KEY TERMS

mau---

confusion agnosia
reversible confusion @h+nm] aphasia
hypo& d t y orientation
hypothenia irreversible eonfusion
electmIytes Alzheimer's &ease
data calldon depression, endogenous
psyehosoeial bistary depression, r e a d
mental sfatus pseudodanentia
amnmiii eIectrownMllsive therapy
(ECT3

~UTLIWE
Aging
Canfusion
Revemible Confwion Ddh'hm)
Causes of Rever~ibleConfusion
Data Cdeceion
Nursing Care of the ConfUsed Client
R d t y Orientathn
Irreversible Confuson
Disease Pragression
Nursing Care
Depression intheuderly
SqmrPt-s
Comnnicamg with the Depressed Client
Treatment
Medications
Z@@ Chapter 11
I'
AGING
Old age is arbib"aa1.y d&d as sixty* years and older. "I% @~poup
contains a very divme ppodation phpf*, mentally, and m o m l ;
ally U ~mimy peopk~ d lbelieve the
~ s t e r a a,d pi-,
of the aged as debilitated, pov- s i d w n 0~~~ and confused.
@ronie &eases are more preadent in the a g d but the per:
ceatage that is diSabIed is very siilaa. Perm& doe8 not p a d i m
change as one becomes old= ItgraduaUydevtlaps throughoutThelifi
cycle. Ifthe individwl is able tu meetthe developmentd tmb of*
age b d and cope with d e &es$em wcountered, the older persea
pill not ijuddenIy become cranky oh his or her six@-% b-ar
C d w i o n is not a part of normal gin$ but a S y m p D ~of d&WZil
Althoagl~there are ce* poor elderly, most law adequate
incomesand assea to live wmEnfab& l?xe agingpersonmaybe deal-
ing with a cment mental h d t h ptoblm as well as a g e n d medid
condition, such as heart W s e , chronfc obstmdive lung @we,
diabetes
The n&r of &rlyhasgreai&naz&sedin the past f e w p a 6
and is expected ta mntiaueto & stead^ Thisis prinoarily due to the
mtimpmvement8 in m&md and child health, h e r e 4 technalo~
in heal& as well as the large and agio$ babYhomer pop~hfibn
There i~ a big dBkrence between the old old and J T O OM. ~ ing ffom brain damage, wmmonly referred to as dme*
Those who are t m h g dxtycfive today are healthim, better dn~ated,~
more afnuent and more outspoken than their oIdes p m . They
speaking up and letting their needs b e h o r n They are using porn&
power m push through impmvments in their lives and p d m k r l y f ~
health care. As a mdt there has been a surge of inter& ih the prab
lem of the aged.
The care of the aged with mental health pmhlenas bas unfom-
natdy lagged bebind D e i n s t i m t i o n ~ o nbad the e%et of m o m
the mentally dW!essed elderly into nii"ghom~s,tyharethefacilities
and p r e p d m of the p m n d are gene&' ina-te to m e %bf
&en Although rhs situationis improving, most of the health &+
dplioes find little challenge in w~rkhgwnh the elder~y,The more
comfno~smental healfh pro6ledis of the aged, melr adW66m,
dementia,and deprasbn ans amsidered to be within the realm ofthe
general pmctitiona
iUWugh the elderly who are meW& distressed are more con
cenzated in nursing homes, many are being taken care o m theit fm-
--
llies. In the future, it is likely that fewer elder& persons d lbe cated
for in SW nnrsingfacilitiies,Nmes m r w in hgspid~,in inetb~s'
offiw, and in the anmnxmip are more apt to be the %.to see these
dients. Xfhur~esm abIe to m e o w the dB-f types ofpmblesl~~
rl
I..
r
w-
Geriatric Mental Heath
thzy may be able to save Borne cIi- great expense in kz-rms of time,
money, stre%, &%stemand independence. More than a few elderly
&me pmblems are die find tbemsel~8in instimiom rather
than Eying independently at home simp&because the d m i m was
patmoed
Confusion is not deatly detined. It means different things to d@er-
ent people. tJienh canbe termed confused if they do not ~ W Wwhere
they are or the day's date. If the answer to a .question is #nappropr&e
or behavior does rrot meet acceptable standaide, the older person tn*SIl
be labeled codwed. Ifthey appear to have a blank stare or $porn 8irn-
ple dfr&ns, older pepple wiU m;ost a&&ly be comidered canfused
CimtMon is one of the maat cornmen problem in old age and
ISe x t x d y detrimentalto the qualtty of lifeb i n y e m . Colifusion
kmtandp~af~butwMtRomthemtemalaTul~-
nal sf?t%~orsoil any ofthe older pmm's body 8ystems. Confusion is
divided &to fhree main caregories: (1)c o W o n referred to as deliri-
um, rwults &omacnte ilhms, drugs, emotional strew, or en&onmenen
talfa- (this 46 the most common type of conftlsion Sern inthis age
group and is g a d y rwers,ible if baed wlyl; izS confusion wdt-
and C3]
m n h i o n associated with &&e disordem and pychosis.
