taking ginkgo." D) "Ringing in the ears is a side effect of ginkgo."
A) "Ginkgo may increase the risk of bruising." Rationale: Ginkgo biloba may increase the risk for bruising and bleeding. There are no indications that sudden withdrawal of ginkgo biloba is unsafe. Ginkgo biloba is possibly effective for treating intermittent claudication (leg pain while walking). There is insufficient evidence to indicate that ginkgo biloba is effective in treatment of tinnitus (ringing in the ears).
Which statement by the wife of a patient with Alzheimer's disease (AD) demonstrates an accurate understanding of her husband's medication regimen? A) "I'm really hoping his medications will slow down his mental losses." B) "We're both holding out hope that this medication will cure his disease." C) "I know that this won't cure him, but we learned that it might prevent a bodily decline while he declines mentally." D) "I learned that if we are vigilant about his medication schedule, he may not experience the physical effects of his disease."
A) "I'm really hoping his medications will slow down his mental losses." Rationale: There is presently no cure for Alzheimer's disease, and drug therapy aims at improving or controlling decline in cognition. Medications do not directly address the physical manifestations of AD.
For which patient should the nurse prioritize an assessment for depression? A) A patient in the early stages of Alzheimer's disease B) A patient who is in the final stages of Alzheimer's disease C) A patient experiencing delirium secondary to dehydration D) A patient who has become delirious following an atypical drug response
A) A patient in the early stages of Alzheimer's disease Rationale: Patients in the early stages of Alzheimer's disease are particularly susceptible to depression, since the patient is acutely aware of his or her cognitive changes and the expected disease trajectory. Delirium is typically a shorter-term health problem that does not typically pose a heightened risk of depression.
The nurse who has administered a dose of risperidone (Risperdal) to a patient with delirium should assess for what intended effect of the medication? A) Lying quietly in bed B) Alleviation of depression C) Reduction in blood pressure D) Disappearance of confusion
A) Lying quietly in bed Rationale: Risperidone is an antipsychotic drug that reduces agitation and produces a restful state in patients with delirium. However, it should be used with caution. Antidepressant medications treat depression, and antihypertensive medications treat hypertension. However, there are no medications that will cause confusion to disappear in a patient with delirium.
Pre-test practice questions: A 78-year-old woman is in the intensive care unit after emergency abdominal surgery. The nurse notes that the patient is disoriented and confused, has incoherent speech, and is restless and agitated. Which action by the nurse is most appropriate? A) Reorient the patient. B) Notify the physician. C) Document the findings. D) Administer lorazepam (Ativan).
A) Reorient the patient. Rationale: The patient is exhibiting clinical manifestations of delirium. Care of the patient with delirium is focused on eliminating precipitating factors and protecting the patient from harm. Give priority to creating a calm and safe environment. The nurse should stay at the bedside and provide reassurance and reorienting information as to place, time, and procedures. The nurse should reduce environmental stimuli, including noise and light levels. Avoid the use of chemical and physical restraints if possible.
The patient is having some increased memory and language problems. What diagnostic tests will be done before this patient is diagnosed with Alzheimer's disease (select all that apply)? A) Urinalysis B) MRI of the head C) Liver function tests D) Neuropsychologic testing E) Blood urea nitrogen and serum creatinine
A) Urinalysis B) MRI of the head C) Liver function tests D) Neuropsychologic testing E) Blood urea nitrogen and serum creatinine Rationale: Because there is no definitive diagnostic test for Alzheimer's disease, and many conditions can cause manifestations of dementia, testing must be done to eliminate any other causes of cognitive impairment. These include urinalysis to eliminate a urinary tract infection, an MRI to eliminate brain tumors, liver function tests to eliminate encephalopathy, BUN and serum creatinine to rule out renal dysfunction, and neuropsychologic testing to assess cognitive function.
What is *vascular dementia*?
