Dementia

Progressive, degenerative brain dysfunction, including

deterioration in memory, concentration, language skills,
visuospatial skills, and reasoning
Progressive forgetfulness, memory loss, and loss of
other cognitive function
Interferes with a persons daily functioning
Not considered a normal part of aging
Dementia: Background
4 million older adults have some form of dementia
How is dementia different from depression and
delirium?
Slower onset
Progressive, not variable
Irreversible
Different causes
Lowest MMSE
Risk Factors for Dementia
Age
Family history
Genetic factors
Head trauma
Vascular disease
Infections
Other modifiable factors
Maintain ideal body weight
Exercise
Avoid smoking
Control hyperlipidemia and hypertension
Exercising the brain with lifelong cognitive activity may help
lower the risk of dementia
Causes of Dementia
Drugs
Environmental
Metabolic
Eyes/Ears sensory deprivation
Nutrition
Trauma/Tumor
Infections
Alcohol abuse or intoxication
Assessing for Dementia
Mini-COG
A reliable and valid instrument used to screen for
cognitive impairment consisting of 3-item recall test
and a clock-drawing test (CDT)
It is evidence-based, easy to administer, and not too
taxing for patient or provider
Is a screening test, doesnt provide diagnosis
CLOCK DRAWING TEST
Types of Dementia
Alzheimers #1
Vascular
Parkinsons
Lewy body
Frontal lobe dementia
Lose inhibition and executive functioning skills earlier than
AD
Normal pressure hydrocephalus
Rare but partially reversible with surgery
Acute onset of a triad of symptoms
slowed cognitive processes, gait disturbances, UI
Alzheimers Disease (AD)
The most common type of dementia seen in
older adults
Advanced age is the single most significant risk
factor
Estimated 5.2 million Americans affected in
2008
5 million over age 65
Estimated to reach 7.7 million in 2030
Projected 11 16 million by 2050
Alzheimers Disease (AD)
May live from 3 20 years or more after
diagnosis
Seventy percent of people with AD live at home
until the latest stages, being cared for mainly by
family members (Alzheimers Association, 2005
Costs $61 billion annually
Expected to exceed $163 billion/yr by 2050
Characterized by progressive memory loss
Average life span of 8 years after dx
Alzheimers Disease (AD)
Two types of abnormal lesions in the brains of
individuals with Alzheimer's disease:
Plaques
Neurofibrillary tangles
Definitive diagnosis is still through biopsy
Dx: early dx is important to maximize function
and QOL as long as possible
Diagnosing Alzheimers
Memory impairment alone doesnt indicate AD
Requires one of the following features
Impaired executive function
Aphasia word finding difficulties
Apraxia cannot carry out motor skills
Agnosia cannot name familiar object
Must rule out delirium, depression, other CNS
disorders, medication side effects, and other medical
conditions first!
Diagnosing Alzheimers (contd)
H & P
Review of medications
Laboratory testing
Neuropsychological screening/testing
Mini Mental Status Exam (MMSE) no longer available in
public domain
Mini-Cog
Imaging
PET scan to rule out dementia
Medications for Dementia
Medications slow progression but do not stop decline
over time
Cholinesterase Inhibitors (CEIs)
donepezil (Aricept)
rivastigmine (Exelon)
galantamine (Razadyne)
N-methyl-D-aspartate (NMDA) Receptor Antagonist
memantine (Namenda) approved for moderate to late stage
Anticholinergics can worsen cognitive function
AD: Warning Signs
Ten warning signs of Alzheimers Disease
Memory loss
Difficulty performing familiar tasks
Problems with language
Disorientation to time and place
Poor or decreased judgment
Problems with abstract thinking
Misplacing things
Changes in mood or behavior
Changes in personality
Loss of initiative
AD: Treatment
Medications (Aricept, Namenda) may help slow
progress but does not change disease course
Symptom management
Behavior
Safety
Nutrition
Hygiene
As dementia progresses, likely to be institutionalized
Support for family/caregiver
Support groups
Respite
Be aware of caregiver strain
Other Types of Dementias
Vascular dementia results from multiple
cerebral infarctions
more rapid and more predictable than AD
risk factors: HTN, hyperlipidemia, history of stroke,
smoking
Lewy body dementia presence of Lewy body
substance in cerebral cortex many
gerontologists consider this the same type of
dementia as AD
Other Types of Dementias
Creutzfeld-Jacob disease (Mad Cow)
Rare brain disorder
Rapid onset and progression
Slow virus
Familial tendency
Destruction of neurons in cortex
Symptoms more varied than AD
Death with 1 year
Other Types of Dementias
Parkinsons disease
Small percentage of those with dementia are this
type
Degeneration of neurons due to lack of
neurotransmitter, Dopamine
Delirium: Background
Also called acute confusion
Occurs in 22- 38% of older patients in the
hospital
Occurs in as many as 40% of long-term care
residents
Associated with increased length of stays in the
hospital and higher mortality rates
Delirium: Background
Altered level of consciousness
Temporary
Reversible
Many treatable causes
Need to distinguish delirium, depression, and
dementia
Delirium
Treatment of delirium requires the diagnosis
and treatment of the underlying physiological
problem while using pharmacologic and non-
pharmacologic interventions to maintain patient
safety and return the patient to the pre-delirium
state (Mauk, pg. 445).