Befare labeling a client as confused, the m s e must be certain that the
problem is not a result offafactors that mimfc confusion (Pignxe11-1).It
is assumed tha~everyone living in the same area shares the same cul-
ture and speah Zhe same language. It IS hard for mosr young people
to reaIize that the d t u r e of the elderly is quite merit f h a the cul-
ture today. The amoms and mannersleamed in youth are canied into
old age. The elderlyperson's owncultu~econtinues to influence his or
her behavior even though the world a r o d is changmg. For emnple,
Mrs Jones, age seventy, was admined to fhe hospitd two
days ago. Her nurses had labeled h e r d e d . While grow-
%up in the old country,her f ' y ate lunch at noon and
dinner at 10:00 EM, a custom she continued to &e. When
her dinner .tray was served at 5:00 P.M., she refused to eat
because itwas not her dinnmime;At 1o:OO P.M., after eveq-
one was in bed she demanded her dinner, stating that she
had had nothing to a t since noon Although her nurses did
/

mt wdvd rhis, ma. JDW, WB SWY

FOWJ- Causes of Reversible Canfuslon
b ~ o y &e only d m fie he^,;h a W-
Reversible confusion is the mosf common type of confusion & ~
lY Pi\- aged Until d&tdy proved acbmvise, confusion ,&odd be a
1 sidered revemible so tha't attapts wilI be made to k d and ek
the causes Dhle ll-1).
-

H Y P d a is aladr 0fsxpp;en in the brain. ApprcKimately 20 per-

f cent ofthe total Oqgen conmption is used by the brain. Nme *@
m o t live for more than a fmminut@ WQW it B@we &re no

--
&pJ& as a visual ~u&%ltio~. storage a% the brain must get s acatinuous supply of m e n .

ineo-
~~~1~~~~ mad
awos%of canfusion inyet :mother
the && of i w e g ~WWiry *@
VSJ?
by fieamal @ng process Conditions such as respiratory disease, cardiac pwbIems7 k=&yp
roidism, hypotdop,and anemia &ern t h e o a e n sup& to *bo@
and thm to the'brain.
IseeaflSe&e mdOf heaidg 4 Hmothermia is a lowaing dfthe body temp- & eld-
i range there is dw & ,po&izay 6f selxmy
pidual turpsaka fpvorite
heap.the%ha ~~it&"
pm
~ , mlk
$e ot she has to
. layer
up the*bh3@
erIy Ev S-itib?. to this cc1nditi:m They do not sense cold as ew-
ily as younger people do, andtheir tempmmm can,&OP to
OUS Ie-1~ 9 q~dddy. P1emperatp-e mt?p 1029F wn~itI@ed,m-
d the and it toot erin presetitas c ~ n f u s i inthe
C aeraw.&s pkon
M ) ~ ethe h~
ahearthese
& am d @p ~m d t s
th-
'ThtrstiS ~ f ? e n = i g I by
L ~older
~ n elderly
~ people. Theym y n& be atyHTe of
men fiedde]:&pmn is a,&ii& rnt@?,$ impol'tane~to them it maybe too much trouble trt get a Brinkq
w~ is,~fr- ma one &y 02 water m y be inae~ssiljle to theaaehydxatia & a very dangero*
,fao iqe &a den& am wsund,,it iiiea~y-for=P@ ' , cbik-iiflonfor the aged, ,&d fhe ~nlly'mptommay be confusioa T&
to fOOrger ae&re or w e.U&rtnnately. when fie is W P ~ true ~ Pwhen electmlytes a& involved. Electrolytes me
d~e~this~&~~!5heisWXAd~*d ~~emicaIs necwary for the hctlo- of the n m e a. m a g hq
usst admitt& the ho$pit& aderlp dims maywaka:Q. in balance with eaeh other, confusion m h .
.middle of%e night and wheac they 'ng$ gg^ ~
be-
,
of bed and tMan&:h,an
@ ~gure

s& a m w
w s
no
a m , p ta orient & d W *Way-
r&g
doubt be
I a blank lost look on
&
cantiidad
@s
confusede and D -
prob4wility. be pput ba& &j bed and m U &Xede
d & is ! 1 CON EFFECT
*ey~d;mlost ;tnd nw,bg unlwwiplgl~&d. ~~~om~~rnlra
to tbie &dta@~~iS. HM&i&Jj
6hmkt+iis@eei1
tjrad ,cek'ffph,&
f u,"g&J
t p m r n " ~anm.
.. . c;m
...~WIJ

D!+&&;r*$ien IRmectfVe Er#m qellPuft@o@t~@ bticise

ova fack.of~&&~lw
DFU& AdWrSeIV:+ffb~bialnewfo@m@nf

,npDsr q@st#ht , C O G. ~. B B @ ~ ~ Brrcinishesbrain cell fun&fanfng

$ensnsoly.laepriw&n ChaWs bmm envfr~nment.
DegrW$a,p slaws braln cell .&nettoning
h1nutWcrq DtmlnTSh%',b@thcell ftinctloning
fns-the brain's environment
Pa, . . Dimhismes rirp cell furicf15h1nd as a
. , I . . . ,

.*L'..
Wult oi stress ef~aots.
, DRUG EFFECT

mnhion, part of which is treatable. If drug-induced confusion fs rec-

ognked, another drug can be substtbted that haeases dariQ in the
client's mind Too often mnfirsion is atttibured to old age and is not
treated at an.
Mrs. Stevens, age eighty&e, was visiting her daughter. The
daughter noticed rhat her mother seemed mnfused. She set
her suitcage down and the next minute could nor $nd it
She turned d e faucet aq saying she wanted a drink of
water, but t h a quickly forgot and I& the wata running.
v

She never did get her drink Even though she had been in
fhe house many times, she wnld not seem to remeruber
where the bathroom The daughter to& Mrs. Stazns
to see the doctor, who admitted her to the hospital.
