Delirium/ Alzheimer's Disease

An older patient is admitted to the hospital with a urinary infection and possible bacterial sepsis. The family is concerned because the patient is confused and not able to carry on a conversation. Which statement by the nurse is most appropriate? A.) "Depression is a common cause of confusion in older adults in the hospital." B.) "It is normal for an older person to have cognitive problems while in the hospital." C.) "The mental changes are most likely caused by the infection and most often reversible." D.) "Drug therapy with antipsychotic agents is indicated to slow the progression of dementia."

Answer: C Rationale: Delirium, a state of temporary but acute mental confusion, is a common, life-threatening, and possibly preventable syndrome in older adults. Clinically, delirium is rarely caused by a single factor. It is often the result of the interaction of the patient's underlying condition with a precipitating event.

D.B. is admitted to a long-term care facility. He has a nursing diagnosis of impaired memory related to effects of dementia. An appropriate nursing intervention for him is to A. let him know what behavior is socially appropriate. B. assist him with all self-care to maintain self-esteem. C. maintain familiar routines of sleep, meals, drug administration, and activities. D. promote orientation at every encounter with the patient by asking the day, time, and place.

Answer: C Rationale: The nurse should maintain familiar routines by identifying usual patterns of behavior for activities such as sleep, medication use, elimination, food intake, and self-care.

The daughter of a patient with early familial Alzheimer's disease (AD) asks how AD is different from forgetfulness. You describe early warning signs of AD, including A.) Forgetting a colleague's name at a party B.) Repeatedly misplacing car keys or a wallet C.) Leaving a pot on the stove that boils dry and burns D.) Having no memory of preparing a meal and forgetting to serve or eat it

Answer: D Rationale: Memory loss that affects job skills: Frequent forgetfulness or unexplainable confusion at home or in the workplace may signal that something is wrong. This type of memory loss goes beyond forgetting an assignment, a colleague's name, a deadline, or a phone number. Difficulty performing familiar tasks: It is not abnormal for most people to become distracted and to forget something (e.g., leave something on the stove too long). People with Alzheimer's disease (AD) may cook a meal but then forget not only to serve it but also that they made it. Misplacing things: For many individuals, temporarily misplacing keys, purses, or wallets is a normal albeit frustrating event. Persons with AD may put items in inappropriate places (e.g., eating utensils in clothing drawers) but have no memory of how they got there.

Alzheimer's Disease

Chronic, progressive, neurodegenerative brain disease 1. Most common form of dementia 2. ~5.4 million Americans suffer from AD - 11% people over age 65 have AD - ~ 33% of those over age 85 have AD - 6th leading cause of death in the United States 3. Only cause of death among the top 10 that cannot be prevented, cured, or even slowed - Burden of care is staggering - Known as the "long good-bye" or "death in slow motion" It is the most common form of dementia, accounting for 60% to 80% of all cases of dementia. AD is named after Alois Alzheimer, a German physician who in 1906 described changes in the brain tissue of a 51-year-old woman who had died of an unusual mental illness. Ultimately, the disease is fatal, with death typically occurring 8 to 10 years after diagnosis, although some patients live for 20 years. The incidence of AD is higher in African Americans and Hispanics. AD has been associated with lower socioeconomic status and education level and poor access to health care. Women are more likely than men to develop AD, primarily because they live longer. Alzheimer's Disease Etiology 1. Exact etiology is unknown but likely due to multiple factors - Greatest risk factor is age Most diagnosed at or after age 65 Not a normal part of aging Age alone is not sufficient to cause AD 2. Exact etiology is unknown but likely due to multiple factors - Family history Those with a 1st degree relative with dementia are more likely to develop AD Even higher risk with > 1 relative Family history is not necessary for an individual to develop AD 3. Familial Alzheimer's disease (FAD) - Clear pattern of inheritance - Onset before age 60 - Rapid disease course 4. Sporadic Alzheimer's disease - No familial connection 5. Brain and heart/circulatory health are closely linked 6. Many factors ↑ risk of CV disease - Diabetes - Hypertension - Obesity - Hypercholesterolemia - Smoking 7. Diabetes significantly ↑ risk of developing AD or other dementia - Diabetes mellitus Chronic high levels of insulin and glucose may be toxic to brain Insulin resistance may interfere with ability to break down amyloid 8. Head trauma Alzheimer's Disease Genetic Link 1. Small percentage of people < 60 years old develop AD - Early-onset: <60 years old - Late-onset: >60 years old When AD develops in someone younger than 60 years old, it is referred to as early-onset AD. AD that becomes evident in individuals older than 60 years old is called late-onset AD. Individuals with a clear pattern of inheritance within a family have familial Alzheimer's disease (FAD). Other cases where no familial connection can be made are termed sporadic. FAD is associated with an early onset (before 60 years of age) and a more rapid disease course. In both FAD and sporadic AD, the pathogenesis of AD is similar. The functioning of the brain is dependent on a good blood supply and nutrients delivered to it by that blood supply. Many factors increase the risk of cardiovascular disease. These include diabetes mellitus, hypertension, obesity, hypercholesterolemia, and smoking. Diabetes dramatically increases a person's risk of developing AD or other types of dementia. Diabetes can contribute to dementia in several ways. Chronic high levels of insulin and glucose may be directly toxic to brain cells. 