Neurocognitive Disorder Case Study (Alzheimer's Disease)

An alteration in which neurotransmitter is most closely associated with the etiology of Alzheimer's disease?

Acetylcholine

Which population group is the fastest growing in the US?

Age>65

8) How should the nurse explain the therapeutic effect of donepezil (Aricept) to the couple? A) Improves thinking and functioning abilities. B) Restores destroyed cells. C) Decreases hallucinations and delusions. D) Reduces periods of depression.

Answer: A. Donepezil (Aricept), classified as an acetylcholinesterase inhibitor, is used in Alzheimer's disease to delay the onset of cognitive decline. At the present time, there are no medications that reverse the course of Alzheimer's disease. Psychotropic medications are sometimes used to treat the hallucinations and delusions that may accompany dementia. However, donepezil (Aricept) is not an antipsychotic medication. Antidepressant medications may be used to treat the depression that often accompanies Alzheimer's disease. Donepezil (Aricept) is not an antidepressant, and, in fact, it may cause depression.

The nurse recognizes that caregivers need respite from the constant care demands of loved ones with Alzheimer's disease.

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23)Harry begins to cry. What initial intervention should the nurse implement? a)Quietly leave the room until Harry is in control of his emotions. b)Remain seated next to Harry while he is crying. c)Reassure Harry that he is taking the best action. d)Encourage Harry to share his feelings at his support group.

Answer: B. The nurse should remain with Harry and allow him to cry and then offer additional support and options.

14)What is the best response by the nurse? a)"You must correct her inaccurate statements to promote reality orientation." b)"You are right to balance her feelings with the need to promote reality." c)"She is attempting to manipulate you and to make sure she gets her own way." d)"There is no reason to attempt to correct Esther because she will not understand."

B. Reality orientation is an important tool for the client with early-stage Alzheimer's disease; however, as the disease progresses, reality orientation often causes the client to become agitated. It is important to recognize the feelings and emotions of the client with Alzheimer's disease. It's not therapeutic to tell the husband answer D. It's not being empathetic.

Suspected elder abuse in the community should be reported to

DCF (adult Protective Services or Law Enforcement.

Delirium disorder characteristics

Duration of the disorder is commonly brief, Is commonly reversible. Level of awareness is affected. Severe migraine headache can lead to this condition. Illusions and hallucinations are common symptoms. Symptoms can occur as a result of cocaine intoxication. Can occur as a result of head trauma

Three types of elder abuse are:

Physical, Financial, Emotional, Sexual, Neglect.

What is pseudodementia?

Pseudodementia is actually depression. Cognitive symptoms of depression often mimic those of neurocognitive disorder.

Neurocognitive disorders charactoristics

Symptoms of this disorder may be confused with depression. Can be caused by a series of small strokes. Personality change is common with this condition. Can occur as a result of head trauma. Disturbance in memory is commonly the first symptom.

Which of these is not an example of elder abuse? a)Although patient complains of pain, the caregiver rarely provides pain meds (prescribed PRN) to the patient. b)Family member responsible for providing care leaves bedbound person unattended all day. c)Patient with severe dementia is left alone for long periods of time without supervision. d)Adult child refuses to have a baby in order to provide parents with the grandchild they deserve.

d)Adult child refuses to have a baby in order to provide parents with the grandchild they deserve.

Elder abuse most commonly occurs in nursing home and residential care facilities.

f

Nurse do not need to report elder abuse unless they are sure that abuse has occurred.

f

What are some factors that are thought to contribute to elder abuse? a. Longer life. Because individuals are living longer, the very old are requiring more and more care. This older age group is the most vulnerable to abuse from caregivers. b. Dependency. Because very old people become increasingly dependent, the strain on caregivers becomes a precondition to abuse. c. Stress. The stress inherent in the caregiver role is a factor in most abuse cases. d. Learned violence. Some clinicians believe that elder mistreatment may be related to retribution on the part of an adult offspring who was abused as a child.

