Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. (Relates to Chapter 60, “Nursing Management: Alzheimer’s Disease, Dementia, and Delirium” in the textbook)

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Three most common in adults  Dementia  Delirium—acute confusion  Depression Often associated with dementia and delirium 2

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Syndrome characterized by dysfunction or loss of  Memory  Orientation  Attention  Language  Judgment  Reasoning 3

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Other characteristics that can manifest  Personality changes  Behavioral problems such as Agitation Delusions Hallucinations 4

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Problems disrupt individual’s  Work  Social responsibilities  Family responsibilities  Physicians usually diagnose when two or more brain functions are significantly impaired. 5

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Not a normal part of aging  Affects 15% of older Americans  ~100 causes of dementia  >60% of patients with dementia have Alzheimer’s disease (AD).  Half of the patients in most long-term care facilities have dementia. 6

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Due to treatable and nontreatable conditions  Two most common causes  Neurodegenerative conditions 60% to 80% of cases  Vascular disorders 7

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Vascular dementia  Loss of cognitive function due to brain lesions caused by cardiovascular disease Ischemic lesions Ischemic-hypoxic lesions Hemorrhagic brain lesions 8

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Vascular dementia (cont’d)  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 9

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Predisposed risks of dementia  Smoking  Cardiac dysrhythmias  Hypertension  Hypercholesterolemia  Diabetes mellitus  Coronary artery disease  Metabolic syndrome 10

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Onset of dementia depends on cause.  Insidious and gradual  Abrupt Vascular dementia tends to be abrupt or progress in a stepwise pattern. 11

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Cause of dementia difficult to distinguish on the basis of symptoms alone 12

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Acute or subacute pattern of change may be more indicative of an infectious or metabolic change. 13

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Classifications  Mild  Moderate  Severe 14

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Initial symptoms are related to changes in cognitive function.  Family members often report to doctor  Memory loss  Mild disorientation  Trouble with words and/or numbers 15

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Focused on cause  Reversible or nonreversible  Thoroughly evaluate patient history  Medical  Neurologic  Psychologic 16

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Physical examination to rule out other medical conditions  Screen for  Cobalamin (vitamin B12) deficiencies  Hypothyroidism  Possibly neurosyphilis 17

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Mild cognitive impairment  May be able to compensate, making diagnoses difficult  American Academy of Neurology recommends Cognitive evaluation Ongoing clinical monitoring due to increased risk of developing dementia 18

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Mental status testing  Mini-Mental State Examination  Commonly used tool  Assesses cognitive functioning 19

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Depression often mistaken for dementia and vice versa  Manifestations of depression, especially in older adults  Sadness  Difficulty thinking and concentrating 20

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Manifestations of depression (cont’d)  Fatigue  Apathy  Feelings of despair  Inactivity 21

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Computed tomography (CT)  Magnetic resonance imaging (MRI)  To characterize central nervous system (CNS) changes:  Single-photon emission computed tomography (SPECT)  Positron emission tomography (PET) 22

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  State of cognitive and functional ability below defined norms that does not meet criteria for dementia  Memory impaired but function normally 23

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Characteristics  Memory complaint  Abnormal memory for age  Intact activities of daily living  Normal general cognitive functioning 24

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  10% to 20% of individuals >65 years old have MCI.  15% of those with MCI will develop dementia. 25

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Presently no widely accepted guidelines for treatment  Insufficient evidence  Research is being conducted.  Primary treatment consists of ongoing monitoring.  Observe for 10 warning signs of AD. 26

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Chronic, progressive, degenerative disease of the brain  Most common form of dementia  ~5.3 million Americans suffer from AD. 27

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Economic cost of care in the United States is at least $148 billion annually.  Burden on patient, family, caregivers, and society as a whole  Women more likely to develop AD 28

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Exact cause is unknown.  Age is most important risk factor.  Familial Alzheimer’s disease 29

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Changes in brain structure and function  Amyloid plaques  Neurofibrillary tangles  Loss of connections between cells and cell death 30

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 31 Fig Pathologic changes in Alzheimer’s disease. A, Plaque with central amyloid core (white arrow) next to a neurofibrillary tangle (black arrow) on the histologic specimen from a brain autopsy. B, Schematic representation of amyloid plaque and neurofibrillary tangle.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 32