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. In addition, high blood glucose along with high cholesterol has a role in atherosclerosis, which contributes to vascular dementia. Diabetes may contribute to poor memory and diminished mental function in various other ways. The disease causes microangiopathy, which damages small blood vessels throughout the body. Ongoing damage to blood vessels in the brain may be one reason why people with diabetes are at a higher risk of cognitive problems as they grow older. People with diabetes may lose brain volume (especially gray matter) as the disease progresses. Head trauma is also a risk factor for dementia. Professional football players and military veterans who had traumatic brain injury or post-traumatic stress disorder are at an increased risk for AD and other types of dementia. Alzheimer's Disease Pathophysiology 1. Changes in brain structure and function - Amyloid plaques - Neurofibrillary tangles - Loss of connections between neurons - Neuron death In both FAD and sporadic AD, the pathogenesis of AD is similar. Effect of Alzheimer's Disease on Brain - On the left is a normal brain. The one on the right is a brain of a person with Alzheimer's disease. Alzheimer's Disease Clinical Manifestations 1. Pathologic changes precede clinical manifestations by 5 to 20 years 2. Alzheimer's Association has developed a list of 10 warning signs that are common manifestations of AD 3. Early warning signs of AD - Memory loss that affects job skills - Difficulty performing familiar tasks - Problems with language - Disorientation to time and place - Poor or ↓ judgment - Problems with abstract thinking - Misplacing things - Changes in mood or behavior - Changes in personality - Loss of initiative 4. Categorized - Mild - Moderate - Severe 5. Progression - Highly variable from person to person - Ranges from 3 to 20 years 6. Initial symptoms are related to changes in cognitive function 7. Family members often report - Memory loss - Mild disorientation - Trouble with words and numbers 8. Normal memory decline does not interfere with ADLs - Recent memory loss - Remote memory loss - Interference with ADLs 9. As the disease progresses - ↓ Personal hygiene - ↓ Concentration and attention - Unpredictable behavior - Delusions and hallucinations 10. Changes are not under control of patient 11. Additional cognitive impairments - Dysphasia - Apraxia - Visual agnosia - Dysgraphia - Inability to recognize family and friends - Wandering 12. Later stages - Unable to communicate - Cannot perform activities of daily living (ADLs) - Patient becomes unresponsive and incontinent - Total care is required 13. Retrogenesis - Process where degenerative changes occur in the reverse order in which they were acquired Developmental stages in children compared with deterioration in AD patients Often it is a family member, in particular the spouse, who reports the patient's declining memory to the HCP. Normal age-related memory decline is characterized by mild changes that do not interfere with activities of daily living (Table 59-6). In AD the memory loss initially relates to recent events, with remote memories still intact. With time and progression of AD, memory loss includes both recent and remote memory and ultimately affects the ability to perform self-care. As AD progresses, personal hygiene deteriorates, as does the ability to concentrate and maintain attention. Ongoing loss of neurons in AD can cause a person to act in altered or unpredictable ways. Behavioral manifestations of AD (e.g., agitation, aggression) result from changes that take place within the brain. They are neither intentional nor controllable by the individual with the disease. Some patients develop delusions and hallucinations. With progression of AD, additional cognitive impairments are noted. These include dysphasia (difficulty comprehending language and oral communication) apraxia (inability to manipulate objects or perform purposeful acts) visual agnosia (inability to recognize objects by sight) dysgraphia (difficulty communicating via writing) Eventually long-term memories cannot be recalled, and patients lose the ability to recognize family members and friends. Other problems include aggression and a tendency to wander. As seen in Table 59-5 there is a relationship between the development stage and deterioration of function. Look at a few examples to show how this table works. It is very appropriate for a person with AD in the moderate stage to feel good about putting together puzzles that belong to his 3-yr-old grandson. In fact, they may play well together on the same task or project. Retrogenesis in Alzheimer's Disease Alzheimer's Disease Diagnostic Criteria 1. Changes in brain - May precede symptoms by many years - May not correlate with behaviors 2. Spectrum of Alzheimer's disease - Preclinical AD - Mild cognitive impairment - Dementia (terminal stage of disease) AD may cause changes in the brain many years before symptoms appear. In addition, symptoms do not always directly relate to abnormal changes in the brain caused by AD. Based on these findings, in 2011 the National Institute on Aging and the Alzheimer's Association proposed revised criteria and guidelines for diagnosing AD. AD is now considered on a spectrum, where dementia marks the terminal stage of the disease (Table 59-7). The stages in this spectrum are preclinical AD, mild cognitive impairment, and dementia due to AD. Guidelines address the use of imaging and biomarkers (discussed in following section on diagnostic studies) that may help determine whether changes are due to AD. Alzheimer's Disease Preclinical Stage 1. No current treatment successfully modifies the progression of AD 2. Early intervention is a future goal - Modify disease before Plaques and tangles have formed Symptoms emerge - Ongoing research A long lag exists between pathologic changes in the brain and manifestations of AD. The future goal would be to modify the disease process of AD before it becomes symptomatic. Once plaques and tangles have formed in sufficient quantity, it may be too late to intervene to prevent the disease or its progression. Although currently all attempts at modifying the disease process have failed, research is ongoing. The model for early intervention is seen in other diseases. Examples include removing polyps to prevent colon cancer, controlling blood glucose in diabetes before the disease progresses to heart and kidney disease, and treating cardiac risk factors before a person has a myocardial infarction. Alzheimer's Disease Mild Cognitive Impairment 1. Mild cognitive impairment (MCI) - 2nd stage in spectrum of AD - Problems with memory, language, other cognitive functions - Noticeable to others - Show up on tests - Do not meet criteria for dementia 2. 