Chapter 60: Nursing Management- Alzheimer's Disease, Dementia, and Delirium

Question 1

Syndrome characterized by dysfunction or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavioral problems such as agitation, delusions, and hallucinations may occur. Ultimately these problems result in alterations in the individual’s ability to work, fulfill social and family responsibilities, and perform ADLs. Often diagnosed when two or more brain functions, such as memory loss or language sills, are significantly impaired. ~100 causes. ~60-70% of pts have Alzheimer’s disease. D/t treatable and non treatable conditions. Two most common causes are neurodegenerative conditions (e.g. AD) and vascular disorders. Sometimes c/b conditions that may be initially reversible but with prolonged exposure irreversible changes may occur.

Answer 1

Dementia

Question 2

Onset of manifestations may be insidious and gradual or more abrupt. Often mistaken for depression. Progressive sx. Duration of months to years. Progressive impairment. Consistently poor performance in mental status testing.

Answer 2

Dementia

Question 3

Chronic, progressive, degenerative disease of the brain Most common form of dementia. Only cause of death among the top 10 that cannot be prevented, red, or even slowed. Exact cause is unknown, but is likely a combination of genetic and environmental factors. Not a normal part of aging, but as with other forms of dementia, age is the most important risk factor for developing it. Genetics (familial), inflammation viruses, DM, smoking, depression.

Answer 3

Alzheimer’s disease (AD)

Question 4

Characteristic findings of AD relate to changes in the brains structure and function. These are:

Answer 4

1) beta amyloid plaques: plaques consist of clusters of insoluble deposits of a protein called beta amyloid, other proteins, remnants of neurons, non-nerve cells such as microglia, and other cells such as astrocytes. These plaques develop in certain areas of the brain used for memory and cognitive function, including the hippocampus. Eventually they attack the cerebral cortex, esp areas responsible for language and reasoning.
2) neurofibrillary tangles: abnormal collections of twisted protein threads inside nerve cells.
3) loss of connections between neurons
4) neuron death (cell death and brain atrophy)
Decrease in ACh

Question 5

Categorized as mild, moderate, and severe. The rate of progression from mild to severe is highly variable and ranges from 3-20 years. Initial manifestations are usually unrelated to changes in cognitive functioning. Pts may have complaints of memory loss, mild disorientation, or trouble with words and numbers. As it progresses, personal hygiene deteriorates, as does the ability to concentrate and maintain attention. Ongoing loss of neurons can cause a person to act in altered or unpredictable ways. Behavioral manifestations result from changes that take place within the brain- they are neither intentional nor controllable. Some pts develop delusions and hallucinations.
May develop dysphagia, apraxia (inability to manipulate objects or perform purposeful acts), visual agnosia (inability to recognize objects by sight), and dysgraphia. Later in the disease, the ability to communicate and to perform ADLs is lost. IN the late stages, the pt is unresponsive and incontinent and requires total care.

Answer 5

AD

Question 6

S/S: cognitive changes (subtle deterioration in memory [1st sign]; loss of recent memory; loss of concentration; significant cognitive impairments; loss of long-term memory); behavior/personality changes (decrease in personal hygiene; agitation, aggression; increased confusion at night [Sundowner’s])

Answer 6

AD

Question 7

Prevention of AD

Answer 7

Nothing known. Important to recognize the disease early, so tx can be started early. Research is being done on: diet changes- more dark-colored fruits/veggies, sorry, more folate and B12, C, E; Exercise; NSAIDs

Question 8

Dx of AD

Answer 8

Dx of exclusion- only autopsy will reveal the brain tissue changes.
Labs (CBC, CMP, thyroid, liver function, drug and alcohol screens, syphilis)
CT or MRI 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 w/o cognitive impairment.
PET can be used to differentiate AD from other forms of dementia.
Neuropsychologic testing with tools such as the Mini-Cog and the Mini-Mental State Examination can help document the degree of cognitive impairment.

Question 9

Tx of Alzheimers disease

Answer 9

No cure, no treatment available to stop the deterioration of brain cells. Goals: controlling the undesirable behavioral manifestations that the pt may exhibit; providing support for the family and caregiver.

Question 10

Drug therapy for AD

Answer 10

Cholinesterase inhibitors: block cholinesterase, the enzyme responsible for the breakdown of ACh in the synaptic cleft. Donepezil (Aricept), rivastigmine (Exelon), and galantamine (Razadyne). Best given early in the disease.
Memantine (Named)- protects the brain’s nerve cells against excess amounts of glutamate, which is released in large amounts by cells damaged by AD. May prevent destructive sequence by blocking the action of glutamate.
Antidepressants- may improve cognition, may help with sleep. SSRIs (fluoxetine [Prozac], streamline [Zoloft], citalopram [Celexa]).
Antipsychotics- can be dangerous.

