1. Confusion and Dementia
Chapter 39
Confusion and Dementia
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2. Cognitive Function and Aging
Changes in the brain and nervous system occur with aging.
Certain diseases affect the brain.
Changes in the brain can affect cognitive function.
Cognitive relates to knowledge.
Cognitive function involves:
Memory
Thinking
Reasoning
Ability to understand
Judgment
Behavior
Review Box 39-1 on p. 612.
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3. Confusion Confusion has many causes. 3 Diseases and infections
Hearing and vision loss
Medication side effects
Brain injury
With aging, there is reduced blood supply to the brain.
Personality and mental changes can result from confusion.
Memory and the ability to make good judgments are lost.
A person may not know people, the time, or the place.
Some people gradually lose the ability to perform daily activities. Behavior changes are common.
The person may be angry, restless, depressed, and irritable.
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4. Delirium
Acute confusion (delirium) occurs suddenly and is usually temporary.
Causes include infection, illness, injury, medications, and surgery.
Treatment is aimed at the cause.
Confusion caused by physical changes cannot be cured.
Some measures help improve function.
Review Box 39-2 on p. 612.
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5. Dementia
Dementia is the loss of cognitive function that interferes with routine personal, social, and occupational activities.
Dementia is not a normal part of aging.
Some early warning signs include:
Recent memory loss that affects job skills
Problems with common tasks
Problems with language; forgetting simple words
Getting lost in familiar places
Misplacing things and putting things in odd places
Personality changes
Poor or decreased judgment
Loss of interest in life
Dementia is a group of symptoms that may occur with certain diseases or conditions.
The person may have changes in personality, mood, or behavior.
Most older people do not have dementia.
If changes in the brain have not occurred, some dementias can be reversed. When the cause is removed, so are the signs and symptoms.
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6. Treatable Causes of Dementia and Permanent Dementia
Treatable causes of dementia include:
Drugs and alcohol
Delirium and depression
Tumors
Heart, lung, and blood vessel problems
Head injuries
Infection
Vision and hearing problems
Permanent dementias result from changes in the brain.
They have no cure.
Alzheimer’s disease is the most common type of permanent dementia.
Function declines over time with permanent dementias.
Review Box 39-3 on p. 613.
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7. Pseudodementia Pseudodementia means false dementia.
The person has signs and symptoms of dementia.
This can occur with delirium and depression.
Delirium and depression can be mistaken for dementia.
Delirium is a state of sudden, severe confusion and rapid brain changes. It is temporary but acute mental confusion.
Delirium signals physical illness in older persons and in those with dementia.
Depression is the most common mental health problem in older persons.
Depression, aging, and some drug side effects have similar signs and symptoms.
In pseudodementia, there are no changes in the brain.
Delirium occurs with physical or mental illness. Usually temporary and reversible, it is common in older persons with acute or chronic illnesses.
Common causes of delirium are infections, heart and lung diseases, poor nutrition, hormone disorders, hypoglycemia, alcohol, and many drugs (including prescription medications).
Delirium is an emergency.
Review Box 39-4 on p. 613.
Depression is often overlooked in older persons. See Chapter 38 for signs and symptoms of depression in older people.
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8. Mild Cognitive Impairment
People with mild cognitive impairment (MCI):
Have ongoing problems with memory, language, and other mental functions
Do not have other losses like confusion, attention problems, and difficulty with language
The problems do not interfere with daily life.
May develop Alzheimer’s disease
Examples of mental functions are attention, judgment, reading, and writing.
The person or others may notice the problems.
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9. Alzheimer’s Disease Alzheimer’s disease (AD) is a brain disease. 9
Nerve cells that control intellectual and social function are damaged and die.
The person has:
Problems with work and everyday functions
Problems with family and social relationships
A steady decline in memory and mental function
The disease is gradual in onset.
AD usually occurs after the age of 60.
The cause is unknown.
The classic sign of AD is gradual loss of short-term memory.
These functions are affected: memory, thinking, reasoning, judgment, language, behavior, mood, and personality.
Nearly half of persons age 85 and older have AD.
A family history of AD increases a person’s risk of developing the disease.
At first, the only symptom may be forgetfulness.
Review Box 39-5 on p. 614.
Review Box 39-6 on p. 615.
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10. Stages of Alzheimer’s Disease
AD is often described in terms of three stages: mild, moderate, and severe.
The Alzheimer’s Association describes seven stages:
No impairment
Very mild cognitive decline
Mild cognitive decline
Moderate cognitive decline
Moderately severe decline
Severe cognitive decline
Very severe decline
AD is often described in terms of three stages. Review Box 39-7 on p. 615 (see Figure 39-3 on p. 616).
In stage 2, the person needs help with activities of daily living (ADL).
Signs and symptoms become more severe as the disease progresses. The disease ends in death.
With mild cognitive decline, family, friends, and others notice problems.
Moderate and moderately severe cognitive decline show progressive losses of memory.
Personality and behavior changes develop with severe cognitive decline.
At the stage of very severe cognitive decline, the person cannot respond to his or her setting, speak, or control movement.