ALL

15)Which technique is most useful in helping a client with Alzheimer's disease recognize the bathroom? a)Place a picture of a toilet on the bathroom door. b)Place a sign that says "bathroom" on the bathroom door. c)Place a colored flag on the bathroom door. d)Place a colored strip of tape at the bathroom entrance.

Answer: A. Picture recognition is a useful tool in helping the client with Alzheimer's disease locate the bathroom. Clients with Alzheimer's disease often lose the ability to read as the disease progresses. The client with Alzheimer's disease is unlikely to associate a colored flag with use of the bathroom. Yellow-colored floor or stairway strips are an often-used safety measure for the elderly who have visual difficulties. However, this is not a useful technique in helping the client with Alzheimer's disease recognize a bathroom.

3)Which understanding by the nurse regarding Alzheimer's disease is accurate? a)Changes in behavior and personality often occur in early Alzheimer's Disease b)Behavior changes may indicate that she has already progressed to a later stage of the disease. c)Behavior changes are probably the result of her effort to cope with her altered mental function. D)Behavior changes usually indicate that the person is feeling depressed about the situation.

Answer: A. Subtle changes in behavior and personality, which would easily be recognized by a loved one, occur even in early Alzheimer's disease.

11)Which information indicates the trazodone (Desyrel) is having the desired effect? a)Esther sleeps through the night. b)Esther is able to control her bladder at times. c)Esther often wanders around through the house. d)Esther denies feeling any pain.

Answer: A. Trazodone (Desyrel) is an antidepressant often used to improve sleep in the client with Alzheimer's disease. Trazodone (Desyrel) has no effect on bladder control. Esther's wandering behavior is not an indication of stabilized cognitive functioning. Trazodone (Desyrel) is not an analgesic.

6)What is the best response by the nurse? a)"These tests are only used to help rule out other causes for Esther's symptoms, since there are no tests that can be used to diagnose Alzheimer's disease." b)"The healthcare provider is looking for changes in the brain that are consistent with Alzheimer's disease or for other conditions that can cause Esther's symptoms." c)"The tests will provide information about the staging of the Alzheimer's disease, so the healthcare provider will know which medications to prescribe for the best treatment." d)"The imaging test results will be used to analyze the effectiveness of the treatment protocol used to shrink the diseased brain tissue."

Answer: B. Although there are no diagnostic tests that provide a definitive differential diagnosis of Alzheimer's disease, several imaging tests provide data that show changes consistent with AD. Other problems that cause dementia may also be found via neuroimaging tests. Diagnostic tests are not typically used to stage Alzheimer's disease. Treatment does not shrink the diseased brain tissue.

10)Which lab tests should be scheduled? a)Serum BUN and creatinine. b)Serum liver enzymes. c)Urinalysis. d)White blood count.

Answer: B. Liver toxicity is a significant side effect of acetylcholinesterase inhibitors, so liver function tests should be monitored regularly. Renal function is not significantly affected by acetylcholinesterase inhibitors. Aricept may cause nocturia or urinary incontinence, but urine will not be affected by the medication. Infection and immunosuppression are not significant side effects of acetylcholinesterase inhibitors.

16)The nurse's response should be based on which understanding about Alzheimer's disease? a)Alzheimer's disease is a rapidly progressing disease, with deterioration that results in a typical lifespan of 2 to 5 years. b)Alzheimer's disease is a chronic disease that can progress with no set sequence and that has a typical lifespan of 5 to 20 years. c)Alzheimer's disease is a chronic, progressive disease with a clearly defined course and a typical lifespan of 20 to 30 years. d)Alzheimer's disease is a chronic disease that stabilizes after an initial rapid deterioration and has no defined lifespan.

Answer: B. This most correctly describes the course of Alzheimer's disease, but the course may be different for some.

21)Which option provides the best respite for Harry? a)Hospice care for Esther. b)Adult day care for Esther. c)Meals on Wheels service for both Harry and Esther. d)A visiting nurse to assess Esther's status.

Answer: B. While Esther is still ambulatory, she can spend several hours a day at an adult day care facility, which would provide Harry with respite from the constant demands of caring for Esther. Hospice care is generally limited to those with a life expectancy of 6 months or less. This will provide an excellent service by bringing a daily meal, but it will not provide Harry with respite from caring for Esther. A visiting nurse can provide assessment and teaching, but this will not provide Harry with respite from caring for Esther.

