Dementia

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Dementia Nursing Care Management and Care Plans

“Maud Shade was eighty when a sudden hush
Fell on her life. We saw the angry flush
And torsion of paralysis assail
Her noble cheek. We moved her to Pinedale,
Famed for its sanitarium. There she’d sit
In the glassed sun and watch the fly that lit
Upon her dress and then upon her wrist.
Her mind kept fading in the growing mist.
She still could speak. She paused, and groped, and found
What seemed at first a serviceable sound,
But from adjacent cells impostors took
The place of words she needed, and her look
Spelt imploration as she fought in vain
To reason with the monsters in her brain.”
― Vladimir Nabokov, Pale Fire

What is Dementia?

Dementia is defined by a loss of previous levels of cognitive, executive, and memory function in a state of full alertness (Bourgeois, Seaman, & Servis, 2008).

  • Dementia has a slow, insidious onset, and is chronic, progressive, and irreversible.

Statistics and Incidences

Cases of dementia are increasing due to longer life expectancy of the world population.

  • There are four clinical dementia syndromes accounting for 90% of all cases after excluding other common reversible causes of cognitive impairment.
  • The rise in dementia and Alzheimer’s disease is alarming and is expected to double every 20 years, from 47 million people in 2015 to 75 million people in 2030 and 131 million in 2050.

Causes

Following are major etiologic categories for the syndrome of dementia:

  • Dementia of the Alzheimer’s type. The exact disease of Alzheimer’s disease is unknown, but several theories have been proposed, such as reduction in brain acetylcholine, the formation of plaques and tangles, serious head trauma, and genetic factors. Pathologic changes in the brain include atrophy, enlarged ventricles, and the presence of numerous neurofibrillary plaques and tangles.
  • Vascular Dementia. This type of dementia is caused by significant cerebrovascular disease. The client suffers the equivalent of small strokes caused by arterial hypertension or cerebral emboli or thrombi, which destroy many areas of the brain. The onset of symptoms is more abrupt than in AD and runs a highly variable course, progressing in steps rather than a gradual deterioration.
  • Dementia due to HIV disease. The immune dysfunction associated with human immunodeficiency virus (HIV) can lead to brain infections by other organisms. HIV also appears to cause dementia directly.
  • Dementia due to head trauma. The syndrome of symptoms associated with dementia can be brought on by a traumatic head injury.
  • Dementia due to Lewy Body Disease. Clinically, Lewy Body disease is fairly similar to AD,; however, it tends to progress more rapidly, and there is an earlier appearance of visual hallucinations and parkinsonian features (Rabins et al, 2006). This disorder is distinctive by the presence of Lewy bodies-eosinophilic inclusion bodies- seen in the cerebral cortex and brainstem (Andreasen and Black, 2006).
  • Dementia due to Parkinson’s disease. Parkinsons’s disease is caused by a loss of nerve cells in the substantia nigra of the basal ganglia. The symptoms of dementia associated with Parkinson’s disease closely resemble those of AD.
  • Dementia due to Huntington’s disease. This disease is transmitted as a Mendelian dominant gene, and damage occurs in the areas of the basal ganglia and the cerebral cortex.
  • Dementia due to Pick’s disease. Pathology occurs from atrophy in the frontal and temporal lobes of the brain. Symptoms are strikingly similar to those of AD, and Pick’s disease is often misdiagnosed as AD.
  • Dementia due to Creutzfeldt-Jakob disease. This form of dementia is caused by a transmissible agent known as a “slow virus” or prion. The clinical presentation is typical of the syndrome of dementia and the course is extremely rapid, with progressive deterioration and death within one year after onset.
  • Dementia due to other general medical conditions. A number of other general medical conditions can cause dementia. Some of these include endocrine conditions, pulmonary disease, hepatic or renal failure, cardiopulmonary insufficiency, fluid and electrolyte imbalances, nutritional deficiencies, frontal or temporal lobe lesions, uncontrolled epilepsy, central nervous system or systemic infections, and other neurological conditions.
  • Substance-induced Persisting Dementia. This type of dementia is related to the persisting effects of substances such as alcohol, inhalants, sedatives, hypnotics, anxiolytics, other medications, and environmental toxins.

Clinical Manifestations

The following symptoms have been identified with the syndrome of dementia:

  • Memory impairment. Impaired ability to learn new information or to recall previously learned information.
  • Impairment in abstract thinking, judgment, and impulse control.
  • Impairment in language ability, such as difficulty naming objects. In some instances, the individual may not speak at all (aphasia).
  • Personality changes are common.
  • Impaired ability to perform motor activities despite intact motor abilities (apraxia).
  • Disorientation. Patient may feel disoriented regarding current place, time, o names of persons they are close with.
  • Wandering. Because of disorientation, patient with dementia may often wander from one place to another.
  • Delusions are common (particularly delusions of persecution).