AKA multiinfarct dementia *Secondary to strokes* Loss of cognitive function due to brain lesions caused by cardiovascular disease - Ischemic lesions - Hemorrhagic brain lesions
Clinical Manifestations of Delirium
Clinical Manifestations of Delirium hypoactivity and lethargy leading to hyperactivity including agitation and hallucination Early manifestations of Delirium inability to concentrate, irritability, insomnia, loss of appetite, restlessness, confusion Later manifestations of Delirium agitation, misperception, misinterpretation, hallucinations
Drug therapy: Alzheimer's disease *Behavioral problems (e.g., agitation, physical aggression, disinhibition)*
Antipsychotics (increased risk of death when used in older demented patients) • haloperidol (Haldol) • risperidone (Risperdal) • olanzapine (Zyprexa) • quetiapine (Seroquel) • aripiprazole (Abilify) Benzodiazepines • lorazepam (Ativan) • clonazepam (Klonopin)
A 59-year-old female patient, who has frontotemporal lobar degeneration, has difficulty with verbal expression. One day she walks out of the house and goes to the gas station to get a soda but does not understand that she needs to pay for it. What is the best thing the nurse can suggest to this patient's husband to keep the patient safe during the day while the husband is at work? A) Assisted living B) Adult day care C) Advance directives D) Monitor for behavioral changes
B) Adult day care Rationale: To keep this patient safe during the day while the husband is at work, an adult day care facility would be the best choice. This patient would not need assisted living. Advance directives are important but are not related to her safety. Monitoring for behavioral changes will not keep her safe during the day.
When providing community health care teaching regarding the early warning signs of Alzheimer's disease, which signs should the nurse advise family members to report (select all that apply)? A) Misplacing car keys B) Losing sense of time C) Difficulty performing familiar tasks D) Problems with performing basic calculations E) Becoming lost in a usually familiar environment
B) Losing sense of time C) Difficulty performing familiar tasks D) Problems with performing basic calculations E) Becoming lost in a usually familiar environment Rationale: Difficulty performing familiar tasks, problems with performing basic calculations, losing sense of time, and becoming lost in a usually familiar environment are all part of the early warning signs of Alzheimer's disease. Misplacing car keys is a normal frustrating event for many people.
The nurse in the long-term care facility cares for a 70-year-old man with severe (late-stage) dementia who is undernourished and has problems chewing and swallowing. What should the nurse include in the plan of care for this patient? A) Turn on the television to provide a distraction during meals. B) Provide thickened fluids and moist foods in bite-size pieces. C) Limit fluid intake during scheduled meals to prevent aspiration. D) Allow the patient to select favorite foods from the menu choices.
B) Provide thickened fluids and moist foods in bite-size pieces. -If patients with dementia have problems chewing or swallowing, pureed foods, thickened liquids, and nutritional supplements should be provided. Foods that are easy to swallow are moist and should be in bite-size pieces. Distractions at mealtimes, including the television, should be avoided. Fluids should not be limited but offered frequently; fluids should be thickened. Patients with severe (late-stage) dementia have difficulty understanding words and would not have the cognitive ability to select menu choices.
The patient has been diagnosed with the mild cognitive impairment stage of Alzheimer's disease. What nursing interventions should the nurse expect to use with this patient? A) Treat disruptive behavior with antipsychotic drugs. B) Use a calendar and family pictures as memory aids. C) Use a writing board to communicate with the patient. D) Use a wander guard mechanism to keep the patient in the area.
B) Use a calendar and family pictures as memory aids. Rationale: The patient with mild cognitive impairment will have problems with memory, language, or another essential cognitive function that is severe enough to be noticeable to others but does not interfere with activities of daily living. A calendar and family pictures for memory aids will help this patient. This patient should not yet have disruptive behavior or get lost easily. Using a writing board will not help this patient with communication.
Benzodiazepines are indicated in the treatment of cases of delirium that have which cause? A) Polypharmacy B) Cerebral hypoxia C) Alcohol withdrawal D) Electrolyte imbalances
C) Alcohol withdrawal Rationale: Benzodiazepines can be used to treat delirium associated with sedative and alcohol withdrawal. However, these drugs may worsen delirium caused by other factors and must be used cautiously. Polypharmacy, cerebral hypoxia, and electrolyte imbalances are not treated with benzodiazepines.