13)Which intervention should the nurse include in the client and family teaching? a)Play classical music every day at the same time. b)Provide Esther with a journal to record her thoughts. c)Help Esther to recognize the strong emotions that she is feeling. d)Remove family items that may cause Esther to dwell in the past.

Answer: C. The goal of cognitive restructuring in the client with early-stage Alzheimer's disease is to challenge the client to alter distorted thought patterns and view the world more realistically. One technique is to help the client recognize emotions such as anger, fear, and anxiety. Music therapy helps to reduce agitation, but it is unlikely to promote cognitive restructuring. Journaling is not a skill that most clients with Alzheimer's disease will be able to perform. Memory techniques are a useful tool that can often assist clients to recognize their identities.

4)Which example represents the forgetfulness typical of Alzheimer's disease? a)Forgetting to buy all the ingredients needed to prepare a meal. b)Forgetting to invite a neighbor over for a meal. c)Forgetting to serve dinner after preparing the meal. d)Forgetting to put the dirty dishes in the dishwasher.

Answer: C. This degree of forgetfulness is typical of the client with Alzheimer's disease. The other options are typical of the average individual.

17)Which is the best response by the nurse? a)"She is showing signs of late-stage disease and she will soon stabilize at her current level of functioning." b)"Esther's healthcare provider will explain the expected disease progression at your next appointment." c)"Every person responds differently to the disease, but it is likely that her ability to function will continue to decline." d)"It is important to maintain a positive attitude and to not worry too much about what will happen next."

Answer: C. This response provides accurate information and an opportunity for further client teaching and emotional support.

9)How should the nurse respond? "a)That is a good idea because her condition will worsen, and she will develop a tolerance to the medication's effect." b)"That may be beneficial, so do not start giving Esther the medication until I discuss this option with her healthcare provider." c)"This medication has many side effects, and it should be taken early in the disease while Esther is still physically strong." d)"This medication provides the most benefit to persons with early-stage Alzheimer's disease, so it is important to start it right away."

Answer: D. Acetylcholinesterase inhibitors, such as donepezil (Aricept), are most useful in stabilizing cognitive decline in early-stage Alzheimer's disease.

22)How should the nurse facilitator respond to this participant's joking behavior? a)Confront the man about this inappropriate behavior. b)Help the man recognize the need to approach his responsibilities seriously. c)Ask the other members of the group to ignore the man's behavior. d)Encourage all group members to use humor as a coping mechanism.

Answer: D. Humor can serve as an effective coping mechanism for the caregiver of a client with Alzheimer's disease.

7)How should the nurse explain this information to Esther and her husband? a)"These results probably indicate that the disease is in the early stages." b)"It is common for test results to change as the disease progresses." c)"Normal lab tests are not typical; the healthcare provider may want to test you again." d)"Normal lab test results help rule out other causes of the symptoms."

Answer: D. There are many causes of dementia, especially in the older client. Lab tests help rule out treatable causes before a diagnosis of Alzheimer's disease is established.

5)Which question is best to ask Esther and her husband to elicit information about possible risk factors for Alzheimer's disease? a)"Do you have a family history of depression or manic behavior?" b)"Have you ever been diagnosed with thyroid gland problems?" c)"Have you recently experienced a stroke, cerebrovascular accident, or transient ischemic attack?" d)"Does anyone in your family have Alzheimer's disease?"

Answer: D. There seems to be a genetic predisposition to the development of Alzheimer's disease for many individuals. Genetic testing may be useful for the differential diagnosis because four genes are currently associated with the disease. In addition, information about previous head trauma, exposure to toxic or metal waste, or any viral illnesses should be elicited when the nurse obtains Esther's history. There is no identified correlation between other mental illnesses and Alzheimer's disease, although persons with the disease often experience depression, and persons with Down syndrome may experience Alzheimer's disease. Thyroid gland problems may cause dementia, but they are not associated with the development of Alzheimer's disease. Cerebrovascular accidents and transient ischemic attacks, or any problem causing a decrease in blood supply to the brain, may worsen Alzheimer's disease, but a history of stroke is not a risk factor for the disease.