10%-20% of people > age 65 have MCI - High risk for developing AD - 15% of people with MCI develop AD - Drug therapy currently not available 3. Primary treatment of MCI is currently based on careful monitoring - Note declining memory or thinking skills - Know 10 early warning signs of AD These manifestations may not be severe enough to interfere with activities of daily living. Because the problems do not interfere with daily activities, the person does not meet the criteria for being diagnosed with dementia. To the casual observer, an individual with MCI may seem fairly normal. However, the person with MCI is often aware of a significant change in memory, and family members may observe changes in the individual's abilities (Table 59-6). Between 10% and 20% of people 65 years old and older have MCI and are at high risk of developing AD. Some individuals with MCI show no progression and do not go on to develop AD, but an estimated 15% of people with MCI eventually do. No drugs have been approved for the treatment of MCI. There is little evidence that medications used in AD (e.g., cholinesterase inhibitors) affect progression to dementia or cognitive test scores in people with MCI. Currently the primary treatment of MCI consists of ongoing monitoring. Recognize the importance of monitoring the patient with MCI for changes in memory and thinking skills that would indicate a worsening of symptoms or a progression to dementia. It is critical that you understand the 10 early warning signs of AD. Alzheimer's Disease Diagnostic Studies 1. No definitive diagnostic test exists for AD - Diagnosed by exclusion - Made once all other possible conditions causing cognitive impairment have been ruled out 2. Comprehensive patient evaluation - Complete health history - Physical examination - Neurologic assessment - Mental status assessment - Laboratory tests 3. Brain imaging tests - CT - MRI - PET Help detect early changes in disease process Enable monitoring of treatment response 4. Definitive diagnosis of AD usually requires an autopsy 5. Biomarkers are promising, but more research is indicated - Level of β-amyloid accumulation in the brain - Injured or degenerating nerve cells 6. Biomarkers include - CSF neurochemical markers β-amyloid and tau proteins Plasma levels are not diagnostic - Imaging biomarkers Volumetric MRI and PET Brain volume correlates with neurodegeneration 7. Neuropsychologic testing can help document degree of cognitive impairment - Mini-Cog - Mini-Mental State Examination (MMSE) - Also used to determine a baseline from which to evaluate change over time In patients with cognitive impairment, there is increased emphasis on early and careful evaluation. Many conditions can cause manifestations of dementia, some of which are treatable or reversible (see Table 59-2). A CT or an MRI scan may show brain atrophy in the later stages of the disease, although this finding occurs in other diseases and can also be seen in persons without cognitive impairment. Positron emission tomography (PET) scanning can be used to differentiate AD from other forms of dementia. A definitive diagnosis of AD usually requires examination of brain tissue and the presence of neurofibrillary tangles and neuritic plaques at autopsy. Biomarkers may be used in some cases to increase the level of certainty about a diagnosis of Alzheimer's dementia and to distinguish Alzheimer's dementia from other dementias. However, more research is needed with biomarkers before they are used routinely in clinical practice. The new criteria and guidelines identify two biomarker categories: (1) biomarkers showing the level of β-amyloid accumulation in the brain and (2) biomarkers showing that nerve cells in the brain are injured or actually degenerating. Biomarkers include (1) cerebrospinal fluid (CSF) neurochemical markers: β-amyloid and tau proteins and (2) imaging biomarkers: volumetric MRI and PET. The level of tau in the CSF is an indication of neurodegeneration. (Plasma levels of tau or β-amyloid are not of any value in diagnosing AD.) In AD, multiple brain structures atrophy and the volume of the brain correlates with neurodegeneration. PET determines brain metabolism using glucose tracers. PET can also be used to detect amyloid. Some imaging biomarkers are used in specialized clinical settings. CSF biomarkers are mainly used for research. PET Scan of Normal and AD Brain - Positron emission tomography (PET) scan can be used to assist in the diagnosis of Alzheimer's disease (AD) by differentiating AD from other forms of dementia. Radioactive fluorine is applied to glucose (fluorodeoxyglucose), and the yellow areas indicate metabolically active cells. A, A normal brain. B, Advanced AD is recognized by hypometabolism in many areas of the brain. The clock drawing test can be used as part of the Mini-Cog or by itself to assess cognitive function. Many students of a younger generation are not familiar with an analog clock. Alzheimer's Disease Inter professional Care 1. No cure - No treatment exists to stop the deterioration of brain cells in AD 2. Interprofessional care is aimed at - Controlling undesirable behavioral manifestations - Providing support for family caregiver Nothing stops or really slows the progression of the disease. Alzheimer's Disease Drug Therapy 1. Drugs available today help many people but not for very long and not very well - Some modest ↓ in rate of decline of cognitive function - No effect on overall disease progression 2. Memantine (Namenda) protects nerve cells against excess amounts of glutamate - Glutamate is released in large amounts by cells damaged by AD 3. Treating associated depression - May improve cognitive ability - May help with sleep problems - SSRIs are often used 4. Antipsychotic drugs - Manage behavioral problems - ↑ Risk of death in older patients Although drug therapy for AD is available (Table 59-11), these drugs do not cure or reverse the progression of the disease. Drugs help many people, but not for very long and not very well. The use of drugs may lead to a modest decrease in the rate of decline of cognitive function. However, the drugs have no effect on overall disease progression. A, Acetylcholine is released from the nerve synapses and carries a message across the synapse. B, Cholinesterase breaks down acetylcholine. C, Cholinesterase inhibitors block cholinesterase, thus giving acetylcholine more time to transmit the message. Cholinesterase inhibitors block cholinesterase, the enzyme responsible for the breakdown of acetylcholine in the synaptic cleft. Cholinesterase inhibitors include donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). Rivastigmine is available as a patch. The attachment of glutamate to N-methyl-D-aspartate (NMDA) receptors permits calcium to flow freely into the cell, which in turn may lead to cell degeneration. Memantine