-
Mrs. Stevens had been on a maintenance dose of digitalis
follpwiag a heart am&several yeafs ago. She told rhenurs-
es that she did not want h a heart pill anymore. Because it
was believed that she needed the drug, it was given to her
by injection As time went on, she became more wnfbed.
hally, the doctor told Mrs. Stevens's datlghta that ahe
must consider nursing home. placement for her m o w .
"After aU,PUT mother is eighty-five.It is -time; the doctor
reasoned! The daugbtpl-relnchntly did as b a e d She t h a
chapter 11
sold her mother's house and disposed of mast of her fur-
hitun?, clothes, and household goods. Mer aIZ her mother
had no use for them anymore, and she needed the money
to pay the expensive nursing home bib.
In the nursing home, Mrs. Stevens told the new nurses that
she did not want her "little yellow* the digitalis. When
it was bmght to her,she clenched her teeth and steadfast-
ly &wedto takeit% time,no injectionsweaegiven The
drug was offeredto her when it was due+but if she refused,
no attempt was made to f m her to take it Mr6. StmmS's
confusion, having been caused by the digidigitalis, began to
dear up and eoenkdy she was discharged. U n f o r m n a ~ ,
by that- she had no home to go to and no belon-
to call her own.%is happened because the confusion was
wrongly assumed to be irrevmible.
m.VIL &red a little better. H e w diagnosed as
Alzhdiner's disease. He was confused, presented bizarre
behavior, and was hostile toward his wife When the chg-
nosis was made, his wife got him to sign a power of attor-
ney and then admitted him to a riming home, Becausethe
nursing home was in wfher town, the client had to have
another doctoz The new doctor saw no reason w h y pheny-
toin OMantin), an anticolrrmlsant had been ordered and
began to wean the client from it As the DiIantin level felL
Mr. Kobeas' &ion began to daar up.
The nmi& s M n o M the change ib his behavior and
soon questioned his diagnosis They asked the dodor to
order a serum phenytoin CDihnth) lev& which was done
Although hrlr. %Roberts w e improving, his Dilanti~l e d was
dangerously high. With the problem and treat-
e& however, he continued to improve
He w a t to senior a- mtm and to c h d socials He
made many &ends and one lady fiend in particdm m t determine needs and tmsfer these needs to the care p h Rotowls
he got bis p o w of attorney back and then decided to
divorce his wife in order to be with his new Mend. He W
able to leave the nursing home and move in with his kdy
friend far a happier ending
In addition, wimple thin@ Eke constipation pain, immobilit~~
other forms of emotional and physid stress can also cam ~ n f U
in the ettefly
Data collection
The thsf part of fhe nursing process is assessment data r0lIeetion
contibutes to the total w w m e n t The LPN/LVN gathers data and
gives infmation to the RW. Before doing any assessment for confu-
sion, the nurse 111ustsee that dients have their glasses and hearing aids,
if needed. The nurse also must be certain that he or she knows the
answers to the questions. For instance, to test long-term memov the
nurse can ask 'What is your birth dater Clients may be confused and
have no idea, but they may know enough to realize that the nmse is
askmg for a date and give ane.To recognize a change,the n m e must
be aware of the Jient's his* and past behaviors. This information
should be contained in a good psychosocial history.
A psychosodal history c o n ~ u t e to
s determine the type of con-
fusion and is the h t step in asseasing conflwion or any ofthe other
problems of the aged If there is reason to believe that the client is con-
fused, information should be obtained from family membw or at
Ieast M e d by them. It isbest to obtain the history in an informal set-
ting (see Chapter 7 for interviewingW q u e . 9 .
The family andlor client must first be aware of thereason for the
bistoq Time should be taken to establish some rapport. This can be
done taking a b u t noncontro& subjeers like the weather. The
basic iden* information can be collected eacjly after that Qienfs
name,address, maritalstatus,nder of children,rebgious preference,
type of work done, and educationallevel are example^ ofbasic identi-
fying information @gm 11-31.
M s m e n t tools are &o availabIe Cbmmanlyused tools are the
Brief Cognitive Rating Scale (BCRSI and the Mini-MentalStatus Exam
(MMSE). These tools look at changes in wgnition or m& s t a t m
The minimum data set (MDSI or another appmved form con-
'aining the same information,is required to be wed by all nm!hg
homes having ce&kd Medfwe beds (see Appendix). It is a compre-
hensive assessment tooL but it is a minimum data set and other infor-
mation may be needed This assessment must be starzed on admission
and wmpIeted within f o m m calendar days, The assessment, along
with its accompanying prmcols and %ger rap sheets, help the nurse
help the nurse understand the probIem he or she has assessed and to
about other problems that might be related. The rap key gives
rime guidelines in care planning. The MDS must be monlinated
s complete aspem of the MDs.
a nurse, but 0th d i s ~ p h e may
 Geriatric Mental Health

- B. WhatthTtlgh does he
Arizona Elks M@r Projects, IRC. pertlculaflyuks? tm,
LONO T@RMEARE UWff DATE: OBfSCts, auituaes,amons,
SOCIAL HISTORY Hospital NO: actlvit?esl
Tne tnfoymation on thts f o m WI be used solely t o alU in theacUusment c wnat thmgs does ne
~f your relative and youto the nursing home 11%. YOUare not obllmefl parncu1ari~ asl~ks?
ta anewer any auestfons that you d w m intruSIVe or U~neCemW,bur ail coblac%,attitudes, aetlonS.