23)Which response is best for the nurse to provide? a)"I would feel guilty for thinking that, too." b)"Why do you feel she would be better off?" c)"You are probably just too tired to think clearly." d)"You have many conflicting emotions right now."

Answer: D. This response restates Harry's feelings and provides the opportunity for him to continue to share his concerns.

1)This exam includes which component? Appetite B) Judgment C) Pupillary Response D) Babinski's Reflex

Answer: Judgment- Evaluation of cognitive function includes assessment of attention, concentration, judgment, perception, learning, memory, communication, language, and speed of processing information.

20)Which questions are most important to ask Harry before developing the plan of care? (Select all that apply) a)"How are your children coping with Esther's disease?" b)"What do you find most stressful in your daily life?" c)"Do you attend a caregiver support group?" d)"How much time do you spend taking care of yourself?" e)"What activities do you attend outside your home?"

Answers: A, B, D, E. This will provide useful information to ascertain whether the children are helping Harry or whether their response is adding to his stress; however, the nurse should involve the children in the conversation to teach the family about the need to provide respite for their father. This question will elicit information concerning the caregiver's perceptions about the stress in his life, which is the most important information for the nurse to obtain. This will provide useful information on the extent of caregiver support Harry will need. This will provide useful information that will help in the nurse's discussion with Harry. The nurse will need to discuss the activities with Harry to ascertain whether these activities are providing respite for him. For example, is he visiting with friends for a couple of hours or is he going to the pharmacy or grocery shopping? The latter are task-oriented and do not provide respite. This will provide useful information for what resources are currently being used, but it is not the most important question to ask Harry.

12)Which information indicates possible serious side effects of trazodone (Desyrel)? (Select all that apply) a)Esther is also taking MAOIs. b)Esther is complaining of perineal pain. c)Esther has urinary urgency. d)Esther has a history of depression. e)Esther has a history of cardiac disease.

Answers: A, B, E. MAOIs and trazodone (Desyrel) are antidepressants that cannot be used in conjunction with each other. There must be a 2-week period without MAOIs before trazadone (Desyrel) is administered. A rare and painful side-effect of trazodone (Desyrel) is persistent engorgement of the clitoris in women or engorgement of the penis, called priapism, in men. Trazadone (Desyrel) may exacerbate coronary problems, and the HCP needs to know this history prior to prescribing trazadone (Desyrel).

19)The nurse is concerned that Esther will develop "sundowning syndrome". Which instructions should be included when teaching Harry some appropriate measures to reduce this problem? (Select all that apply) a)Provide Esther with a relaxing backrub at bedtime. b)Keep some light on in the bedroom at night. c)Eliminate Esther's fluid intake after the evening meal. d)Increase toileting to every hour from supper until bedtime. e)Provide a calm atmosphere during the day.

Answers: A, B, E. Touch, as well as other relaxation techniques, is useful in reducing the nocturnal confusion referred to as "sundowning syndrome". Maintaining some light in the room after dark is useful in reducing the nocturnal confusion referred to as sundowning syndrome. A calm atmosphere during the day is useful in reducing the nocturnal confusion referred to as sundowning syndrome. It is important to maintain adequate fluid intake to avoid dehydration, which can be a contributing factor to the confusion of the client with Alzheimer's disease, but elimination of evening fluids does not affect sundowning behaviors. A regular toileting schedule should be maintained, but an hourly schedule is excessive and unnecessary, and does not affect sundowning behaviors.

18)The nurse provides teaching to Harry to help reduce Esther's urinary incontinence. Which actions are most important for Harry to initiate? (Select all that apply) a)Keep a commode at the bedside. b)Keep a bell handy for Esther to ring when she needs to void. c)Take Esther to the bathroom every 2 hours. d)Ask Esther if she needs to use the bathroom after meals. e)Establish a toileting schedule at the same time daily.