may prevent this destructive sequence by blocking the action of glutamate. Selective serotonin reuptake inhibitors include fluoxetine (Prozac), sertraline (Zoloft), fluvoxamine (Luvox), and citalopram (Celexa). The antidepressant trazodone (Desyrel) may help with problems related to sleep. However, this agent may result in hypotension. Although antipsychotic drugs are approved for treating psychotic conditions (e.g., schizophrenia), they have been used for the management of behavioral problems (e.g., agitation, aggressive behavior) that occurs in patients with AD. The Food and Drug Administration (FDA) has warned that antipsychotics are not indicated for the treatment of dementia-related psychosis. However, the warning does not mean that the drugs cannot be used for these patients with dementia. Alzheimer's Disease Nursing Assessment 1. Subjective Data - Past health history - Medications - Health perception-health management - Nutritional-metabolic - Elimination (incontinence) - Activity-exercise - Sleep-rest pattern - Cognitive-perceptual 2. Objective Data - Disheveled appearance - Neurologic Early, middle, late Useful questions for the patient and informant are, "When did you first notice the memory loss?" and "How has the memory loss progressed since then?" Alzheimer's Disease Nursing Diagnoses - Impaired memory - Self-neglect - Risk for injury - Wandering Nursing diagnoses for AD may include, but are not limited to, the following: Impaired memory related to the effects of dementia Self-neglect related to memory deficit, cognitive impairment, and neuromuscular impairment Risk for injury related to impaired judgment, gait instability, muscle weakness, and sensory/perceptual alteration Wandering related to cognitive impairment Alzheimer's Disease Planning 1. Overall goals for patients - Maintain functional ability as long as possible - Be maintained in a safe environment with a minimum of injuries - Have personal care needs met - Have dignity maintained 2. Reduce caregiver stress - Maintain personal, emotional, and physical health - Cope with long-term effects of caregiving Alzheimer's Disease Health Promotion 1. Keep your brain healthy - Avoid harmful substances - Challenge your mind - Exercise regularly - Stay socially active - Avoid trauma to the brain - Take care of mental health - Treat diabetes - Take care of your heart - Get enough sleep - Get the right fuel Can AD be prevented? Although there is no known definitive way to prevent AD, there are several things that we can do to keep our brain healthy and modify our risks for developing dementia Decreasing Risk of Cognitive Decline The following are tips to reduce the risk of cognitive decline and dementia. 1. Avoid harmful substances: Excessive drinking and drug abuse can damage brain cells. Stop smoking as it increases the risk of cognitive decline. 2. Challenge your mind: Read frequently, do crossword puzzles. Keep mentally active. Learn new skills. Go back to school. This strengthens the brain connections and promotes new ones. 3. Exercise regularly: Even low to moderate level activity such as walking or gardening three to five times per week can make you feel better. Daily physical activity, even in older adults, can decrease the risk for cognitive decline. 4. Stay socially active: Pursue social activities that have meaning to you. Family, friends, church, and a sense of community may all contribute to better brain health. 5. Avoid trauma to the brain: Because traumatic brain injury may be a risk factor for developing AD, promote safety in physical activities and driving. Use the car seat belt. Wear a helmet when playing contact sports or riding a bike. Fall proof your home. 6. Take care of mental health: Recognize and treat depression early. Depression may cause or worsen memory loss and other cognitive impairment. 7. Treat diabetes: Better blood glucose control can help to prevent the cognitive decline associated with diabetes. 8. Take care of your heart: Risk factors for cardiovascular disease and stroke (hypertension, obesity) negatively impact your cognitive health. Heart health is linked to brain health. 9. Get enough sleep: Not getting enough sleep may result in problems with memory and thinking. 10. Get the right fuel: A healthy and balanced diet low in fats and high in vegetables and fruits help to reduce the risk of cognitive decline. Alzheimer's Disease Nursing Implementation 1. Early recognition and treatment are important 2. Inform patients and their families regarding early signs of AD Alzheimer's Disease Acute Care 1. Diagnosis is very traumatic 2. Patient often responds with - Depression - Denial - Anxiety and fear - Withdrawal - Feelings of loss 3. Assess your patients for depression and suicidal ideation - Counseling and antidepressants may be indicated 4. Family caregivers may be in denial, delaying critical early care - Accept their ability to cope 5. Ongoing monitoring important - Work in collaboration with patient's caregiver - Teach caregiver how to manage clinical manifestations effectively as they change over time - Patient and caregiver have overlapping but unique problems and needs 6. AD patients subject to hospitalization for other problems 7. Inability to communicate symptoms places responsibility on caregiver and health care professionals 8. Hospitalization can precipitate - Worsening of dementia - Development of delirium Along with patient assessment, assess family caregivers and their ability to accept and cope with the diagnosis. You are often responsible for teaching the caregiver to perform the many tasks that are required to manage the patient's care. Hospitalization of the patient with AD can be a traumatic event for both the patient and caregiver and can precipitate a worsening of dementia or development of delirium. Patients with AD hospitalized in the acute care setting will need to be observed more closely because of concerns for safety, frequently oriented to place and time, and given reassurance. Anxiety or disruptive behavior may be reduced with using consistent nursing staff. Alzheimer's Disease Ambulatory Care 1. Family members and friends care for most AD patients in their homes 2. Various facilities should be evaluated - Consider stage of AD patient when choosing - Nursing care intensifies over time 3. In early stages, memory aids may provide benefit - Depression often develops - Advance directives should be set 4. Adult day care can provide - Caregiver respite - Stimulation for AD patient 5. Severity of problems and amount of care intensifies over time - Demands on caregiver can exceed