InFormationaven wlll be Comlderefl confldentbl. adlvltier~
clienfs name: Date admttted: o. DffiEflbe nfr dany mutlne prior
Age: mte of birih: How long InTucson: to qomlng t o me EBS.
Marl@l-us: M I I W I 1 D f 1 St 1 PreulousaW: e. m a t pOSSeSlOhsare most
m~iglotx c~ergman'sname: Important to him?
ResBonsibleperson: and address'.
R,&WOnShlP: LONG TERM CAR#? UNIT PSYCHOSOCIALN U A T M N
amnosis:
I. Name. HWpl@iNO.:
A. Tell me about Marital Status: MI I w ( 1 D t t s I 1 ~ge
befwe he m m e in. Admitted mril: Adrmttedtoward:
Wna9 tyse OF pewon w s hhV3
(How Would YOU deSWlbB hTma) I.C I U I S S T R E N G T H S $ R I D ~
kebtive'5N&W RdatMnshlD:
9. HOW waul@you dMCflbe his A. Pm71v suppori Yes1 1 Nor I
rel~onshlp wlth hls famHV7 I. wno was7 comment:
IRremeyableto visltP) 2. Frequency
C. HOW wauid W M ~ ei850it)B his 3, Cllant's lieact~mto vlslts
~ela%lonshlp wffn prtgnds? a ~amllyrsamonto c~ienr -, Is
,.., . . I
fire Utey abie €0VlW B. Aalument to llllrsss .a
D. was rel@ionan ImPorta~
yes t ) NO IJ comment
4. Knowl%dgewtllnesc; I 3 uhaward I I tlmlted
pamr m nrs rife?
I ) modwte I I well aware
E. Whatllind ofWOrk dld he do? 2. Stage of loss t t denfa1 I !anger
(EdudlOtlal leV&I%i
( I baraalh I f acceptance
IHW m g UWPIOW? tMred?)
3. IhdBPBndeht as much as Yes1 I NO[ )
E HOWdid ne usuallv handle
possmle? cornmsne
pmbtems Or dlfflcUl8eSl
to the instlNtMn
C. AdJuSmm@
n. AFTER IUNESS I . Aceepts therapeutic n s )~N O (I

I-
A Date w d n s k
~roenrn comment:
B. whtcn of me dhaneesmat YOU
2.Aecspts need to b~ fn yes1 I #of I
hsye &iced concernedYOU
nurstng home comment:
themom
a occup~eskime YBSI I NO( I
C, matfactors did vou considel'
constnrmweiy comment:
before deciarng on nursm
D. Sdcfallzation
home placement7
1. Relates well to ather VBS( 1 NO1 1
UI. M E 5 WO DWJKES
Olienk ~0mment:
A Does he have any wlents?
2. Paytblpat~In acthffies Y-1 ) NOI I
tsnglng, dancmg, pslntina.
writing, 6tc.L comment
FIGURE 11-3 Continued.
FIGURE 11.3 psychosocial history and assessment samples.
- .4. .
Y I 9 Chapter I1
-
I
Geriatric Mental Health
-
-
The p~~ history provides a haelink to u\thicb present
' I
1
E. meml Cauaclty
I. mert
P, orlented
motlons
3. AUPTODPF;~M
yes( I
TIW I 1
WI I

Vest I No(
cnmm
wrsun 6
1
1 Place I I II behavior can he mrnpmd It proaides ihf'omatiidn on the client's
srrengths and sup~oft system available t?shim or her. The Mary. can
help det&dnewhe@er the confusion is rwersible and pmdde dues
as to the cawe and Wtment of the c0nWan. The hbmq can be
a. MBmW pdst wan& 1 I PreserE events I 1 taken at a f o d but mom rrften the inftnm@i(mig o W e d
&ugh inEennal c o n ~ t i o n (Eigwe
s
F. Pemnal chaa@frristi$s
Yes1 I Me1 1
I 11-%I,
Mer rereipcing the basic identity Wrmatio~ the nurse can ask
I. o~~tge~na yes ( I NO( I 7. Mature
the M y fernhe majm problem, thebehaviorthat led themto believe
n inteu1gant Yes l I No l 1 8. S ~ R S I G V ~ Yest f Not I
the clienf needed help. How the hefam1y views the henfbion and how
3. QUlet Yes l l No l ) 4. HaPPV Ye%( INOL i
4. ~ggmwve ye$ I I ~g t 1 "1. oemawing Yes 4 NO I 1 I
they ta& about their eIdwiy relative will give the nntse an Sdea ofthe
5. AltPUTstTG Yes I 1 No ( ) 4% Coping I
amoun! and m e of fa^@ support avafkble. The number of"Mends
6. Selffhh Y S I ) NO [ 1 ~echamm with whom the clierit still bas hasntact aad the strength ofrehgotls
belie& are also indicators ~fmpport avadI&le to the client
11.UKESAND-
A. ACttVR&P
0. FOO(1:
. To detamine whether the pment behavior is a w e I the nurse
needs to h o w what the client W& Wte m o a i y Was he outgoing or
ol bnw? Was she fastidious or sloppy? Did he slwp well at n&ht a
C. OM@&.
D. Amtuaes
wake often? TXIas she practical or a dwmez? Rid he m abwa
\I) drugs? Dfd shekep busy or appear bored?Did he hold B ~ problem
B
Ill. Fm
. LY ,I
in or did he tallt them OWa t was a fspicalday.like?
