Chapter 60: Nursing Management: Alzheimer’s Disease, Dementia, and Delirium – Flashcards

A syndrome characterized by dysfunction or loss of: Memory Orientation Attention Language Judgment Reasoning Personality changes Behavioral problems *60-80% of patients with dementia have Alzheimer's disease (AD)* and they are often lumped together

*Neurodegenerative disorders* - this is insidious and gradual in onset- • Alzheimer's disease • Dementia with Lewy bodies (DLB) • Frontotemporal lobar degeneration (FTLD) • Down syndrome • Amyotrophic lateral sclerosis (ALS) • Parkinson's disease • Huntington's disease *Vascular diseases* - this is abrupt in onset w/stepwise progression- • Vascular (multiinfarct) dementia -Vascular dementia can often be prevented through treatment of risk factors: Hypertension, diabetes, smoking, hypercholesterolemia, dysrhythmias. • Subarachnoid hemorrhage (potentially reversible) • Chronic subdural hematoma (potentially reversible)

*Toxic, metabolic, or nutritional diseases* • Alcoholism • Thiamine (vitamin B1) deficiency (potentially reversible) • Cobalamin (vitamin B12) deficiency (potentially reversible) • Folate deficiency (potentially reversible) • Hyperthyroidism (potentially reversible) • Hypothyroidism (potentially reversible) *Immunologic diseases or infections* • Multiple sclerosis • Chronic fatigue syndrome • Infections (e.g., Creutzfeldt-Jakob disease) • Acquired immunodeficiency syndrome (AIDS) • Meningitis (potentially reversible) • Encephalitis (potentially reversible) • Neurosyphilis (potentially reversible) • Systemic lupus erythematosus (potentially reversible) *Systemic diseases* • Uremic encephalopathy (potentially reversible) • Dialysis dementia (potentially reversible) • Hepatic encephalopathy (potentially reversible) • Wilson's disease *Trauma* • Head injury (potentially reversible) *Tumors* • Brain tumors (primary) (potentially reversible) • Metastatic tumors (potentially reversible) *Ventricular disorders* • Hydrocephalus (potentially reversible) Drugs (potentially reversible cognitive impairment) • Anticholinergics • phenytoin (Dilantin) • Opioids • Hypnotics • Tranquilizers • Antiparkinsonian drugs • Cardiac drugs: digoxin, methyldopa (Aldomet) • Cocaine • Heroin

AKA multiinfarct dementia *Secondary to strokes* Loss of cognitive function due to brain lesions caused by cardiovascular disease - Ischemic lesions - Hemorrhagic brain lesions

*Aging* is greatest risk factor - FMHx (first degree relative) - *Diabetes* a) Insulin resistance, which causes high blood glucose and in some cases leads to type 2 diabetes, may interfere with the body's ability to break down amyloid, a protein that forms brain plaques in AD b) High blood glucose also produces oxygen-containing molecules that can damage cells, in a process known as oxidative stress c) high blood glucose along with high cholesterol has a role in the atherosclerosis, which contributes to vascular dementia d) microangiopathy, which damages small blood vessels throughout the body, may be causing ongoing damage to blood vessels in the brain and lead to increased risk of cognitive problems - head trauma - Obesity - Smoking - Cardiac dysrhythmias - Hypertension - Hypercholesterolemia - Coronary artery disease

Memory loss Mild disorientation Trouble with words and/or numbers

Depression *Onset* Dementia- Usually insidious Depression- Often coincides with life changes. Often abrupt. *Progression* Dementia- Slow Depression- Variable, rapid to slow but may be uneven. *Duration* Dementia- Years (usually 8-20) Depression- Can be several months to years, especially if not treated. *Thinking* Dementia- Difficulty with abstract thinking, impaired judgment, words difficult to find. Depression- Intact but with apathy, fatigue. May be indecisive. Feels sense of hopelessness. May not want to live. *Perception* Dementia- Misperceptions often present. Delusions and hallucinations. Depression- May deny or be unaware of depression. May have feelings of guilt. *Psychomotor behavior* Dementia- May pace or be hyperactive. As disease progresses, may not be able to perform tasks or movements when asked. Depression- Often withdrawn and hypoactive. *Sleep-wake cycle* Dementia- Sleeps during day. Frequent awakenings at night. Fragmented sleep. Depression- Disturbed, often with early morning awakening.