resources - May need long-term care placement Special dementia units are becoming increasingly common Emphasis is on safety Long-term care and assisted living facilities may be good for one person but may not be suitable for another. Also, what is helpful for a person at one point in the disease process may be completely different from what is best when the disease progresses. Patients with AD progress through the stages at variable rates. The nursing care required by the patient with AD changes as the disease progresses, which emphasizes the need for regular assessment and support. Regardless of the setting, the severity of the problems and amount of nursing care intensify over time. The specific manifestations of the disease will depend on the area of the brain involved. Nursing care is focuses on decreasing clinical manifestations, preventing harm, and supporting the patient and caregiver throughout the disease process. An example of a memory aid is a calendar. Depression may be related to the diagnosis of an incurable disorder, as well as the impact of the disease on activities of daily living (e.g., driving, socializing with friends, participating in hobbies or recreational activities). Decisions related to care should be made with the patient, family members, and interprofessional care team early in the disease. You have a role in advising the patient and the caregiver to initiate health care decisions, including advance directives, while the patient has the capacity to do so. This can ease the burden for the caregiver as the disease progresses. Adult day care is one of the options available to the person with AD. Although programs vary in size, structure, physical environment, and staff experience, the common goals of all day care programs are to provide respite for the family and a protective environment for the patient. During the early and middle stages of AD, the person can still benefit from stimulating activities that encourage independence and decision making in a protective environment. The respite from the demands of care allows the caregiver to be more responsive to the patient's needs. For example, many facilities have designated areas that allow the patient to walk freely within the unit while the unit is secured, so the patient cannot wander outside of it. As the patient with AD progresses to the late stages (severe impairment) of AD, there is increased difficulty with the most basic functions, including walking and talking. Total care is eventually required. Alzheimer's Disease Behavioral Problems 1. Occur in most patients with AD 2. These problems include - Repetitiveness - Delusions - Hallucinations - Agitation - Aggression 3. Problems - Altered sleep patterns - Wandering - Hoarding - Resisting care 4. Can be unpredictable and challenging - Often lead to placement of patients in institutional care settings 5. Assess patient's - Physical status - Environment Move patient or remove stimulus 6. Reassure patient about safety 7. Rely on mood and behavior rather than verbal communication - Don't ask patient "why" 8. Nursing strategies to address difficult behaviors - Redirection - Distraction - Reassurance 9. Do not threaten to restrain patient or call HCP 10. Exhaust options before using drugs 11. Sundowning - Specific type of agitation - Patient becomes more confused and agitated in late afternoon or evening May be due to disruption of circadian rhythms 12. Nursing interventions for sundowning - Create a quiet, calm environment - Maximize exposure to daylight - Evaluate medications - Limit naps and caffeine - Consult health care provider on drug therapy Behavioral problems occur in about 90% of patients with AD. Behavior is unpredictable. Can be challenging for caregiver. Caregivers need to be aware that these behaviors are not intentional and are often difficult to control. Behavioral problems are often the reason that patients are placed in institutional care settings. When these behaviors become problematic, you must plan interventions carefully. Check the patient for changes in vital signs, urinary and bowel patterns, and pain that could account for behavioral problems. Then assess the environment to identify factors that may trigger behavior disruptions. Do not ask the confused or agitated patient challenging "why" questions. The person with AD cannot think logically. If the patient cannot verbalize distress, validate his or her mood. Rephrase the patient's statement to validate its meaning. Closely observe the patient's emotional state. Use reality orientation to orient to time, place, and person. Ways to distract the agitated patient may include providing snacks, taking a car ride, sitting on a porch swing or rocker, listening to favorite music, watching videotapes, looking at family photographs, or walking. Use of repetitive activities, songs, poems, music, massage, aromas, or a favorite object can be soothing to patients. A calming family member can be asked to stay with the patient until the patient becomes calmer. Monitor the patient frequently, and document all interventions. The use of positive nurse actions can reduce the use of chemical (drug therapy) restraints. Disruptive behaviors have been treated with antipsychotic drugs (Table 59-11). Before these drugs are used, all other measures of treating behavioral issues should be exhausted. Behaviors related to sundowing include agitation, aggressiveness, wandering, resistance to redirection, and increased verbal activity such as yelling. Other possible causes include fatigue, unfamiliar environment and noise (especially in an acute care setting), medications, reduced lighting, and sleep fragmentation. When a patient has sundowning, remain calm and avoid confrontation. Assess the situation for possible causes of the agitation. Nursing interventions that may be helpful include (1) creating a quiet, calm environment; (2) maximizing exposure to daylight (open blinds and turn on lights during the day); (3) evaluating medications to determine if any could cause sleep disturbance; (4) limiting naps and caffeine; and (5) consulting with the HCP regarding drug therapy. Management of sundowning can be challenging for you, the patient, and the family. Alzheimer's Disease Safety 1. Risks - Injury from falls - Ingesting dangerous substances - Wandering - Injury to others and self with sharps - Burns - Inability to respond to crisis 2. Minimize risks in home environment - Assist caregiver in assessing home environment for safety risks - Implement all possible safety strategies 3. Supervision 4. Wandering is major concern - Observe