Astageof 10s ~enlal() Anger I 1 18ar9em S 1
Concerning ~e h e i o n , the nwse shoukl ask que%timsueh
Dgpreslon ( I Resignation 1 1 II

L
"I as the ii,Itavin$: W e n did the confused behavior stiu~?~ T a s the
8. Rel&mnnnlpwrtn slienk
omer gradmi or s u d d d Tan the funfly think of Borne sW&
IV. PO'PEW1IRLPRDBLXPIIS event &at happened just before the co-n hegap?" %&at af
k la^^ M s t [ i n ~ ~ n I J b&avi~i+does the dient e&iiit nwf" W tbe ca&sian gottenWOM
or betterr"
 3. What sari? are we in?
e \what is to&ys date1
5. isthi this?
It is possible for a person to m a k a mistake with the day's date
Without bebg &ed The par is anather matter. Ifit is Em2 a d
the cIient says it is 1945, mnfUsion is pment Thne is the most eas&
lost sphere oferimtaion; therefore it is important to detgrmine all
fair sphw.

Abstract Thinking. Thb is the abiiiyto generah anti categodze

things. It h a htgher cagnffim pow~lrthat is loa when wnfusign Be@
in. 'Ib resf &sttact thc clfent ccm be asked k, in- a
ptoverbsnr$as'"Ilze~s isahYa~$reenerontheothet+side"Some
ather pmcibs we % "atitch in t h e wvm nine" or "d& m tyour
chickensbefmtheyare hateheddEthe Ehnt is stiilaMeto&&k
&stmet$, he orshe willbe able to generabe the pmverh.For insma!,
the cornbed pason may interpret the k t p r o d as The neig&m
bas peeher g w P This is concreb 'ff'the client k able to g e n e r h , he
ox *he d say that it means that pesple o h see o r h a as hiroing
ttimgsbEtterthantheybase.
Amorhwway to test fbr tib$tFact thinking is to ash sach quektio~~
as
1. H m are un apple and an q e alike.?
2. How are a b i d and a pIme alike?
It does n8t matter what fhe client mwem as 10% as he or she
vsesthewordsrhq.both.The client cmw'Thgrbotheat,th$i.bcrth
have hair,or theyboth makegood pefs!'Wbaf the nume is lookul$ for
is the abiliy ko g m a W The cat ha hatr and the bM has feathersd
isa~~hcreteassluer.~he&ientmpondirrginthiswaywouldfailthe
taat H
,- &rp a r e d t w Muen&
~ ifBngZish is his OF her
second1angu~,the cUent Mtinnot m d m d the pprouerb.

Judgment.The client inrho lorn judgment is m d a A person who

is not c o ~ w i u g i v m
e w e m to the fo11omhj~
qttestiona that reflect
his or her underspandkg of s a f q What would do i f p u sinv
SDm%anedrop a I i g M &game bn the caipet?s "How wuld you get
somethjag bicrm a high s h e
State of Consciausness. This area is obseryed. Do &en= show an
interest in &bigs a r m d them?Are therial& and amre
Intellectual Functtoning. The dient'g ability to cnmuniEate is an
in&cation of his or her intellectnalfunctioning. Can the client carry on
a logioal wnve~sation? Does he or she use words conecw IS t k can-
vemlion cm&.t&t? h e the an- relevmtl U: the dient & post-
stroke,the client maJT have:
sa afmda-itn k b i i to r d past eqmlences (mmpkte or
partidl
agnosfa-failure to req@ze or identify objects. Sensorgability
is intact.
aphasia-difficulg or i n a b w to express w d s and phrases
A couple of sther ways to assess i n t e g d h ~ t k d n g are W
see if the ean f o h at least a Uhree-8tep iss@~Ctim "Take&s
paper, fold it in half,then fold it in balfagain, and then tearit along the
folded Iin& is an m p l e of a mdt4,Ie-step &?&on The client can
aIso be aked to de a m a t h m a 1 problem such as S& threes or
sevens.
Hwrt mtd lung Heartaqd Iung sounds
Emotions.The n m e mmt obseme the c l i d s behavior. Dee8 i8 rn functioning CQIOT and canamon of the skin
inappr0priate-l If it do= the nume must Then detamhe wh&wiS i~ Puallty of the pulse and refpirafton
a &mge in b&ai01 B~ardleessof hav biz= ~r bppropriilte the
clients b W m , be or orhe m a he tonsidered confused unless fha
behavior is a change.
When Shirley Adam, a&e eighfy4woIwas admitted to the
hosph& she was in need of a bath. Her hair war; messed
and clothes were db+qand ton Shortly after admis- Pain
sfon, she had aciphed a stack of paper -6, toweb pins,
match pads, a d pens.Shs had hidden them in her bedside
table ThiS behavior dow mt m ~ eata q t a b l ~
stand@& SO
she would most emtaidy be cansideEd confu8ed.