Answers: A, C, D, E. This may be useful in establishing a routine to promote continence, and it will provide easy access for nocturia. Continence may be promoted if the client with Alzheimer's disease is taken to the bathroom on a regular schedule of at least every 2 hours during the day. This may be useful because it is likely to help establish a pattern that promotes continence. Toileting at the time of arising in the morning, after meals, and before bedtime is a good way to establishing this schedule. Esther may not associate the object of the bell with the need to void.

2)When the nurse is assessing Esther's cognitive function, which questions are appropriate to include in the mental status exam? (Select all that apply) a)Ask Esther to list 3 different types of fruits, colors, and animals b)Tell Esther to write a ten-sentence story about her early childhood c)Instruct Esther to find five different objects hidden in the room D)Give Esther a photo of a circle and ask her to fill in the times on the clock e)Ask Esther what she would do if she smelled gas in the house

Answers: A, D, E. These activities provide quick screening data about cognitive function

How does vascular neurocognitive disorder (NCD) differ from NCD due to Alzheimer's disease?

Vascular neurocognitive disorder differs from Neurocognitive Disorder due to Alzheimer's Disease (NCDAD) in that it has a more abrupt onset and runs a highly variable course. Progression of the symptoms occurs in "steps" rather than as a gradual deterioration as in NCDAD.

As the disease worsens, Harry cares for Esther in their home with the help of the home health care team until her Alzheimer's disease progresses to the point at which she is completely bedridden and is no longer able to perform any self-care measures. Harry notifies the nurse that he plans to place Esther in a long-term care facility. While speaking with the nurse, Harry states, "I think she would be better off if she died, but I feel so guilty for even thinking that."

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Because Esther will be taking donepezil (Aricept), the nurse schedules her for lab tests in 6 months.

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Early indicators from the mental status exam show that Esther has impaired cognitive functioning. The nurse explains to Esther and her husband that a number of different problems can result in altered cognition. The nurse discusses early warning signs and risk factors for Alzheimer's disease with the couple and Esther's husband replies, "Esther doesn't act like herself anymore."

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Elder abuse

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Esther is scheduled for lab work and neuroimaging tests, including a magnetic resonance imaging (MRI) and a positron emission tomography (PET). Esther's husband asks the nurse what these tests will show.

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Esther's husband calls the nurse 2 months later and gives her an update on Esther's condition.

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Esther's husband states, "I know this disease will worsen. Shouldn't we wait to use this medication until Esther really needs it?"

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Esther's lab tests include a CBC, TSH, T3, T4, electrolytes, BUN, and glucose levels. The results are all normal.

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Harry calls the nurse some time later and reports that Esther's behavior is deteriorating more quickly than he was expecting. He states, "It's only been 2 years since all this started. I thought this disease progressed very slowly. Am I doing something wrong?"

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Harry describes Esther's current behaviors, which include increasing memory loss, frequent wandering, inability to perform self-care when she is feeling highly stressed, urinary incontinence, and limited ability to maintain a conversation. He asks the nurse what to expect next.

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Harry reports that Esther frequently makes statements that are inaccurate, but he is reluctant to correct her too often, because she told him that it makes her feel stupid.

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Medication Therapy Since the lab test results are normal, and neuroimaging tests are consistent with Alzheimer's disease, the nurse develops a plan of care for Esther and her husband that is consistent with the medical diagnosis of Alzheimer's disease. Esther receives prescriptions for trazodone (Desire) and donepezil (Aricept).

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One morning a week, Harry participates in a caregiver support group. He finds that sharing his frustrations and concerns with other people experiencing the same situation provides comfort and support, as well as some useful caregiver tips. One male member of the support group jokes about the problems he has taking care of his spouse.

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The nurse also advises Harry that there will come a time when Ester will be unable to recognize the bathroom and he will need to help her to prevent toileting accidents.

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The nurse identifies "distorted thought processes" as a priority problem for Esther. Focusing on this problem, the nurse provides client teaching to Esther's husband, Harry. The nurse instructs Harry about measures to promote cognitive restructuring.

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The nurse recognizes that Harry is experiencing caregiver role strain and develops a plan of care for him.

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