for precipitating factors or events - Patient can be registered with Medical Alert + Safe Return GPS As the patient's cognitive function declines over time, the patient may have difficulty navigating physical spaces and interpreting environmental cues. Teach the caregiver to take the following steps: Have stairwells well lit. Handrails should be graspable. Tack down carpet edges. Remove throw rugs and extension cords. Use nonskid mats in tub or shower. Install handrails in bath and by commode. Wandering may be related to loss of memory or to side effects of drugs, or it may be an expression of a physical or emotional need, restlessness, curiosity, or stimuli that trigger memories of earlier routines. When someone with AD is discovered missing, every second counts. To assist caregivers with locating them, the Alzheimer's Association and the MedicAlert Foundation have created an alliance to offer MedicAlert + Alzheimer's Association SafeReturn. The Safe Return program includes identification products (e.g., bracelet, necklace, wallet cards), a national photo/information database, a 24-hour toll-free emergency crisis line, local chapter support, and wandering behavior education and training for caregivers and families. Tracking devices such as a global positioning system (GPS) can also be used to detect and find people who wander. These devices can be placed in shoes, sewn into pockets, worn as a bracelet or pendant, or clipped to a belt. Alzheimer's Disease Pain Management 1. Pain should be recognized and treated promptly - Monitor patient's responses - Patients can have difficulty communicating complaints - May exhibit changes in behavior Because of difficulties with oral and written language associated with AD, patients may have difficulty expressing physical complaints, including pain. Pain can result in alterations in the patient's behavior, such as increased vocalization, agitation, withdrawal, and changes in function. Alzheimer's Disease Eating and Swallowing Difficulties 1. Undernutrition is a problem in moderate and severe stages - Loss of interest in food - Decreased ability to self-feed (feeding apraxia) - Co-morbid conditions 2. When chewing and swallowing become difficult, use - Pureed food - Thickening liquids - Nutritional supplements 3. Quiet and unhurried environment 4. Easy-grip utensils 5. Offer liquids frequently 6. Finger foods may allow self-feeding 7. Short-term possibilities - Nasogastric (NG) feedings - Percutaneous endoscopic gastrostomy (PEG) tube Nutritional deficiencies can result. In long-term care facilities, inadequate assistance with feeding may add to the problem. Distractions at mealtimes, including the television, should be avoided. Low lighting, music, and simulated nature sounds may improve eating behaviors. For the long term the NG tube is uncomfortable and may add to the patient's agitation. A percutaneous endoscopic gastrostomy (PEG) tube provides another option. PEG tubes can be problematic, since patients with AD are particularly vulnerable to aspiration of feeding formula and tube dislodgment. The potential positive outcomes to be gained from nutritional therapies are considered in light of overall outcome goals and potential adverse effects of the specific therapy. Alzheimer's Disease Oral Care 1. In late stages, patient will be unable to perform oral self-care - Dental problems are likely to occur - Patient may pocket food, adding to potential tooth decay - Inspect mouth regularly and provide mouth care Dental caries and tooth abscess can add to patient discomfort or pain and subsequently may increase agitation. Alzheimer's Disease Infection Prevention 1. Common - Urinary tract infection - Pneumonia Ultimate cause of death in many AD patients 2. Manifestations need prompt evaluation and treatment Because of feeding and swallowing problems, the patient with AD is at risk for aspiration pneumonia. Reduced fluid intake, prostate enlargement in men, poor hygiene, and urinary drainage devices (e.g., catheter) can predispose to bladder infection. Any manifestations of infection, such as a change in behavior, fever, cough (pneumonia), or pain on urination (bladder), need prompt evaluation and treatment. Alzheimer's Disease Skin Care 1. In late stages, patients are at risk for skin breakdown - Incontinence, immobility, and undernutrition 2. Tend to rashes, areas of redness 3. Keep skin dry and clean 4. Change patient's position regularly It is important to monitor the patient's skin over time. Alzheimer's Disease Elimination Problems 1. Urinary and fecal incontinence during middle to late stages 2. Habit or behavioral retraining may ↓ episodes 3. Constipation may relate to immobility, dietary intake, ↓ fluids Urinary and fecal incontinence lead to an increased risk of urinary tract infection and the need for increased nursing care. The combination of aging, other health problems, and swallowing difficulties may increase the risk of complications associated with the use of mineral oil, stimulants, osmotic agents, and enemas. Alzheimer's Disease Caregiver Support 1. AD disrupts all aspects of personal and family life - Very stressful - Caregivers also exhibit adverse consequences Employment and emotional and physical health Can result in family conflict and strain 2. Caregiving increases risk for development of dementia - Chronic and severe stress can affect the hippocampus Hippocampus is a region of the brain responsible for memory 3. Assess caregiver expectations More than 15 million Americans provide unpaid care for people with Alzheimer's or other dementia. Most of these are family members providing care in the home. Work with the caregiver to assess stressors and to identify coping strategies to reduce the burden of caregiving. For example, ask which behaviors are most disruptive to family life at a given time, while remembering that this is likely to change as the disease progresses. Determining what the caregiver views as most disruptive or distressful can help to establish priorities for care. Safety of the patient is a high priority. It is also important to assess what the caregiver's expectations are regarding the patient's behavior. Are the expectations reasonable given the progression of the disease? A family and caregiver teaching guide based on the disease stages is provided in Table 59-14. Other tips for caregivers are listed in Table 59-15. A nursing care plan for the family caregiver (eNursing Care Plan 59-2) is available on the website for this chapter. Alzheimer's Disease Evaluation 1. Expected Outcomes - Functions at highest level of cognitive ability - Performs basic personal care activities of daily living including Bathing, dressing, feeding, and toileting by self or with assistance as needed - Experiences no injury - Remains in restricted area during ambulation and activity