Chronic, progressive, degenerative disease of the brain - Most common form of dementia (60-80%) *age is most important risk factor*

Changes in brain structure and function: - *Amyloid plaques*: 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. - *Neurofibrillary tangles*: Abnormal collections of twisted protein threads inside nerve cells Main component is a protein called tau (the railroad tie for microtubules) - *Loss of connections between neurons* and *Neuron death*: results in structural damage and atrophy of the affected areas of brain

1) Memory loss that affects job skills 2) Difficulty performing familiar tasks 3) Problems with language 4) Disorientation to time and place 5) Poor or decreased judgment 6) Problems with abstract thinking 7) Misplacing things 8) Changes in mood or behavior 9) Changes in personality 10) Loss of initiative

- ↓ Personal hygiene - ↓Concentration and attention - Unpredictable behavior - Delusions and hallucinations - Dysphasia - Apraxia (difficult or impossible to make certain motor movements) - Visual agnosia (inability to process visual sensory information) - Dysgraphia (inability to write, primarily in terms of handwriting, but also in terms of coherence) - Some long-term memory loss - Wandering Late stage: Unable to communicate Cannot perform activities of daily living (ADLs) Patient becomes unresponsive and incontinent.

Process where degenerative changes occur in the reverse order in which they were acquired So essentially developmentally age backwards - eventually being unable to sit up without assistance, smile or hold up own head

1) Preclinical AD EARLY INTERVENTION IS THE GOAL - Modify disease before plaques and tangles have formed and symptoms emerge (research is ongoing, current attempts unsuccessful) 2) Mild cognitive impairment (MCI) - Individuals have problems with memory, language, or another essential cognitive function that are severe enough to be noticeable to others and show up on tests, but not severe enough to interfere with activities of daily living. - causes of MCI include: Stress, anxiety, depression, physical illness 3) Dementia (terminal stage of disease)

NO Diagnosed by exclusion once all other possible conditions causing cognitive impairment have been ruled out A definitive diagnosis of AD usually requires examination of brain tissue and the presence of neurofibrillary tangles and neuritic plaques at autopsy

• History and physical examination, including psychologic evaluation • Neuropsychologic testing, including Mini-Cog, Mini-Mental State Examination • Brain imaging tests: CT, MRI, MRS, PET (atrophy, disease progression) • Complete blood count • Electrocardiogram • Serum glucose, creatinine, BUN • Serum levels of vitamins B1, B6, B12 • Thyroid function tests • Liver function tests • Screening for depression

• Drug therapy for cognitive problems • Behavioral modification • Moderate exercise • Assistance with functional independence • Assistance and support for caregiver

Cholinesterase inhibitors - Cholinesterase inhibitors block cholinesterase, the enzyme responsible for the breakdown of acetylcholine in the synaptic cleft thus longer time for acetylcholine to transmit message • donepezil (Aricept) • rivastigmine (Exelon) • galantamine (Razadyne) N-methyl-D-aspartate (NMDA) receptor antagonist - Protects nerve cells against excess amounts of glutamate • memantine (Namenda)

Selective serotonin reuptake inhibitors (SSRIs) • sertraline (Zoloft) • fluvoxamine (Luvox) • citalopram (Celexa) • fluoxetine (Prozac) Atypical antidepressants • mirtazapine (Remeron) • trazodone (Desyrel)

Antipsychotics (increased risk of death when used in older demented patients) • haloperidol (Haldol) • risperidone (Risperdal) • olanzapine (Zyprexa) • quetiapine (Seroquel) • aripiprazole (Abilify) Benzodiazepines • lorazepam (Ativan) • clonazepam (Klonopin)

zolpidem (Ambien)

Redirection Distraction Reassurance

Sundowning is a specific type of agitation Alzheimer's patients can experience Patient becomes more confused and agitated in late afternoon or evening. Cause is unclear. To manage it: Create a quiet, calm environment. Maximize exposure to daylight. Evaluate medications. Limit naps and caffeine. Consult health care provider on drug therapy.

Behavioral problems (sundowning) Safety (falls, burns, ingesting toxic substance, wandering) Pain management (difficult bc can't always communicate they're in pain) Eating and swallowing difficulties (undernutrition) Oral care (inspect mouth and provide oral care regularly) Infection prevention (UTI, PNA) Skin care (Incontinence, immobility, and undernutrition increase risk of skin breakdown) Elimination problems (Urinary and fecal incontinence, constipation) Caregiver support

Characterized by presence of Lewy bodies in brainstem and cortex Abnormal deposits of the protein α-synuclein Typically have symptoms of parkinsonism (e.g. hallucinations, short-term memory loss, unpredictable cognitive shifts, and sleep disturbances) Indicated by dementia + 2 of the following: - Extrapyramidal signs (e.g. bradykinesia, rigidity, and postural instability, but not always a tremor) - Fluctuating cognitive ability - Hallucinations Medications may include levodopa/carbidopa and acetylcholinesterase inhibitors