Delirium: Potential causes
Fluid and electrolyte
imbalances
Infection
CHF
Medications
Pain
Impaired cardiac or
respiratory function
Emotional stress
Unfamiliar surroundings
Malnutrition
Anemia
Dehydration
Alcoholism
Hypoxia
Causes of Delirium
Drugs
Electrolytes
Liver failure
Infection
Renal failure
Impaction
UTI or urinary retention
Metastasis
Delirium: Signs/Symptoms
Sudden onset
Disorientation to time and place
Altered attention
Impaired memory
Mood swings
Poor judgment
Altered LOC
Decreased MMSE score (less than depression, but
more than dementia)
Delirium: Treatment
Detect promptly by good H & P
MMSE, GDS and CAM are good assessment
tools
CBC, Lytes, LFTs, Renal function, Serum
calcium and glucose, UA, CXR, EKG, O2 Sat
For all Older Adults with
Cognitive Impairment
Maintain privacy and dignity
Realize their value as a unique individual
Maintain independence for as long as possible
Minimize restraints find other answers to
address wandering
Continue human contact and environmental
stimulation Repetition
Delirium
Acute confusion
Four basic features
Acute onset or fluctuating course
Inattention
Disorganized thinking
Altered level of consciousness
Primary treatment is to eliminate the cause
Delusion of theft and phantom intruder
Potential Causes of Delirium
Inadequate or inappropriate
pain control
Medications (including new
or change in dose)
Fecal impaction
Infection/fever
Injury/severe illness
Electrolyte imbalance
(glucose, Na+)
Dehydration
Change in surroundings
Hypoxia
Age
Male gender
Cognitive impairment
(dementia)
Hypotension
Malnutrition
Depression
Alcoholism
Restraints
Multiple IVs, lines, tubes
Assessing for Delirium
Delirium is often unrecognized by clinicians
Hence patients should be assessed frequently using a
standardized tool to facilitate prompt identification and
management of delirium and underlying etiology
Confusion Assessment Method (CAM)
Sensitivity of 94-100%
Specificity of 89-95%
CAM The Short Version
1. Acute Onset
Is there evidence of an acute change in mental status
from baseline?
2. Inattention
Does the patient have difficulty focusing attention;
easily distractible; have difficulty keeping track of
what is being said?
Does this behavior fluctuate; come and go or
increase and decrease in severity?
3. Disorganized thinking
Is the patients thinking disorganized or incoherent, such as
rambling or irrelevant conversation, unclear or illogical flow
of ideas, or unpredictable switching from subject to subject?
4. Altered level of consciousness
Overall, how would you rate this patients level of
consciousness?
Alert = normal
Vigilant = hyper-alert, overly sensitive to environmental stimuli,
startled very easily
Lethargic = drowsy, easily aroused
Stupor = difficult to arouse
Coma = unarousable
Uncertain
CAM Continued
Should assess patient on admission and during
each shift
Engage pt. in conversation for about one
minute. Ask:
What brought you to the hospital?
How are you feeling now?
Delirium is identified only if there is evidence of
features 1 and 2, and either 3 or 4 (or both)
Nursing Interventions/Strategies
Use general strategies (as appear in next slides)
Address specific issues/behaviors
Wandering
Aggression
Restlessness
Agitation
Physical comfort
Pain