Chapter 59

Question 1

Discuss the similarities between depression and dementia.

Answer 1

*Manifestations of depression, especially among older adults, may include sadness, difficulty concentrating, fatigue, apathy, feelings of despair, and inactivity. When depression is severe, poor concentration and attention may result, causing memory and functional impairment.
*Can last for years, hyperactivity, sleep-wake cycle is disturbed.

Question 2

List the cognitive domains that may be affected by dementia

(five)

Answer 2

Complex attention, executive function, language, learning, and memory

Question 3

cognitive decline of dementia: 8

Answer 3

1. Onset is usually insidious
2. Progression is slow
3. Duration is years (average of 8 years but can be much longer)
4. Difficulty with abstract thinking, impaired judgment, words are difficult to find
5. Often have misperceptions. 6. Delusions and hallucinations.
6. May pace or be hyperactive. As disease progresses, may not be able to perform tasks or movements when asked.
7. Sleeps during day. Frequent awakenings at night. Fragmented sleep.

Question 4

cognitive decline of depression: 7

Answer 4

1. Abrupt onset, although initially can be subtle
2. Abrupt progression. Can fluctuate from day to day
3. Duration is hours to days to weeks. Can be prolonged in some
4. Thinking is disorganized and distorted. Slow or accelerated incoherent speech.
5. Perception is distorted. Delusions and hallucinations.
6. Variable psychomotor behavior. Can be hyperactive or hypoactive, or mixed.
7. Disturbed sleep. Reversed sleep-wake cycle.

Question 5

cognitive decline of delirium: 7

Answer 5

1. Onset often coincides with life changes. Often abrupt.
2. Progression is variable, rapid to slow but may be uneven.
3. Duration can be several months to years, especially if not treated
4. Thinking is intact but with apathy, fatigue. May be indecisive. Feels a sense of hopelessness. May not want to live.
5. May deny or be unaware of depression. May have feelings of guilt.
6. Psychomotor behavior is often withdrawn and hypoactive.
7. Sleep-wake cycle is disturbed, often with early morning awakening

Question 6

Give 3 examples of potentially reversible causes of dementia.

Answer 6

Folate deficiency
Thiamine deficiency
Hyper/hypothyroidism

Question 7

Give 3 examples of the most common neurodegenerative diseases that may cause dementia.

Answer 7

Down syndrome
Parkinson’s disease
Huntington’s disease

Question 8

Define mixed dementia.

Answer 8

Occurs when 2 or more types of dementia are present at the same time.

Question 9

Describe the onset of dementia when caused by infectious or metabolic diseases.

Answer 9

An acute change that occurs over days to weeks OR subacute change that occurs over weeks to months.

Question 10

Distinguish early onset from late onset dementia.

Answer 10

Early onset → When AD develops in someone younger than 60 years old
Late onset → When AD develops in someone over 60 years old.

Question 11

Cite the reason why more women develop AD than men.

Answer 11

Women are more likely to develop AD than men, mainly because they live longer

Question 12

Cite 2 most important risk factors for developing AD

Answer 12

Aging and family history.

Question 13

Discuss how diabetes increases the risk of developing AD and other dementias. (2)

Answer 13

*Chronic high levels of insulin and glucose may be directly toxic to brain cells.
*Insulin resistance, which causes high blood glucose and can lead to type 2 diabetes, may interfere with the body’s ability to break down amyloid, a protein that forms brain plaques in AD.

Question 14

Cite the relationship between head trauma and development of dementia.

Answer 14

Head trauma is a risk factor for dementia. Professional football players and military veterans who had traumatic brain injury or posttraumatic stress disorder have an increased risk for AD and other types of dementia.

Question 15

Review the 4 brain changes found in persons with dementia.

Answer 15

Amyloid plaques
Neurofibrillary tangles
Loss of connections between neurons
Neuron death

Question 16

Cite the late structural changes in the brain because of AD.

Answer 16

Affected parts of the brain begin to shrink in a process called brain atrophy. By the final stage of AD, brain tissue has shrunk significantly.

Question 17

Define the term retrogenesis and how this could impact care of a person with AD.

Answer 17

Is the process in which the decline in AD mirrors, in reverse order, brain development that occurs from birth.

Question 18

Discuss the problems with diagnosing AD and the need to rule out other problems.

Answer 18

When all other possible conditions that can cause cognitive impairment have been excluded, a clinical diagnosis of AD can be made. A comprehensive evaluation includes a complete health history, physical exam, neurologic and mental status assessment, and lab tests. A definitive diagnosis of AD requires an exam of brain tissue at autopsy and findings of neurofibrillary tangles and plaques.

Question 19

List 4 overall goals for patients with AD

Answer 19

1.Maintain functional ability for as long as possible
2.Be in a save environment with a minimum of injuries
3.Have personal care needs met
4.Have dignity maintained

Question 20

Cite 2 problems that could occur in response to a person with AD being hospitalized.

Answer 20

Hospitalization can precipitate a worsening of dementia or development of delirium among patients with AD.