Rare disorder caused by shrinking frontal and temporal lobes of the brain - One type of FTLD is Pick's disease May be abnormal microscopic deposits called Pick bodies, but not always - Often misdiagnosed as Alzheimer's and can be misdiagnosed as psychiatric disorder BUT occurs at a younger age than AD (usually 40-70) and there is marked SYMMETRIC LOBAR ATROPHY of the temporal and/or frontal lobes Manifestations: disturbances in behavior (unusual behavior), sleep, personality, and eventually memory

uncommon disorder characterized by an obstruction of flow of CSF causing a buildup in the brain Symptoms of Normal pressure hydrocephalus -dementia, urinary incontinence, difficulty walking

Creuta felet-Jakob disease "Mad Cow Disease" rare and fatal brain disorder caused by a prion protein Earliest symptoms of Creuta felet-Jakob disease "Mad Cow Disease" memory impairment and behavioral changes As Crueta felet -Jakob disease progresses what symptoms become evident mental deterioration, involuntary movements (muscle jerk), weakness in the limbs, blindness, eventually coma

Delirium a state of temporary but acute mental confusion, is a common life-threatening and possible preventable syndrome in older adults Clinical Manifestations of Delirium hypoactivity and lethargy leading to hyperactivity including agitation and hallucination Onset of Delirium Develops over 2-3 day period Early manifestations of Delirium inability to concentrate, irritability, insomnia, loss of appetite, restlessness, confusion Later manifestations of Delirium agitation, misperception, misinterpretation, hallucinations What is the distinct difference between delirium and dementia -the person exhibits sudden cognitive impairment, disoriention or clouded sensorium is likely to have delirium Diagnostic Studies of delirium -Confusion assessment Model Patients at risk for Delirium those with neurologic disorders (stroke, dementia, CNS infection, Parkinson's disease) sensory impairment, advanced age

d. syndrome characterized by cognitive dysfunction and loss of memory. Rationale: Dementia is a syndrome characterized by dysfunction in or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavioral problems such as agitation, delusions, and hallucinations may result.

c. cognitive changes secondary to cerebral ischemia. Rationale: Vascular dementia is the loss of cognitive function that results from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions caused by cardiovascular disease. In this type of dementia, narrowing and blocking of arteries that supply the brain causes a decrease in blood supply.

d. patient history and cognitive assessment. Rationale: The diagnosis of dementia depends on determining the cause. A thorough physical examination is performed to rule out other potential medical conditions. Cognitive testing (e.g., Mini-Mental State Examination) is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. Diagnosis of dementia related to vascular causes is based on the presence of cognitive loss, the presence of vascular brain lesions demonstrated by neuroimaging techniques, and the exclusion of other causes of dementia. Structural neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI) is used in the evaluation of patients with dementia. A psychologic evaluation is also indicated to determine the presence of depression.

b. Caused by variety of factors and may progress to AD Rationale: Although some individuals with mild cognitive impairment (MCI) revert to normal cognitive function or do not go on to develop Alzheimer's disease (AD), those with MCI are at high risk for AD. No drugs have been approved for the treatment of MCI. A person with MCI is often aware of a significant change in memory.

b. memory problems and mild confusion. Rationale: An initial sign of AD is a subtle deterioration in memory.

a. maintain patient safety. Rationale: The overall management goals are that the patient with AD will (1) maintain functional ability for as long as possible, (2) be maintained in a safe environment with a minimum of injuries, (3) have personal care needs met, and (4) have dignity maintained. The nurse should place emphasis on patient safety while planning and providing nursing care.

b. memory impairment, muscle jerks, and blindness. Rationale: Creutzfeldt-Jakob disease (CJD) is a fatal brain disorder caused by a prion protein. The earliest symptom of the disease may be memory impairment and behavioral changes. The disease progresses rapidly, with mental deterioration, involuntary movements (i.e., muscle jerks), weakness in the limbs, blindness, and eventually coma

d. A 78-year-old man admitted to the medical unit with complications related to heart failure Rationale: Risk factors that can precipitate delirium include age of 65 years or older, male gender, and severe acute illness (e.g., heart failure). The 78-year-old man has the most risk factors for delirium

A) "Ginkgo may increase the risk of bruising." Rationale: Ginkgo biloba may increase the risk for bruising and bleeding. There are no indications that sudden withdrawal of ginkgo biloba is unsafe. Ginkgo biloba is possibly effective for treating intermittent claudication (leg pain while walking). There is insufficient evidence to indicate that ginkgo biloba is effective in treatment of tinnitus (ringing in the ears).

D) A 72-year-old female is unable to locate the address where she has lived for 10 years. Rationale: An early warning sign of Alzheimer's disease is disorientation to time and place such as geographic disorientation. Occasionally misplacing items and joking about memory loss are examples of normal forgetfulness. Impaired ability to recognize family and close friends is a clinical manifestation of middle or moderate dementia (or Alzheimer's disease). Incontinence and inability to perform self-care activities are clinical manifestations of severe or late dementia (or Alzheimer's disease).