Question 11

Nursing care for AD

Answer 11

Provide structure and consistency- routines; place for everything; clocks; calendars.
Prevent overstimulation- ensure undisturbed sleep; TV off most of the time.
Prevent/control agitation- look for signs of discomfort; redirect; distract; reassure; limit number of choices; give simple direction.
DO NOT: threaten, confront, explain, take offense, restrain. Avoid drugs, if possible.
Prevent injury (i.e. wandering, falls): 24 hr supervision; medic alter bracelets; alarms on doors, room close to the nurse’s desk; provide space for safe pacing; provide boundaries (red tape); fall prevention interventions
Disturbed sleep patterns (i.e. Sundowner’s syndrome)- open blinds/turn on lights during the day; limit naps and caffeine; look for meds that cause sleeping problems; keep the pt very active during the day; create a bedtime ritual
As the disease progresses- usually need adult daycare and often need institutionalization; nutrition (thickened liquids, supplements); infection prevention (UTI, pneumonia); total care (turn q2hr, suction, personal care); caregiver support; watch for depression in pt and family.

Question 12

Second leading cause of dementia. Develops more quickly. Associated with CVA/TIAs. Depression common

Answer 12

Vascular dementia

Question 13

Decline similar to AD with addition of sleep disturbances. Visual hallucinations and parkinsonian-like movements (rigidity). Dysphagia

Answer 13

Dementia with Lewy Bodies (DLB)

Question 14

Localized atrophy of frontal and temporal lobes. Behavior and personality changes. 1* progressive aphasia

Answer 14

Frontotemporal lobar degeneration

Question 15

Occurs when 2 or more types of dementia are present at the same time. Characterized by hallmark abnormalities of AD and another type of dementia such as vascular dementia or DLB

Answer 15

Mixed dementia

Question 16

Rare but reversible. Obstruction in flow of CSF. Enlarged ventricles but no rise in ICP. Associated with traumatic head injury, meningitis, encephalitis. Triad of sx: gait disturbance, urinary incontinence, and cognitive dysfunction

Answer 16

Normal pressure hydrocephalus

Question 17

Rare and fatal brain disorder. C/b a prion protein (found in beef from animals infected with “mad cow disease”). Risk of contracting it is extremely rare. Supportive tx.

Answer 17

Creutzfeldt-Jakob disease (CJD)

Question 18

A state of temporary but acute mental confusion, is common, life-threatening, and possibly preventable syndrome. Most frequent cx of hospitalization in older pts. Reversible impairment of cerebral oxidative metabolism and multiple NT abnormalities. Impairment such as confusion, hallucination, or delusion is not a normal aspect of aging and may represent an active disease process. Change in LOC and cognition that develops over a short period of time. Sx may fluctuate over time. Can be superimposed on dementia. Reversible cause.
Rapid onset. Lucid intervals. Duration of hours to 1 month. Fluctuates in severity. Mental status testing improves when pt recovers. C/b an interaction of their underlying condition with a precipitation event.

Answer 18

Delirium

Question 19

Mnemonic for causes of delirium

Answer 19

Dementia, dehydration 
Electrolyte imbalances, emotional stress 
Lung, liver, heart, kidney, brain
Infection, ICU
Rx drugs 
Injury, immobility 
Untreated pain, unfamiliar environment 
Metabolic disorders

Question 20

Nursing care for dementia

Answer 20

Careful assessment (use Mini-Mental State Exam). CT/MRI to look for vascular changes. Similar as care for AD

Question 21

Nursing care for delirium

Answer 21

Recognition of high risk pts. Careful assessment (use confusion assessment method). Labs, CT/MRI only if injury suspected. Eliminate precipitating factors. Reorient frequently. Calm, safe environment. Personal contact. Eyeglasses, hearing aids. Drugs only for severe anxiety.

Question 22

Manifestations are often confused with dementia (disorders often occur together. Intellectual deterioration can be extreme). Memory and functional impairment can be significant if severe. Treatable.

Answer 22

Depression

Question 23

AD caregiver support

Answer 23

AD disrupts all aspects of personal and family life (very stressful). Caregivers also exhibit adverse consequences (employment and emotional and physical strain. Can result in family conflict and strain). Caregiving increases risk for development of dementia (chronic and severe stress can affect the hippocampus [region of the brain responsible for memory]).

Question 24

A pt with Alzheimer’s disease has a nursing dx of impaired memory r/t the effects of dementia. What is an appropriate nursing intervention for the pt?

a) let the pt know what behavior is socially appropriate.
b) assist the pt with all self-care to maintain self-esteem
c) maintain familiar routines of sleep, meals, drug administration, and activities
d) At every encounter with the pt, ask the day, time, and place to promote orientation

Answer 24

c) maintain familiar routines of sleep, meals, drug administration, and activities