Which nursing intervention is most appropriate when caring for patients with dementia? Avoid direct eye contact. Lovingly call the patient "honey" or "sweetie." Give simple directions, focusing on one thing at a time. Treat the patient according to his or her age-related behavior.
C) Give simple directions, focusing on one thing at a time. Rationale: When dealing with patients with dementia, tasks should be simplified, giving directions using gestures or pictures and focusing on one thing at a time. It is best to treat these patients as adults, with respect and dignity, even when their behavior is childlike. The nurse should use gentle touch and direct eye contact. Calling the patient "honey" or "sweetie" can be condescending and does not demonstrate respect.
Unlicensed assistive personnel (UAP) working for a home care agency report a change in the alertness and language of an 82-year-old female patient. The home care nurse plans a visit to evaluate the patient's cognitive function. Which assessment would be most appropriate? A) Glasgow Coma Scale (GCS) B) Confusion Assessment Method (CAM) C) Mini-Mental State Examination (MMSE) D) National Institutes of Health Stroke Scale (NIHSS)
C) Mini-Mental State Examination (MMSE) Rationale: The MMSE is a commonly used tool to assess cognitive function. Cognitive testing is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. The CAM is used to assess for delirium. The GCS is used to assess the degree of impaired consciousness. The NIHSS is a neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss.
Outline the pathology of Alzheimer's Disease
Changes in brain structure and function: - *Amyloid plaques*: β-amyloid fragments come together in clumps to form plaques that attach to the neuron. Microglia react to the plaque, and an inflammatory response results. - *Neurofibrillary tangles*: Abnormal collections of twisted protein threads inside nerve cells Main component is a protein called tau (the railroad tie for microtubules) - *Loss of connections between neurons* and *Neuron death*: results in structural damage and atrophy of the affected areas of brain
What is Dementia with Lewy bodies (DLB)?
Characterized by presence of Lewy bodies in brainstem and cortex Abnormal deposits of the protein α-synuclein Typically have symptoms of parkinsonism (e.g. hallucinations, short-term memory loss, unpredictable cognitive shifts, and sleep disturbances) Indicated by dementia + 2 of the following: - Extrapyramidal signs (e.g. bradykinesia, rigidity, and postural instability, but not always a tremor) - Fluctuating cognitive ability - Hallucinations Medications may include levodopa/carbidopa and acetylcholinesterase inhibitors
Drug therapy: Alzheimer's disease *Decreased memory and cognition*
Cholinesterase inhibitors - Cholinesterase inhibitors block cholinesterase, the enzyme responsible for the breakdown of acetylcholine in the synaptic cleft thus longer time for acetylcholine to transmit message • donepezil (Aricept) • rivastigmine (Exelon) • galantamine (Razadyne) N-methyl-D-aspartate (NMDA) receptor antagonist - Protects nerve cells against excess amounts of glutamate • memantine (Namenda)
What is Alzheimer's disease?
Chronic, progressive, degenerative disease of the brain - Most common form of dementia (60-80%) *age is most important risk factor*
The home care nurse is visiting patients in the community. Which patient is exhibiting an early warning sign of Alzheimer's disease? A) A 65-year-old male does not recognize his family members and close friends. B) A 59-year-old female misplaces her purse and jokes about having memory loss. C) A 79-year-old male is incontinent and not able to perform hygiene independently. D) A 72-year-old female is unable to locate the address where she has lived for 10 years.
D) A 72-year-old female is unable to locate the address where she has lived for 10 years. -An early warning sign of Alzheimer's disease is disorientation to time and place such as geographic disorientation. Occasionally misplacing items and joking about memory loss are examples of normal forgetfulness. Impaired ability to recognize family and close friends is a clinical manifestation of middle or moderate dementia (or Alzheimer's disease). Incontinence and inability to perform self-care activities are clinical manifestations of severe or late dementia (or Alzheimer's disease).
