Chapter 16: Cognitive Disorders: Delirium, Dementia, and Amnestic Disorders Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.
2 Dementia Alzheimer’s disease most common form Cause unclear
3 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Etiologic Theories of Alzheimer’s Disease Vascular dementia Angiopathy and blood-brain incompetence Neurotransmitter and receptor deficiencies Abnormal brain proteins and their products Genetic defects
4 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Irreversible Dementias Alzheimer’s Vascular dementia Parkinson’s dementia Pick’s disease Creutzfeldt-Jakob disease Diffuse Lewy body disease Progressive supranuclear palsy Down’s syndrome dementia
5 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Reversible Dementia Vitamin B 12 deficiency Depression
6 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Delirium Short development time Fluctuating consciousness Cognition impaired Disorientation to time and place Inability to focus Incoherent speech Continual aimless activity
7 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Amnestic Disorders Memory disturbance (transient or chronic) related to: Effects of a medical condition Persisting effects of substance use or toxin exposure
8 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Alzheimer’s Disease Stage 1: Mild Insidious changes Recent memory impairment Neologisms Cognitive losses in: Communicating Calculating Recognition Sensory/motor functions intact Self-awareness leads to depression
9 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Alzheimer’s Disease Stage 2: Moderate Cognitive decline increases (amnesia, disorientation, apraxia, aphasia, agnosia, perseveration) Behavior problems (catastrophic reactions, wandering/pacing, sundowning) Self-care deficit Poor judgment Sleep disturbance
10 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Alzheimer’s Disease Stage 3: Severe Loss of meaningful communication Total dependence on caregivers Incontinence Secondary illnesses related to immobility
11 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Caregiver Criteria Knowledge of disease Uses positive interactions during care giving Plans and develops resources for self-care Legal and financial plans for client and self Backup system in case of emergency
12 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment Provide appropriate environment. Establish rapport. Tools: Mini-Mental State Examination (MMSE) Dementia Mood Assessment Scale (DMAS) Blessed Dementia Rating Scale (BDRS)
13 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment of Neurologic Deficits Perception and organization Attention span Language Memory Emotional control Reasoning and judgment
14 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Mood and State of Mind Assessments required before: Admission to a skilled nursing facility Use of psychotropic medication Use of restraint Document: Direct quotes from client MSE results on regular basis
15 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessing for Depression Variable onset, abrupt Reversible with treatment Clear sensorium Normal attention span Selective memory impairment Intact thinking but displays: Hopelessness Helplessness
16 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment of Functional Ability and Behavior Functional ability: ADLs IADLs Behavior related to: Mood Perceptual/cognitive deficit Day/night reversal Poor impulse control
17 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Assessment of Physical Manifestations Altered nutritional status Aspiration Gait changes Feeling cold Incontinence
18 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Nursing Diagnoses Cluster around: Safety and health risks Perceptual/cognitive disturbance Disruption in coping abilities
19 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Outcome Identification Consider: Client outcomes Caregiver outcomes
20 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Planning Consider: Short-term plans Long-term plans
21 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Implementation Inform client/family/caregivers about plan. Promote independence as long as possible. Keep all interactions calm, reassuring. Time activity to coincide with client calm state. Empathize with client’s feelings. Validate client’s feelings with words.
22 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Implementation, cont’d. Maintain client’s self-esteem. Avoid negative responses to failures. Provide simple choices. Provide structured routines. Praise success. Simplify communication.
23 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Implementation, cont’d. Repeat as needed. Break tasks into separate components. Provide short, simple activities. Allow time to be alone. Be flexible to reduce frustration.
24 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Treatment Interdisciplinary team Medication Bedtime sedation, anxiety, aggression, dementia Therapeutic activities
25 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Levels of Care Acute care Day care In-home care Residential care Skilled nursing facility Hospice