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11. Behaviors and Problems
The following behaviors are common with AD:
Getting upset, worried. or angry more easily, acting depressed
Wandering, pacing a lot of the time
Losing interest in things
Sundowning
Hallucinations
Delusions
Catastrophic reactions
Agitation and restlessness
Aggression and combativeness
Abnormal sexual behaviors
Repetitive behaviors
Screaming and communication problems
Rummaging and hiding things, believing others are hiding things
AD changes how a person behaves and acts. Health-related issues can make the problems worse. According to the National Institute on Aging (NIA), problems in the person’s setting can also aggravate the person’s behavior.
Promoting Safety and Comfort: Behaviors and Problems on p. 616.
Persons with AD are not oriented to person, time, and place.
The disease causes the behaviors. The disease is responsible, not the person.
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12. Behaviors and Problems (Cont’d)
Leaving the center without staff knowledge is called elopement.
With sundowning, signs, symptoms, and behaviors of AD increase during hours of darkness.
A hallucination is seeing, hearing, smelling, or feeling something that is not real.
Delusions are false beliefs.
Paranoia is a disorder of the mind in which the person has false beliefs (delusions) and suspicion about a person or situation.
Review Teamwork and Time Management: Wandering on p. 616.
Review Promoting Safety and Comfort: Paranoia on p. 618.
Review Caring About Culture: Communication Problems on p. 619.
Review Focus on Communication: Communication Problems on p. 619.
Review Box 39-8 on p. 619.
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13. Care of Persons with Alzheimer’s Disease and Other Dementias
Usually the person is cared for at home until symptoms are severe.
Adult day care may help.
Assisted living or nursing center care may be required.
Sometimes hospital care is needed.
The person and family need your support and understanding.
Currently AD has no cure.
Over time, persons with AD depend on others for care.
You must treat these persons with dignity and respect. They have the same rights as persons who are alert and active.
The person can have other health problems and injuries. Report any change in the person’s usual behavior to the nurse.
Infection is a risk from poor hygiene, inactivity, and immobility.
The person needs to feel useful, worthwhile, and active. Activities are based on what the person enjoys and can do.
Review Teamwork and Time Management: Care of Persons With AD and Other Dementias on p The care plan will include many of the measures listed in Box 39-9 on pp
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14. Memory Care Units Special care units 14
Many nursing centers have special memory care units for persons with AD and other dementias.
Some units are secured.
According to OBRA, secured units are physical restraints.
The center must follow OBRA rules.
At some point, the person’s condition progresses from stage 2 to stage 3, so the secured unit is no longer needed for safe care. The person is transferred to another unit.
Licensing and accrediting agencies have standards of care for special care units.
The center must use the least restrictive approach.
A dementia diagnosis and a doctor’s order are needed to place a person on a secured unit. At least every 90 days, the health team reviews the person’s need for a secured unit. The person’s rights are always protected.
Staff must have special training in the care of persons with dementia. The unit must have programs that promote dignity, personal freedom, and safety.
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15. The Family as Part of the Health Care Team
Long-term care is needed when:
Family members cannot meet the person’s needs.
The person no longer knows the caregiver.
Family members have health problems.
Money problems occur.
The person’s behavior presents dangers to self and others.
The family is an important part of the health team.
The family has special needs.
Adult children are in the sandwich generation.
Caregivers need much support and encouragement. Many join AD support groups.
Home care and nursing center care are stressful. There are physical, emotional, social, and financial stresses.
Adult children are caught between their own children needing attention and an ill parent needing care. Caring for two families is stressful. Caregivers can suffer from anger, anxiety, guilt, depression, and sleeplessness. They need to focus on their own health.
Review Box on p. 622.
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16. Validation Therapy Validation therapy
The health team decides if validation therapy might help a person.
Validation therapy is based on these principles:
All behavior has meaning.
Development occurs in a sequence, order, and pattern.
If a person does not successfully complete a stage of development, unresolved issues and emotions may surface later in life.
A person may return to the past to resolve such issues and emotions.
Caregivers need to listen and provide empathy.
If the therapy is used in your center, you will receive the training needed to use it correctly.
Validation therapy considers that certain tasks must be completed during a stage of development. A stage cannot be skipped. Each stage is the basis of the next stage.
Attempts are not made to correct the person’s thoughts or bring the person back to reality.
Review the examples in the text of validation therapy provided on p. 623.
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17. Quality of Life
Quality of life is important for all persons with confusion and dementia.
The person has a right to:
Privacy and confidentiality
Personal choice
Keep and use personal items
Be free from abuse, mistreatment, and neglect
Be free from restraints
Activity and a safe setting promote quality of life.
If the person does not know or is not able to exercise his or her rights, the family knows the person’s rights.
Protect the person from exposure.
Only those involved in the person’s care are present for care and procedures.
The person is allowed to visit in private.
The family makes choices if the person cannot.
Protect the person’s property from loss or damage.
Report any signs and symptoms of abuse to the nurse at once.
Restraints require a doctor’s order.
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