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  People develop some plaques in their brain tissue.  In AD plaque is greater in certain parts.  Clusters of insoluble plaque β-amyloid, other proteins, remnants of neurons, non-nerve cells, and other cells 33

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 34 Fig Current etiologic theories for the development of Alzheimer’s disease. A, Abnormal amounts of β-amyloid are cleaved from the amyloid precursor protein (APP) and released into the circulation. The β-amyloid fragments come together in clumps to form plaques that attach to the neuron. Microglia react to the plaque and an inflammatory response results. B, Tau proteins provide structural support for the neuron microtubules. Chemical changes in the neuron produce structural changes in tau proteins. This results in twisting and tangling (neurofibrillary tangles).

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Where plaques develop in the parts of the brain used for  Memory  Cognitive function Hippocampus  Eventually develops in the cerebral cortex 35

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Neurofibrillary tangles  Abnormal collections of twisted protein threads inside nerve cells  Main component is a protein called tau. 36

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Gradual loss of connections between neurons  Leads to damage and then death of neurons  Affected parts of brain shrink. Brain atrophy Significant in final state of AD 37

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 38 Fig Effects of Alzheimer’s disease on the brain. This figure shows slices from two brains. On the left is a normal brain from a 70-year-old; on the right is the same region from a 70-year-old with Alzheimer’s disease. The diseased brain is atrophic with loss of cortex and white matter, most marked in the hippocampal region (H).

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  May play significant role in how the brain processes β-amyloid protein  ↑ β-amyloid protein  ↑ risk  First gene associated with AD  Epsilon (E)-4 allele of apolipoprotein E (ApoE) gene on chromosome 19 39

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Researchers interested in link between inflammation and AD  Theory suggests that formation of free radicals damages neurons  loss of function  Oxidative damage leads to inflammation. 40

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Researchers (cont’d)  Another area is focusing on link between cardiovascular disease and AD.  Common risk factors for heart disease are associated with increased risk of AD. 41

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Pathologic changes precede clinical manifestations by 5 to 20 years.  Alzheimer’s Association has developed a list of 10 warning signs. 42

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Early signs of Alzheimer’s disease  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 43

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Early signs of AD (cont’d)  Misplacing things  Changes in mood or behavior  Changes in personality  Loss of initiative 44

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Categorized similarly to those for dementia  Mild  Moderate  Late  Progression is variable from person to person and ranges from 3 to 20 years. 45

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Initial sign is subtle deterioration in memory.  Inevitably progresses to more profound memory loss  Manifestations easier to recognize when family member or patient seeks medical help. 46

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Recent events and new information cannot be recalled.  Behavioral manifestations are not intentional or controllable because of ongoing loss of neurons.  Some develop psychotic manifestations. 47

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  In AD that has progressed,  Dysphasia  Apraxia  Visual agnosia  Dysgraphia  Some long-term memory loss  Wandering 48

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Late stages  Long-term memory loss  Unable to communicate  Cannot perform activities of daily living (ADLs)  Patient may be unresponsive and incontinent, requiring total care. 49

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Diagnosis of exclusion  No single clinical test  Made once all other possible conditions causing cognitive impairment have been ruled out 50

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Comprehensive patient evaluation  Complete health history  Physical examination  Neurologic assessment  Mental status assessment  Laboratory tests 51

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Brain imaging tests  CT  MRI  SPECT  PET  Allow monitoring in early stages and treatment response 52

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 53 Fig Positron emission tomography (PET) scan can be used to assist in the diagnosis of Alzheimer’s disease (AD). 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.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Neuropsychologic testing can help document degree of cognitive impairment.  Mini-Mental State Examination (MMSE)  Also used to determine a baseline from which to evaluate change over time 54

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  No cure  Collaborative management aimed at  Improving or controlling decline in cognition  Controlling undesirable behavioral manifestations  Providing care for the caregiver 55

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Cholinesterase inhibitors  Used to treat mild and moderate dementia  Block cholinesterase, enzyme responsible for breaking down acetylcholine  Improve or stabilize cognitive decline but do not cure or reverse 56

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 57 Fig Mechanism of action of cholinesterase inhibitors. 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.