Dementia

Dementia 1. Neurocognitive disorder with dysfunction or loss of - Memory - Orientation - Attention - Language - Judgment - Reasoning 2. Other characteristics that can manifest - Personality changes - Behavioral problems such as Agitation Delusions Hallucinations 3. Problems ultimately disrupt individual's - Work - Social responsibilities - Family responsibilities - Ability to perform ADLs Dementia Etiology and Pathophysiology 1. Due to treatable and nontreatable causes - Treatable conditions can become irreversible with prolonged exposure or disease 2. Most common causes - Neurodegenerative conditions - Vascular disorders 3. Vascular dementia - Also called multiinfarct dementia - Loss of cognitive function due to brain lesions caused by cardiovascular disease Ischemic lesions Hemorrhagic brain lesions - Result of decreased blood supply from narrowing and blocking of arteries that supply brain - Can be caused by a single stroke or by multiple strokes 4. Mixed dementia - 2 or more types of dementia present at the same time - Hallmark abnormalities of Alzheimer's disease + another type of dementia Usually vascular dementia 5. Normal pressure hydrocephalus - Uncommon - Caused by obstruction of CSF flow Meningitis, encephalitis, head injury Manifestations - dementia, urinary incontinence and difficulty walking - Treatable when diagnosed early Treatable causes may initially be reversible (Table 59-2). The most common causes of dementia are neurodegenerative conditions, with the majority of cases being Alzheimer's disease. Vascular conditions are the second most common cause of dementia. Vascular dementia, also called multiinfarct dementia, is loss of cognitive function resulting from ischemic or hemorrhagic brain lesions caused by cardiovascular disease. This type of dementia is the result of decreased blood supply from narrowing and blocking of arteries that supply the brain. Vascular dementia may be caused by a single stroke (infarct) or by multiple strokes. Usually the other type of dementia is vascular dementia, but it can be other types. If diagnosed early, normal pressure hydrocephalus is treatable by surgery in which a shunt is inserted to divert the fluid away from the brain. Dementia Clinical Manifestations 1. Onset of dementia depends on cause - Gradual and progressive over time Neurologic degeneration - Abrupt Vascular dementia tends to be abrupt or progress in a stepwise pattern Dementia Diagnostic Studies 1. Diagnosis is focused on determining the cause - Thorough medical, neurologic, psychologic history, and mental status testing Rule out other conditions - Neuroimaging techniques The diagnosis of dementia is focused on determining the cause (e.g., reversible versus nonreversible factors). Screening for cobalamin (vitamin B12) deficiency and hypothyroidism is often performed. Based on patient history, testing for neurosyphilis may be performed. Neuroimaging techniques (CT or MRI) may be used to rule out or confirm causes of dementia. (Diagnostic studies for Alzheimer's disease are discussed later.) Nursing and Interprofessional Management 1. Similar to management and drug therapy of patients with AD - Vascular dementia can often be prevented through treatment of risk factors Hypertension, diabetes, smoking, hypercholesterolemia, cardiac dysrhythmias

Neurodegenerative Diseases

Dementia with Lewy bodies (DLB) 1. Characterized by presence of Lewy bodies in brainstem and cortex - Intraneural cytoplasmic inclusions 2. Features of Parkinson's disease - Medication therapy may assist with symptoms Since it has some features of Parkinson's disease, medication therapy may assist with symptoms. Frontotemporal lobar degeneration (FTLD) - Rare - Caused by shrinking frontal and temporal lobes of the brain - Care is supportive FTLD is characterized by disturbances in behavior, sleep, personality, and eventually memory.

Delirium

Three most common cognitive problems in adults 1. Delirium (acute confusion) 2. Dementia 3. Depression These problems often occur together State of temporary but acute mental confusion - Common problem - Life-threatening syndrome Often preventable and/or reversible The three most common cognitive problems in adults are dementia, delirium (acute confusion), and depression. Although this chapter focuses on dementia and delirium, depression is often associated with these conditions. Depression is often mistaken for dementia in older adults, and, conversely, dementia for depression. Manifestations of depression (especially in the older adult) include sadness, difficulty thinking and concentrating, fatigue, apathy, feelings of despair, and inactivity. When depression is severe, poor concentration and attention may result, causing memory and functional impairment. When dementia and depression occur together (as happens in many patients with dementia), the intellectual deterioration can be extreme. Depression, alone or in combination with dementia, is treatable. The challenge is to make an accurate and early assessment and diagnosis (Table 59-1). Delirium affects as many as 50% of people older than 65 years who are hospitalized, and as many as 80% of patients in an ICU. Delirium Etiology and Pathophysiology Dementia is leading risk factor 1. Delirium is a risk factor for subsequent development of dementia 2. Linked to onset - Stress - Surgery - Sleep deprivation - Pain and depression Especially in postop older patients 3. Older patients have limited compensatory mechanisms to deal with physiologic insults such as - Hypoxia - Hypoglycemia - Dehydration 4. Older patients are more often treated with multiple drugs - More susceptible to drug-induced delirium Dementia is the leading risk factor for delirium. Furthermore, delirium is a risk factor for the subsequent development of dementia. Delirium may cause permanent neuronal damage and lead to dementia. Stress, surgery, and sleep deprivation have been linked to the onset of delirium. Pain and depression also contribute to delirium, especially in postoperative older patients. Many medications, including sedative-hypnotics, opioids (especially meperidine [Demerol]), benzodiazepines, and drugs with anticholinergic properties, can cause or contribute to delirium, especially in older or vulnerable patients. Delirium Mnemonic for Causes - Dementia, dehydration - Electrolyte imbalances, emotional