B) Provide thickened fluids and moist foods in bite-size pieces. Rationale: If patients with dementia have problems chewing or swallowing, pureed foods, thickened liquids, and nutritional supplements should be provided. Foods that are easy to swallow are moist and should be in bite-size pieces. Distractions at mealtimes, including the television, should be avoided. Fluids should not be limited but offered frequently; fluids should be thickened. Patients with severe (late-stage) dementia have difficulty understanding words and would not have the cognitive ability to select menu choices.

A) Reorient the patient. Rationale: The patient is exhibiting clinical manifestations of delirium. Care of the patient with delirium is focused on eliminating precipitating factors and protecting the patient from harm. Give priority to creating a calm and safe environment. The nurse should stay at the bedside and provide reassurance and reorienting information as to place, time, and procedures. The nurse should reduce environmental stimuli, including noise and light levels. Avoid the use of chemical and physical restraints if possible.

C) Mini-Mental State Examination (MMSE) Rationale: The MMSE is a commonly used tool to assess cognitive function. Cognitive testing is focused on evaluating memory, ability to calculate, language, visual-spatial skills, and degree of alertness. The CAM is used to assess for delirium. The GCS is used to assess the degree of impaired consciousness. The NIHSS is a neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss.

A) Lying quietly in bed Rationale: Risperidone is an antipsychotic drug that reduces agitation and produces a restful state in patients with delirium. However, it should be used with caution. Antidepressant medications treat depression, and antihypertensive medications treat hypertension. However, there are no medications that will cause confusion to disappear in a patient with delirium.

B) Losing sense of time C) Difficulty performing familiar tasks D) Problems with performing basic calculations E) Becoming lost in a usually familiar environment Rationale: Difficulty performing familiar tasks, problems with performing basic calculations, losing sense of time, and becoming lost in a usually familiar environment are all part of the early warning signs of Alzheimer's disease. Misplacing car keys is a normal frustrating event for many people.

C) Give simple directions, focusing on one thing at a time. Rationale: When dealing with patients with dementia, tasks should be simplified, giving directions using gestures or pictures and focusing on one thing at a time. It is best to treat these patients as adults, with respect and dignity, even when their behavior is childlike. The nurse should use gentle touch and direct eye contact. Calling the patient "honey" or "sweetie" can be condescending and does not demonstrate respect.

A) "I'm really hoping his medications will slow down his mental losses." Rationale: There is presently no cure for Alzheimer's disease, and drug therapy aims at improving or controlling decline in cognition. Medications do not directly address the physical manifestations of AD.

D) An older patient who takes multiple medications to treat various health problems Rationale: Polypharmacy is implicated in many cases of delirium, and this phenomenon is especially common among older adults. Brain atrophy, if associated with cognitive changes, is indicative of dementia. Alterations in sleep and environment, as well as pain, may cause delirium, but this is less of a risk than in an older adult who takes multiple medications.

A) A patient in the early stages of Alzheimer's disease Rationale: Patients in the early stages of Alzheimer's disease are particularly susceptible to depression, since the patient is acutely aware of his or her cognitive changes and the expected disease trajectory. Delirium is typically a shorter-term health problem that does not typically pose a heightened risk of depression.

C) Alcohol withdrawal Rationale: Benzodiazepines can be used to treat delirium associated with sedative and alcohol withdrawal. However, these drugs may worsen delirium caused by other factors and must be used cautiously. Polypharmacy, cerebral hypoxia, and electrolyte imbalances are not treated with benzodiazepines.

B) Use a calendar and family pictures as memory aids. Rationale: The patient with mild cognitive impairment will have problems with memory, language, or another essential cognitive function that is severe enough to be noticeable to others but does not interfere with activities of daily living. A calendar and family pictures for memory aids will help this patient. This patient should not yet have disruptive behavior or get lost easily. Using a writing board will not help this patient with communication.

A) Urinalysis B) MRI of the head C) Liver function tests D) Neuropsychologic testing E) Blood urea nitrogen and serum creatinine Rationale: Because there is no definitive diagnostic test for Alzheimer's disease, and many conditions can cause manifestations of dementia, testing must be done to eliminate any other causes of cognitive impairment. These include urinalysis to eliminate a urinary tract infection, an MRI to eliminate brain tumors, liver function tests to eliminate encephalopathy, BUN and serum creatinine to rule out renal dysfunction, and neuropsychologic testing to assess cognitive function.

B) Adult day care Rationale: To keep this patient safe during the day while the husband is at work, an adult day care facility would be the best choice. This patient would not need assisted living. Advance directives are important but are not related to her safety. Monitoring for behavioral changes will not keep her safe during the day.