1. Chapter 16: Cognitive Disorders: Delirium, Dementia, and Amnestic Disorders Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

2. 2 Dementia  Alzheimer’s disease most common form  Cause unclear

3. 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. 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. 5 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Reversible Dementia  Vitamin B 12 deficiency  Depression

6. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 19 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Outcome Identification Consider:  Client outcomes  Caregiver outcomes

20. 20 Copyright © 2012, 2007 Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Planning Consider:  Short-term plans  Long-term plans

21. 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. 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. 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. 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. 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