Patients at risk for Delirium: _____________
Those with neurologic disorders (stroke, dementia, CNS infection, Parkinson's disease) sensory impairment, advanced age
A major goal of treatment for the patient with AD is to a. maintain patient safety. b. maintain or increase body weight. c. return to a higher level of self-care. d. enhance functional ability over time.
a. maintain patient safety. Rationale: The overall management goals are that the patient with AD will (1) maintain functional ability for as long as possible, (2) be maintained in a safe environment with a minimum of injuries, (3) have personal care needs met, and (4) have dignity maintained. The nurse should place emphasis on patient safety while planning and providing nursing care.
Which statement(s) accurately describe(s) mild cognitive impairment (select all that apply)? a. Always progresses to AD b. Caused by variety of factors and may progress to AD c. Should be aggressively treated with acetylcholinesterase drugs d. Caused by vascular infarcts that, if treated, will delay progression to AD e. Patient is usually not aware that there is a problem with his or her memory
b. Caused by variety of factors and may progress to AD Rationale: Although some individuals with mild cognitive impairment (MCI) revert to normal cognitive function or do not go on to develop Alzheimer's disease (AD), those with MCI are at high risk for AD. No drugs have been approved for the treatment of MCI. A person with MCI is often aware of a significant change in memory.
Creutzfeldt-Jakob disease is characterized by a. remissions and exacerbations over many years. b. memory impairment, muscle jerks, and blindness. c. parkinsonian symptoms, including muscle rigidity and tremors at rest. d. increased intracranial pressure secondary to decreased CSF drainage.
b. memory impairment, muscle jerks, and blindness. Rationale: Creutzfeldt-Jakob disease (CJD) is a fatal brain disorder caused by a prion protein. The earliest symptom of the disease may be memory impairment and behavioral changes. The disease progresses rapidly, with mental deterioration, involuntary movements (i.e., muscle jerks), weakness in the limbs, blindness, and eventually coma
The early stage of AD is characterized by a. no noticeable change in behavior. b. memory problems and mild confusion. c. increased time spent sleeping or in bed. d. incontinence, agitation, and wandering behavior.
b. memory problems and mild confusion. Rationale: An initial sign of AD is a subtle deterioration in memory.
Vascular dementia is associated with a. transient ischemic attacks. b. bacterial or viral infection of neuronal tissue. c. cognitive changes secondary to cerebral ischemia. d. abrupt changes in cognitive function that are irreversible.
c. cognitive changes secondary to cerebral ischemia. Rationale: Vascular dementia is the loss of cognitive function that results from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions caused by cardiovascular disease. In this type of dementia, narrowing and blocking of arteries that supply the brain causes a decrease in blood supply.
Which patient is most at risk for developing delirium? a. A 50-year-old woman with cholecystitis b. A 19-year-old man with a fractured femur c. A 42-year-old woman having an elective hysterectomy d. A 78-year-old man admitted to the medical unit with complications related to heart failure
d. A 78-year-old man admitted to the medical unit with complications related to heart failure -Risk factors that can precipitate delirium include age of 65 years or older, male gender, and severe acute illness (e.g., heart failure). The 78-year-old man has the most risk factors for delirium.
The clinical diagnosis of dementia is based on a. CT or MRS. b. brain biopsy. c. electroencephalogram. d. patient history and cognitive assessment.
d. patient history and cognitive assessment. Rationale: The diagnosis of dementia depends on determining the cause. A thorough physical examination is performed to rule out other potential medical conditions. Cognitive testing (e.g., Mini-Mental State Examination) is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. Diagnosis of dementia related to vascular causes is based on the presence of cognitive loss, the presence of vascular brain lesions demonstrated by neuroimaging techniques, and the exclusion of other causes of dementia. Structural neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) is used in the evaluation of patients with dementia. A psychologic evaluation is also indicated to determine the presence of depression.
Dementia is defined as a a. syndrome that results only in memory loss. b. disease associated with abrupt changes in behavior. c. disease that is always due to reduced blood flow to the brain. d. syndrome characterized by cognitive dysfunction and loss of memory.
d. syndrome characterized by cognitive dysfunction and loss of memory. Rationale: Dementia is a syndrome characterized by dysfunction in or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavioral problems such as agitation, delusions, and hallucinations may result.