However, $ 8 a o a his- had been Wn, it mnld have
r m d d &at $hirlq bad b m this way dl her He.She was
brought up in a very poor fkidy. dpater was a pfdi)m
commodii and there was little for bathing md wahing .-
clothes. .The M y had ver$ litile,$0 thq savd whatma 1. Vml signs.These are very sensitive indicaton of change in the
item they could find TI&% was $one in case &ere was a use state of the elderly's hcalth 'I3r.v can indicate dehydration,
fomd fbr &em W.Sbirley'g's action8were p a ofher life- poor circulation w d the prescnn- of disease
long pa- She WBSnat r& confused, 2. IIraring. The nurse must ask simple yes-and-noquestions. Ire
Ras the. &nt reoently s h m & g f ~
of~depression, anKiq~or or she can also ask a clicnt to repeat what was heard.
pa.rm&? T h e conditions, vvbi& w W€ablerhaoe been lmotraW
c-e amfwioa

5. Nutritional Sttitus. Has there been a weight change?Are there
loose &nturs or bad teeth? How good is fhe dienfs
appetite? \W"nat 1
- of foad is he or she eeariag?Who does
tha cooking? How many meals per daF
6. En*-% Ha6 there been a recent k g e m the client's
life'?Does hc or she b e f w t h i n g s around? Is M e
enough S~TJ.WV stimulationvdthout being too m&? Are
there orienting ifems amwd such as docksi calendarsdend
newspapers?Ts thm a windm m the client can see night and
day??Is t h e a night-lightturned on?
Z Eliminatim. Is &me a problem with wm~parionor diarrhea?
Is fke &ent able to get to the ba&oarnT 18 there embarrass-
maat about using a bedpan? mat does the &ent w u d y take-
fra constipation?
8. Paia, Is pain present? Where is it?When did it start? How
m e is it?Is it wmtant or %term%fimtPIs there a n w g
that priggem it? D m the ordered medication help?
8. Mqbili@ The nurse must dewtnine wherher clients a ~ abIe
e
to walk w i d or without t19sistancc Me They like@to f . Are
they able to turn themsdw inh i?
Gerimic Mental Health
!
20. Chronic Disease Has there been a change in any of the pres-
ent chronic diseases? The nurse needs information about the
diseases that d e c t f3ecirculation or endocrine s y s k m in
particular because these are most likely to cause confusion
tl. Medicatiom. Tt is important to determine what medications
the clieht is taking. Is tbe client raking any over-the-counter
drugs? When it is determined that confusion results, the
nurse should think about medications &t There are many
medieations that cause amfusion in the elder&.
U. A m Q x How much activity does the client have?What kind
of activiiy does he or she enjoy?
The nurae is only one of marg who assist in determining
whefher confusion d t s . If it is determined to &st the confwion
should always be thought of as reversfble. The psychosocial l & t q
and the assessment should give dues as to the cause.Treat the cause
and the confusion will di8app;n: It is important to remember that
there can be a reversible coconfusion supaimposed on irreversible con-
Nursing Care of the Confused Client
Rwmible wnfusion canbe prevented. Nurses have control wer many
of the aspect4 that can cause or contribute to the confusion That
m e w there is much they on do to prevent it Vhenevez nun= have
an elderly client admitted to their care, t h q should sce that the client
has orienting item in the environment such as clockszcalendars,and
reality orientation boards. They shoula encourage *its by l k i l y and
&ds who have familiar faces. It is irnpoRant too, that they make
sure their elderly client has sufficient fluids. Nmes must attend to
other activities of daily living as we& such as adequate nutrition?good
hygiene, and physical activity. Be alert for sundowner syndrome. This
client confuses day and night and wants to sleep aU day and be awake
allnight The client can become agitated and quite difEicuft to redire&
Reallty Orientation
Reality orientation is a pmms by which confused people are
reminded of orienting cues inthe environment They are taught to use
these cus to reorient themselves in time and place. Reality orientation
goes on for tww-fow hours a day. lmmediacp, 8impliagr1and con-
sistency are the main @am.Immediacy means that the nurse must
respond to c3ienlts quickly.If he or she asks them a question, she must
allow them time to aaSWert but not so much time that clienf9 lose
interest Clients' q ~ e ~ fmbus ~t be
~ answered right away, and they
I
 GeWilc Mental Health

As with the aggressive client a l l tasks need to be broken down

into simple steps. The direction$for each step are given one at a time.
Clients rhenneed time to respond Their cbncentratlon is limited ivld
memory for recent events is poor, sq it is a good idea to call confused
clientsby their first m e . Generally, the earlier something is learned,
the longer it is retained.
For some clients, reality orientation takes weeks to accomplish a
simple change, and for others a takes months. Some clients do not
benefit from it at all. The important thing is that the nurse not become
discouraged. Without consistency, the process will defintdy not work
The reasons fca e~nfusionand the stage of the ilInes6 will be factors
that will affect the appropriat~essof reality orientation. If used at
inappropriate times, it can frustrate the cIient
Really orientation goes on twenty-fourhours a day. The client is
told where he or she is, the day, the date, and the nurse's name first
thing in the morning and several times throughout the day. Other
i n f o d o n that can be induded is the time of the next me& the
weather, or upcoming events.
A reality orientation board is often pasted in a prominent plare
(Figwe 11-7). It s e s to provide the same orienting information The
board should have a colorfulbackground.It mnsr be at eye level. It may
be necessary to have twe boards, one for ambulant clients and one for
tho~ein wheelchairs. Needless to say, all reality orientation boards
should be current

IW This is t h e E l k s Long T e r w Care Center

The d a y is: Friday
The date is: M a y 8,2002
The city is: Tucson
The state is: Arizona
The next H o l i d a y is: M o t h e r s D a y

1 The weather outside is: Sunny I

1 WP Chapter ?I
Mimy institutim aJso have a formal oirgutation clas5 to supple-
ment the twenrj-four-honr prue;ram, The classes me hdd ti^ a d-
lighted, quier place 61@&.en to thirty minutes each day, %ch d m
s h d d be limited to h e w s h p"p1e Besides enmm@g redky,
these @essimare used to help clients r e l m a task such as telling
time ?@ga s h o or ~ writing with a pencil Audio&nals such as pic-
mm, word and picture cards,large blo* and puzzles, felt boar*,
mhmm, and a tape r w d a as well as mock-UPSof docks and calen-
dars, are necessaq to m a k q the 1es8m con-, h p e udshing to
m a formalpro$ram must begin by c o all theau&o
~ and~ Vjsu-
a1d a l available.