Question 21

Describe the importance of completing an advance care directive before a person with AD loses capacity to do so.

Answer 21

*You have a role in advising the patient and 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.

Question 22

List 9 common behavioral problems that occur in persons with AD.

Answer 22

Repetitiveness
Delusions
Hallucinations
Agitation
Aggression
Altered sleeping patterns
Wandering
Hoarding
Resisting care

Question 23

List 4 physical or emotional reasons why a person with AD may exhibit behavioral problems.

Answer 23

Pain
Frustration
Temperature extremes
Anxiety

Question 24

Describe 5 nursing interventions/strategies that could be done to decrease behavioral problems.

Answer 24

Creating a quiet, calm environment
Maximizing exposure to daylight by opening blinds and turning on lights during the day
Evaluating medications to determine if any could cause sleep problems
Limiting naps and caffeine
Consulting with the HCP about drug therapy

Question 25

Describe the PAINAD scale and how this tool is used for persons with advanced dementia

Answer 25

*score of 0-10 (higher is worse pain)
*Items are: breathing independent of vocalization, negative vocalization, facial expression, body language, consolability

Question 26

Review why undernutrition can be problematic in the moderate and severe stages of AD

Answer 26

Loss of interest in food and decreased ability to self-feed, as well as co-morbid conditions, can result in significant nutritional problems. In long-term care facilities, inadequate aid with feeding may add to the problem.

Question 27

Describe interventions that could address chewing and swallowing problems

Answer 27

*Use pureed foods, thickening liquids, and nutritional supplements
* A quiet and unhurried environment without distractions (ie: TV) at mealtimes can be helpful. Low lighting, music, and simulated nature sounds may improve eating behaviors. Easy-grip eating utensils and finger foods may allow the patient to self-feed. Liquids should be offered frequently.

Question 28

Describe the characteristics of delirium.

Answer 28

State of confusion develops over days to hours. The patient has a decreased ability to direct, focus, sustain, and shift attention and awareness. Deficits in memory, orientation, language, visuospatial ability, or perception may be present. The patient may be hypoactive or hyperactive. Emotional problems include fear, depression, euphoria, or perplexity. Sleep may be disturbed.

Question 29

Cite the leading risk for developing delirium.

Answer 29

Dementia

Question 30

Discuss the relationship between underlying conditions and precipitating events which lead to delirium.

Answer 30

Delirium is often the result of the interaction of the patient’s underlying condition with a precipitating event. Delirium can occur after a relatively minor insult in a vulnerable patient or serious medical illness like bacterial meningitis

Question 31

Review the mnemonic for causes of delirium

Answer 31

D ementia, dehydration
E lectrolyte imbalances, emotional stress
L ung, liver, heart, kidney, brain
I nfection, ICU
R x drugs
I njury, immobility
U ntreated pain, unfamiliar environment
M etabolic disorders

Question 32

Describe early and late manifestations of delirium. (7E, 4L)

Answer 32

Early:
Inability to concentrate, disorganized thinking, irritability, insomnia, loss of appetite, restlessness, and confusion

Late:
Agitation, misperception, misinterpretation, and hallucinations

Question 33

Contrast the 3 key distinctions between dementia and delirium

Answer 33

Delirium and NOT dementia
Sudden cognitive impairment
Sudden disorientation
Sudden Clouded sensorium

Question 34

Cite the reason why delirium is so difficult to diagnose, especially in critically ill patients.

Answer 34

Diagnosing delirium is complicated because many critically ill patients cannot communicate their needs.

Question 35

Review various blood, urine, and other tests used to help determine the cause of delirium

Answer 35

CBC, serum electrolytes, BUN, creatinine levels, ECG, UA, live function test, thyroid function test, O2 sat. Drug and ETOH levels may be obtained. Unexplained fever or nuchal rigidity is present and meningitis or encephalitis is suspected, a lumbar puncture may be done. CSF is examined for glucose, protein, and bacteria.. If the patient’s history includes head injury, appropriate x-rays or scans may be ordered. In general, brain imaging studies, such as CT and MRI, are used only when head injury is known or suspected.

Question 36

Describe 5 nursing interventions that could help improve safety when caring for patients with delirium.

Answer 36

1. Provide the patient with reassurance and reorienting information as to place, time, and procedures. Clocks, calendars, and lists of scheduled activities are helpful.
2. Reduce environmental stimuli, including noise and light levels.
3. Personal contact through touch and verbal communication can be an important reorientating strategy.
4. Relaxation techniques, music therapy, and massage.
5. Hearing aids and glasses if the patient has them.

Question 37

Describe the indications for medication management of agitation manifested in delirium.

Answer 37

Drug therapy is reserved for patients with severe agitation, especially when it interferes with needed medical treatments. Agitation can put the patient at risk for falls and injury. Medication therapy is used cautiously because many of the drugs used to manage agitation have psychoactive properties. Drugs should be used only when nonpharmacologic interventions have failed.