Assessment and Diagnostic Findings

Laboratory tests can be performed to rule out other conditions that may cause cognitive impairment.

  • Complete blood cell count (CBC). Abnormalities in complete blood cell count and cobalamin levels require further workup to rule out hematologic disease.
  • Liver enzyme levels. Abnormalities found in screening of liver enzyme levels require further workup to rule out hepatic disease.
  • Thyroid-stimulating hormone (TSH) levels. Abnormalities in thyroid-stimulating hormone levels require further workup to rule thyroid disease.
  • Rapid plasma reagent. Abnormalities in rapid plasma reagent (RPR) require further workup to rule out syphilis.
  • HIV serology. Abnormalities in HIV serology and/or PCR require further workup to rule out HIV/AIDS.
  • Paraneoplastic antibodies. Abnormalities in paraneoplastic antibodies require further workup to rule out autoimmune encephalitis.
  • CSF proteins. Abnormalities in CSF proteins tau, P-tau, and 14-3-3 require further workup to rule out Creutzfeldt-Jakob disease.

Medical Management

To date, only symptomatic therapies are available and thus do not act on the evolution of the disease.

  • Experimental therapies. A variety of experimental therapies have been proposed for dementia; these include anti-amyloid therapy, reversal of excess tau phosphorylation, estrogen therapy, vitamin E therapy, and free radical scavenger therapy; however, results of these studies have yielded disappointing results.
  • Dietary measures. There are no special dietary considerations for dementia; however, caprylidene (Axona) is a prescription medical food that is metabolized into ketone bodies, and the brain can use these ketone bodies for energy when its ability to process glucose is impaired. Brain-imaging scans of older adults and persons with dementia reveal dramatically decreased uptake of glucose.
  • Physical activity. Routine physical activity and exercise may have an impact on dementia progression and may perhaps have a protective effect on brain health; the patient’s surroundings should be safe and familiar; maintaining structured routines may be helpful to decrease patient’s stress in regard to meals, medication, and other therapeutic activities aimed at maintaining cognitive functioning.

Pharmacological Management

The mainstay of therapy for patients with dementia is the use of centrally acting cholinesterase inhibitors to attempt to compensate for the depletion of acetylcholine in the cerebral cortex and hippocampus.

  • Cholinesterase inhibitors. Cholinesterase inhibitors are used to palliate cholinergic deficiency.
  • N-Methyl-D-Aspartate antagonists. The only drug in the N-methyl-D-aspartate (NMDA) antagonist class that is approved by the US Food and Drug Administration is memantine; this agent may be used alone or in combination with AChE inhibitors.
  • Nutritional supplement. Medical foods are dietary supplements intended to compensate specific nutritional problems caused by a disease or condition; caprylidene is indicated for clinical dietary management of metabolic processes associated with mild to moderate dementia.

Nursing Management

The nursing management of a client with dementia include the following:

Nursing Assessment

Assessment of a client with dementia include the following:

  • Psychiatric interview. The psychiatric interview must contain a description of the client’s mental status with a thorough description of behavior, flow of thought and speech, affect, thought processes and mental content, sensorium and intellectual resources, cognitive status, insight, and judgment.
  • Serial assessment. Serial assessment of psychiatric status is necessary for determining fluctuating course and acute changes in mental status, interviews with family members should be included and can be crucial in the treatment of infants and young children with cognitive disorders.

Nursing Diagnosis

Nursing diagnoses that you can use for developing nursing care plans for patients with dementia include:

  • Risk for trauma related to disorientation or confusion.
  • Risk for self-directed or other-directed violence related to delusional thinking.
  • Chronic confusion related to alteration in structure/function of brain tissue.
  • Self-care deficit related to cognitive impairment.
  • Risk for falls related to cognitive impairment.

Nursing Care Planning and Goals

The major nursing care planning goals for dementia are:

  • Client will accept explanations of inaccurate interpretation within the environment.
  • With assistance from caregiver, client will be able to interrupt non-reality-based thinking.

Nursing Interventions

The nursing interventions for a dementia client are:

  • Orient client. Frequently orient client to reality and surroundings. Allow client to have familiar objects around him or her; use other items, such as a clock, a calendar, and daily schedules, to assist in maintaining reality orientation.
  • Encourage caregivers about patient reorientation. Teach prospective caregivers how to orient client to time, person, place, and circumstances, as required. These caregivers will be responsible for client safety after discharge from the hospital.
  • Enforce with positive feedback. Give positive feedback when thinking and behavior are appropriate, or when client verbalizes that certain ideas expressed are not based in reality. Positive feedback increases self-esteem and enhances desire to repeat appropriate behavior.
  • Explain simply. Use simple explanations and face-to-face interaction when communicating with client. Do not shout message into client’s ear. Speaking slowly and in a face-to-face position is most effective when communicating with an elderly individual experiencing a hearing loss.
  • Discourage suspiciousness of others. Express reasonable doubt if client relays suspicious beliefs in response to delusional thinking. Discuss with the client the potential personal negative effects of continued suspiciousness of others.
  • Avoid cultivation of false ideas. Do not permit rumination of false ideas. When this begins, talk to client about real people and real events.
  • Observe client closely. Close observation of client’s behavior is indicated if delusional thinking reveals an intention for violence. Client safety is a nursing priority.