The elass must be weli planned, The leadmshdd have a set goal
and objectks in mind and should go slowly to allow eaeh client to
progress a c e t a b or her ab&ies. The leader should try to keep
the class lively and maid putting my'client on tke s p d If he oz she
& a &nt a qwtTon and geD no response,the txZr&e C a n q 1 9 f i
*I would h t o helpyou idmtf@this or read this or m r this?' what-
emr fhecase may be. The idea is k?p m e a loss of selfesteem @
cow@ ammrem or wm attemps atB-IZI should be InajsedThe
%qmtance of touch should n e w be forgo=
A typical seasion may go like thL%
Nurse "Good morning, John Stevens! Sbe wauld then pro-
&togreeteach clientby~ldmkRemeddngtheimpr-
W e of much, she would d d e their hands. l k b is OLE
reality orientation &a Itis pIafined to he@ h p ~ V ~ m u n -
ory and exercise themind It is ela;aen o1&Ckinthe m m -
ing. The sun is shining and The t m p m m is e m f i v e
wees.
. COBS), $Mile&anent&or, incorrectly,senility. S ~ S i m p l y r e f e r to
XSaan,mwtenmNhatmon@b?Vthereis no
answerJshe would wait a minute and thas;tyl would m e
to help you answer that qne&on, B m It is s u m m a n m
DoyoulikesmwBm~XSam orno, his
e f b t d d be p h e d A"Bfc0u~se summer is a great We,
isn't it? Georgq can yon&& of some good things to do in
the summ&eT If Go* says "G0 a ~ ~ @theid~ aurse
~ amiosclerosis, Creutzfeld-Jakob's disease, and adult hydrocepbalu~,
might mppd with "That5 dght W s a g m t idea Ve
couldsithdesunortakeadAndre~r~do~touenjoy
going outside?
Names are ahyap mentioned ~ w h ~ a q u e s t iis n b?bed.
o to
This alerts the cliJiept to &e 03- ngatiion. m e co* dli-
shuld never be given a nkhatbe bp the care$=, ineluw Top;"
"Em:' of 'Deadeat: C.
7
8 ,/r;
t
Getiatilc Mental Health
Not aU & n t s M m e e d to fhe same degree?and some nm
succeed at all. It is essential that the ppersomel d&g with them do
not become &conraged Redii orientaton-tskes time.
Reminiscing is an integral part of orientation and b I v a the
discussion of We experienw Yaithin a group. Because the person with
demen6awill remember past events longer than Current ones, the past
wents provide a topic for communication Gommunication is
means by which people validate their self worth If a person f a
accepted by a group SewFwteaa. d l be improved. Most ofken the
group bacomes supportive. Their acceptance acts as a h S e r a g h t
the manly lossm felt by the elderly
Verbalizing about We experienm give8 clients an opportuniq to
rethink and reorganize. their Em. lloey fan then see the meanings of
same p a ~events
t and fmd new m e w s for ofhers. These rn-s
h&lpto &te the woah fffthe clients' h'es.
a e m n
isiw provides a means of e f k t b interaction with the
mentally impaired elderly It also provides a tie te presentday r&qs
The n m e or therapist takes people kom where they are in memory
and guides &em to fhe prpresent
IRREVERSIBLE CONFUSION
There is no sure way ta tell whether a &at has reversible or ine-
vexsible eonfusion; therefore, it is bRst to as$ume that confiasion is
revmibIe qnd rule out all possible mUses. The nnrse is only arre of
m y who vvillpaaidpate in malting fhis detennkdoa but he or $he
is in a position to &many dues.
Immmible eonfusion is mned dementia, 0C- brain m o m e
6
old age. The was popular when dementia wes believed to be a
normal part of aging, but nnfurhlnatdy it mnahs in use.
The cause ofirrwmiible Eonfafiion is brain damage. '&ere
are several. causes of brain datnage, but the most common fs
Alzheimer's disease. Other major causes are mui- or s m r -
a1small strob, which aceounts far 2b t~ 25 percent Ahheher's
mult%oEarctwhich a r m s for 5 to 20 percent; and an others, such as
which account for 5 to 10 percent Eable 1l-f).