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Memantine (Namenda) protects nerve cells against excess amounts of glutamate. 58

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Depression often treated with selective serotonin reuptake inhibitors  May help with sleep problems  Antiseizure drugs  Manage behavioral problems  Stabilize mood 59

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Subjective data  Past health history  Medications  Health perception  Nutritional state  Eliminating properly—incontinence 60

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Subjective data (cont’d)  Activity-exercise habits and state  Sleep-rest pattern  Cognitive-perceptual state 61

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Objective data  Disheveled appearance  Neurologic Early, middle, late 62

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Impaired memory  Self-care deficit  Risk for injury  Grief  Wandering 63

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Overall goals for patient  Maintain functional ability as long as possible.  Maintain safe environment.  Personal care needs met  Dignity maintained 64

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Overall goals for caregiver of a patient  Reduce caregiver stress.  Maintain personal, emotional, and physical health.  Cope with long-term effects associated with caregiving. 65

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  No known method to reduce risk of AD  Antioxidants may be of benefit.  Promote safety in physical activities and driving.  Recognize and treat depression.  Genetic testing not performed on a regular basis 66

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Early recognition and treatment important  Nurse should inform patients and family regarding early warning signs. 67

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Diagnosis traumatic for patient and family  Patient often responds with  Depression  Denial  Anxiety and fear  Isolation 68

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Nurse should assess for depression and suicidal ideation.  Counseling and antidepressants may be indicated.  Family members may be in denial, delaying critical early care. 69

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Nurse should also assess family members and their ability to cope and accept diagnosis.  Ongoing monitoring important  Work in collaboration with patient’s caregiver.  Teach caregiver how to manage care. 70

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  AD patients subject to other health care problems  Inability to communicate symptoms places responsibility on caregiver and health care professionals.  Hospitalization can precipitate a worsening of disease or delirium. 71

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Family members and friends care for most AD patients in their homes.  Various facilities should be evaluated.  Consider stage of AD patient when choosing.  Nursing care intensifies over time. 72

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  In early stages, memory aids may provide benefit.  Drugs must be taken regularly.  Drug compliance can be challenging.  Adult day care can provide  Caregiver respite  Stimulation for AD patient 73

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Demands on caregiver can exceed resources, and total care is needed.  Person may need to be placed in a long-term care facility.  Special units for AD patients are growing in long-term care facilities.  Emphasis is on safety. 74

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Occur in 90% of AD patients  These problems include  Repetitiveness  Delusions  Illusions  Hallucinations 75

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Problems (cont’d)  Agitation  Aggression  Altered sleep patterns  Wandering  Resisting care 76

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Behavior is unpredictable.  Can be challenging for caregiver  Behaviors are not intentional and are difficult to control.  Often lead to placement in institutional settings 77

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Are a patient’s way of responding to precipitating factor  Pain  Frustration  Temperature extremes  Anxiety 78

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Assess patient’s  Physical status  Environment  Reassure patient about his or her safety. 79

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Nursing strategies to address difficult behaviors  Redirection  Distraction  Reassurance  Do not threaten or restrain patient if frustrated. 80

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  AD patients can experience sundowning.  Specific type of agitation  Patient becomes more confused and agitated in late afternoon or evening.  Cause is unclear.  Remain calm and avoid confrontation. 81

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Nursing interventions: sundowning  Create a quiet, calm environment.  Maximize exposure to daylight.  Evaluate medications.  Limit naps and caffeine.  Consult health care provider on drug therapy. 82

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Risks  Injury from falls  Ingesting dangerous substances  Wandering  Injury to others and self  Fire or burns  Inability to respond to crisis 83

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Special attention to home environment to decrease risk  Supervision is needed. 84

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Nurse can help caregiver in assessing home environment for safety risks.  Wandering is major concern.  AD patient can register with Safe Return. 85

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Pain should be recognized and treated promptly.  Monitor patient’s response.  Patients can have difficulty communicating complaints.  May exhibit changes in behavior 86

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Undernutrition problem in middle and late stages  Loss of interest in food  Decreased ability to self-feed  Co-morbid conditions 87

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  When chewing and swallowing become difficult, use  Pureed food  Thickening liquids  Nutritional supplements  Quiet and unhurried environment  Easy-grip utensils 88

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Offer liquids frequently.  Finger foods may allow self-feeding.  Short-term possibilities  Nasogastric (NG) feedings  Percutaneous endoscopic gastrostomy (PEG) tube 89