stress - Lung, liver, heart, kidney, brain - Infection, ICU - Rx Drugs - Injury, immobility - Untreated pain, unfamiliar environment - Metabolic disorders Delirium Clinical Manifestations 1. Can present with a variety of manifestations 2. Delirium usually develops over a 2- to 3-day period - Can develop within hours 3. Early manifestations often include - Inability to concentrate - Disorganized thinking - Irritability - Insomnia - Loss of appetite - Restlessness - Confusion 4. Later manifestations may include - Agitation - Misperception - Misinterpretation - Hallucinations 5. Can last from 1 to 7 days - Some manifestations may persist for months or years - Some patients do not completely recover 6. Manifestations are sometimes confused with dementia 7. Key distinctions of delirium rather than dementia - Sudden cognitive impairment - Disorientation - Clouded sensorium Patients with delirium can present with a variety of manifestations ranging from hypoactivity and lethargy to hyperactivity, including agitation and hallucinations. Patients can also have mixed delirium, manifesting both hypoactive and hyperactive symptoms. Manifestations of delirium are sometimes confused with those of dementia. A key distinction between delirium and dementia is that the person who exhibits sudden cognitive impairment, disorientation, or clouded sensorium is more likely to have delirium rather than dementia. A comparison of dementia, delirium, and depression is presented in Table 59-1. Delirium Diagnostic Studies 1. Diagnosis complicated by inability to communicate - Medical history - Psychologic history - Physical examination - Careful attention to medications - Cognitive measures - Confusion Assessment Method (CAM) 2. Laboratory tests to explore the cause - Serum electrolytes - Blood urea nitrogen level - Creatinine level - Complete blood count (CBC) - Drug and alcohol levels 3. Laboratory tests - Electrocardiogram (ECG) - Urinalysis - Liver and thyroid function tests - Oxygen saturation level - Lumbar puncture Diagnosing delirium is complicated because many critically ill patients cannot communicate their needs. The Confusion Assessment Method (CAM) tool has been extensively studied and is a reliable method of assessing for delirium. Table 59-18 presents CAM. Once delirium has been diagnosed, explore potential causes of delirium. Drug and alcohol levels may be obtained. If unexplained fever or nuchal rigidity is present, and meningitis or encephalitis is suspected, a lumbar puncture may be performed Delirium Nursing/Interprofessional Momt 1. Treatment is important since many cases are potentially reversible 2. Your role in caring for a patient with delirium - Prevention - Early recognition - Treatment 3. Focus on eliminating precipitating factors - Protect patient from harm - Encourage family members to stay at bedside 4. If delirium is secondary to infection, antibiotic therapy is started 5. Reorientation and behavioral interventions—used in all patients with delirium - Create a calm and safe environment - Provide reassurance - Pay attention to environmental stimuli Clocks, calendars, noise, and light levels 6. Patient experiencing delirium is also at risk for - Immobility - Skin breakdown 7. Nurse should also focus on supporting the family and caregivers Prevention of delirium involves recognition of high-risk patients. Patient groups at risk include those with neurologic disorders (e.g., dementia, stroke, CNS infection, Parkinson's disease), sensory impairment, and older age. Other risk factors include surgery, hospitalization in an ICU, and untreated pain. See Table 59-16. Care of the patient with delirium focuses on eliminating precipitating factors. If it is drug induced, medications are discontinued. Keep in mind that delirium can also accompany drug and alcohol withdrawal. Depending on patient history, drug screening may be performed. Fluid and electrolyte imbalances and nutritional deficiencies (e.g., thiamine) are corrected if appropriate. If the problem is related to environmental conditions (e.g., an overstimulating or understimulating environment), changes should be made. If delirium is secondary to chronic illness such as chronic kidney disease or heart failure, treatment focuses on these conditions. A therapeutic environment may include encouraging family members to stay at the bedside, providing familiar objects and family photos, transferring the patient to a private room or one closer to the nurses' station, and planning for consistent nursing staff if possible. Use reorientation and behavioral interventions in patients with delirium. Personal contact through touch and verbal communication can be an important reorienting strategy. If the patient uses eyeglasses or a hearing aid, these should be made readily available because sensory deprivation can precipitate delirium. Avoid the use of restraints. The interprofessional care team may need to address issues related to polypharmacy, pain, nutritional status, and potential for incontinence. Give attention to increasing physical activity or providing range-of-motion exercises, when appropriate, and maintaining skin integrity. Patient education materials are available at www.ICUdelirium.org. Delirium Drug Therapy 1. Reserved for those patients with severe agitation - Interferes with needed medical therapy - Puts patient at increased risk for falls and injury - Used when nonpharmacologic interventions have failed 2. Dexmedetomidine (Precedex) for sedation 3. Neuroleptics - Haloperidol (Haldol) - Risperidone (Risperdal) - Olanzapine (Zyprexa) - Quetiapine (Seroquel) 4. Short-acting benzodiazepines Drug therapy is used cautiously because many of the drugs used to manage agitation have psychoactive properties. Dexmedetomidine (Precedex), an α-adrenergic receptor agonist, has been used in ICU settings for sedation. Haloperidol can be administered IV, IM, or orally and will produce sedation. In addition to sedation, other side effects with antipsychotics include hypotension; extrapyramidal side effects, including tardive dyskinesia (involuntary muscle movements of the face, trunk, and arms) and athetosis (involuntary writhing movements of the limbs); muscle tone changes; and anticholinergic effects. Carefully monitor older patients receiving antipsychotic agents. Short-acting benzodiazepines (e.g., lorazepam [Ativan]) can be used to treat delirium associated with sedative and alcohol withdrawal or in conjunction with antipsychotics to reduce extrapyramidal side effects. However, these drugs may worsen delirium caused by other factors and must be used cautiously.