Evaluation

The outcome criteria for a patient with dementia include:

  • With assistance from caregiver, client is able to distinguish between reality-based and non-reality based thinking.
  • Prospective caregivers are able to verbalize ways in which to orient client to reality, as needed.

Documentation Guidelines

Documentation needed for a client with dementia include the following:

  • Individual findings, including factors affecting, interactions, nature of social exchanges, specifics of individual behavior.
  • Cultural and religious beliefs, and expectations.
  • Plan of care.
  • Teaching plan.
  • Responses to interventions, teaching, and actions performed.
  • Attainment or progress toward the desired outcome.

Practice Quiz: Dementia

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1. Edward, a 66-year-old client with slight memory impairment and poor concentration, is diagnosed with primary degenerative dementia of the Alzheimer’s type. Early signs of this dementia include subtle personality changes and withdrawal from social interactions. To assess for progression to the middle stage of Alzheimer’s disease, the nurse should observe the client for:

A. Occasional irritable outbursts.
B. Impaired communication.
C. Lack of spontaneity.
D. Inability to perform self-care activities.

1. Answer: B. Impaired communication.

  • Option B: Signs of advancement to the middle stage of Alzheimer’s disease include exacerbated cognitive impairment with obvious personality changes and impaired communication, such as inappropriate conversation, actions, and responses.
  • Options A and C: Initially, memory impairment may be the only cognitive deficit in a client with Alzheimer’s disease. During the early stage of this disease, subtle personality changes may also be present. However, other than occasional irritable outbursts and lack of spontaneity, the client is usually cooperative and exhibits socially appropriate behavior.
  • Option D: During the late stage, the client can’t perform self-care activities and may become mute.

2. Nurse Pauline is aware that Dementia, unlike delirium, is characterized by:

A. Slurred speech.
B. Insidious onset.
C. Clouding of consciousness.
D. Sensory perceptual change.

2. Answer: B. insidious onset.

  • Option B: Dementia has a gradual onset and progressive deterioration. It causes pronounced memory and cognitive disturbances.
  • Options A, C, and D: These are all characteristics of delirium.

3. The nurse is aware that the following ways in vascular dementia different from Alzheimer’s disease is:

A. Vascular dementia has more abrupt onset.
B. The duration of vascular dementia is usually brief.
C. Personality change is common in vascular dementia.
D. The inability to perform motor activities occurs in vascular dementia.

3. Answer: A. Vascular dementia has more abrupt onset.

  • Option A: Vascular dementia differs from Alzheimer’s disease in that it has a more abrupt onset and runs a highly variable course.
  • Option B: The duration of delirium is usually brief.
  • Option C: Personality change is common in Alzheimer’s disease.
  • Option D: The inability to carry out motor activities is common in Alzheimer’s disease.

4. A 65 years old client is in the first stage of Alzheimer’s disease. Nurse Patricia should plan to focus this client’s care on:

A. Offering nourishing finger foods to help maintain the client’s nutritional status.
B. Providing emotional support and individual counseling.
C. Monitoring the client to prevent minor illnesses from turning into major problems.
D. Suggesting new activities for the client and family to do together.

4. Answer: B. Providing emotional support and individual counseling.

  • Option B: Clients in the first stage of Alzheimer’s disease are aware that something is happening to them and may become overwhelmed and frightened. Therefore, nursing care typically focuses on providing emotional support and individual counseling.
  • Options A, C, and D: The other options are appropriate during the second stage of Alzheimer’s disease when the client needs continuous monitoring to prevent minor illnesses from progressing into major problems and when maintaining adequate nutrition may become a challenge. During this stage, offering nourishing finger foods helps clients to feed themselves and maintain adequate nutrition.

5. Nurse Kate would expect that a client with vascular dementia would experience:

A. Loss of remote memory related to anoxia.
B. Loss of abstract thinking related to emotional state.
C. Inability to concentrate related to decreased stimuli.
D. Disturbance in recalling recent events related to cerebral hypoxia.

5. Answer: D. Disturbance in recalling recent events related to cerebral hypoxia.

  • Option D: Cell damage seems to interfere with registering input stimuli, which affects the ability to register and recall recent events; vascular dementia is related to multiple vascular lesions of the cerebral cortex and subcortical structure.

References

Sources and references for this study guide for delirium:

  • Black, J. M., & Hawks, J. H. (2005). Medical-surgical nursing. Elsevier Saunders,.
  • Videbeck, S. L. (2010). Psychiatric-mental health nursing. Lippincott Williams & Wilkins.
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