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  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. 90

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Common  Urinary tract infection  Pneumonia Ultimate cause of death in many AD patients  Manifestations need prompt evaluation and treatment. 91

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  In late stages, patient are at risk for skin breakdown.  Incontinence, immobility, and undernutrition  Tend to rashes, areas of redness.  Keep skin dry and clean.  Change patient’s position regularly. 92

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Urinary and fecal incontinence during middle to late stages  Habit or behavioral retraining may ↓ episodes  Constipation may relate to immobility, dietary intake, ↓ fluids 93

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  AD disrupts all aspects of personal and family life.  Very stressful  Caregivers also exhibit adverse consequences. 94

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Work with caregiver to  Assess stressors  Identify coping strategies  Find a support group Local Alzheimer Association chapter 95

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Patient goals  Functions at highest level of cognitive ability  Performs self-care, bathing, dressing, and toileting with assistance as needed  Experiences no injury  Uses assistive devices appropriately for ambulation support 96

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Patient goals (cont’d)  Uses effective coping strategies to manage grief related to diagnosis of AD  Verbalizes reality of health situation  Remains in restricted area during ambulation and activity 97

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Lewy body dementia (LBD)  Characterized by presence of Lewy bodies in brainstem and cortex  Common cause of dementia  Often unrecognized 98

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  LBD (cont’d)  Symptoms of Parkinsonism Hallucinations Short-term memory loss Unpredictable cognitive shifts Sleep disturbances 99

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  LBD (cont’d)  Dementia plus two of the following indicates a possible diagnosis: Extrapyramidal signs such as bradykinesia, rigidity, and postural instability, but not always a tremor Fluctuating cognitive ability Hallucinations 100

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  LBD (cont’d)  Medications determined on an individual basis  Standard treatment plan has not been determined.  Nursing care for LBD patients relates to management of dementia. 101

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Creutzfeldt-Jakob disease (CJD)  Rare and fatal brain disorder  Caused by a prion protein 102

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  CJD (cont’d)  Earliest symptoms Memory impairment Behavior changes 103

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  CJD (cont’d)  Disease progresses rapidly. Mental deterioration Involuntary movements Weaknesses in limbs Blindness Eventual coma  No diagnosis or treatment 104

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Pick’s disease  Type of frontotemporal dementia  Rare brain disorder  Characterized by Disturbances in behavior Sleep Personality Eventual memory loss 105

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Pick’s disease (cont’d)  Major distinguishing characteristic is marked symmetric lobar atrophy of temporal and/or frontal lobes.  Relentless progression 106

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Normal-pressure hydrocephalus  Uncommon disorder  Characterized by obstruction in the flow of CSF, causing a buildup of fluid in brain 107

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  Normal-pressure hydrocephalus (cont’d)  Symptoms Dementia Urinary incontinence Difficulty in walking  Meningitis, encephalitis, or head injury may cause condition. 108

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. The daughter of a patient with early familial Alzheimer’s disease (AD) asks how AD can be detected. The nurse describes early warning signs of AD, including: 1. Forgetting a colleague’s name at a party. 2. Repeatedly misplacing car keys or a wallet. 3. Leaving a pot on the stove that boils dry and burns. 4. Having no memory of preparing a meal and forgetting to serve or eat it. Audience Response Question 109

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. A patient with Alzheimer’s disease has a nursing diagnosis of impaired memory related to effects of dementia. An appropriate nursing intervention for the patient is to: 1. Let the patient know what behavior is socially appropriate. 2. Assist the patient with all self-care to maintain self- esteem. 3. Maintain familiar routines of sleep, meals, drug administration, and activities. 4. At every encounter with the patient, ask the day, time, and place to promote orientation. Audience Response Question 110

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 111

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  72-year-old man was brought in by his daughter to see his primary physician.  He was asked to retire because of erratic performance at work. 112

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  He has had no appetite or energy since wife’s death 6 months ago.  He recently lost his car downtown and had to take a cab home. 113

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc.  He is unable to recognize surroundings.  Today, he is unshaven with oversized slacks and a worn shirt. 114

Copyright © 2011, 2007 by Mosby, Inc., an affiliate of Elsevier Inc. 1. What possible problems do his symptoms suggest? 2. What important teaching should you do with him and his daughter? 115