Mukih&ct refers to a series of smsU vascular accidents tm-
mody called si?vk.The most common cawe &strokes in the elder-
ly is a blod dot in one of the brain vessels. The clot nrts && w-
gen and glucose supply bebind it The result is dearh to the pan ofthe
brm denied mygen. Fkfmrhagea can also be a came of brain &-
age but are mom apt to o m in a younger person,
 Gerlatrlc Mental Health
1
"-
h adult hydrocephalus, t
h e k a ddkn in the oe9sek that drain
the cerebrospinal fluid fmmrhe brain The fitrid builds up in theskun
and c a w damageto the brain &. The damaae &adv done m o t
be repaired, httt futllre damage w be p m t z by ~m&calIypiacing
a shrmt in the bra& Ag long as the shmt remrdna open, it drah
..> . . &thtt excess fluid'
hemlplegp
Alvheimer'a is by far the most cammon cause_ of dementia,
Wemhslon, dlniness,. - .. a~counting for EJ ro 60 percent The ornet Is 8bw and gradual B then
o r e h d t i c hypotenSief3, :
s e sitlaw@ngconfbion until dmth QCCLB'S, asuaIIp from
p ~ ~ ~ g mvvith
beridaclles, %t@pl,qes6 ,i pneumonia, d n q urinary hfectbns, or other complications ofinnno-
Intmmlal usually aff&.gliomas HtaZlacbe,&~!&l%ibh$.. 4 bilits. The f w y may redl same &essfirl eu~nt,suchss s u r p y , that
neoplasm cause ut@hwb blurred~tsten,severesnx~&~
happened shortly befine &e mConfon became a p p m Stress does
~nhe~iwd ~ n v o i mu$o$ y ~ ..* not came demenrh but tf seems to sped up the progrim of
movemen*, Alzheimer's &ease, The co&d~n awming bgfm the eve~tmay
~ l o c ~ a~n
g etne ~~ogmrsslve daemtatton, have been so tilight rhat the -paid M e a f t e n or pasmi it a f F
dmlnwe of erasses Peet when walking as no& f o ~ ~ .
cere~r0splnal fluid Thexe am two major changes that ocnrt m &e tend n m u s
~lowmtingvlrus. R~P~#PT@Q~~.@A, system, Deposits d a starchlikeprotein in the brain me 5 m on a m p
mu.ple atroppy
sy; These plaques, a% they are d& intm&e with t r m s i o n of
lnjuw lmrn,@late nonprogres%ive impulses through the nem die, The neaiby nemns Eigme 11-81,
detBf!oraMon undergo the seamil dban$e.The nemon abtapbiw, and the axan and
i

Alzheimer's Mulilpte May tiav? ,beepl,o@@a, ,.,,, Writes then map ammd tbe EeIls and entangle &em in a mass of
sevare.paln, instdlau§ I,,
tissue, These are a W y &m$a~.They develop mostly Qthe COP
begmnlng, grog&sl$gle , :
deteriotatron; , . .:j
.;..,'1,Y.
texwd cause forgetting ofihe high* C O ~ V functions
E Grst
pick's ~trophvof me rrontql Progiesslve ifreveBID@'
and Gemporal lobes& memow ~ossand! . ':i
;1
thebmin, aqo"oig,m dptgloratlOn dP
wttn a~aono~tsm inkmIfw6ig~,,
13',

When dementia results from small sfrokes, the m e t is abrupt

Confusion starts as soon ss the blood flow to the brain is jeopapdid
but it does not increase. Each time the client has a small stroke be or
shebecomes more confused. There canbe some impmvement as brain
edema subsidqd but the client never my recovm. Alang with the
mental symptoms, the client will have the usual physical symptem~of
stroke, such as weakness, pmalysis on one side, or loss of speech
Arteriosckosis is hardening of theaftaies.Because this results
less blood going through the vessels, blood supply to the brain cen6 iS
diminihed. Arteriosclerosis is also accompanied by high blood greS
sure. Ifthe pressurebecomeshigh enough, brain hemorphage can0- FICURG 11-8 m e neuron. In Alzhetmerersdisease, t h e axan a11d
Creutzfeld-Jahb's disease is also very r e It is causes by prior% dendrites entangle themselves around the atraphied bodV of
and the WUIS~of the disease is rapid. the cell.
-".- - __
,'
3Q6 Chapter 71
- -
The muse of the & w e is not known, ~ L m G earchis on%O%.
Swemltheories have been advanced,b u t n e u m m m m i ~
seem ta be
&e m W pmmisiog at fhe mdment The posqible factom associated
with the dwdopment a f A & e b ~ s&dude:
e her^. A gene has clearly bwa identivied that muses one type
of &z&imer's disease. Clients with De,wnwngsyndrome almst
& d y develop Aleheim&s E they b e pphst fhirty.
Isi r$ge. The M d e n e of M e b d s @ a w e s with ge.AUpeople
get 0 1 6 they
~ ~ s e a to bemme mare vulnerable to thc dbea&e,
m nIuiihm crmam&rn tn &miinThese has been .aa
I& =&
increased duminm (Ymc13ntratbn hmd in fhe br- ofpw
,
ple with z&l&&f$ &ease For a time it was &ohought an
increased ingaiion of aluminum might be the culprit P d e r
studies have shown that it is p r ~ b b abresultmther =thana
muse of b a n a n a
B e r a ~ s esyrnptams of m e l d - J & o b ' S
Slopa-@a&ngwifirs.
to ~~s disease, some eta& have looked at
as a came Thus fkr<rhiS theory r d s unprmen,
@ N m m e . A chrmge in the amount ofthe neWtfanS- the
mftter, amtycha,ba in a client wltb a f d tendmcy
disease seems ro be the mrst a e c e p b l themy
~ w d a Within
~ where thewould not have wed it before.In the third stage, forgetting
the next f~ pm, therewill be new & o l W ~ inhmitors
e inm@a$es.Perception changes, and clientg map not recogme familiac
on the mad&. Currentlr, donepezil (Meept) is themost fr&
q u e d y p r e s a i ~ medimaon
d In mild to modsate Meimer's
d i s e , Arhpt has helped to make a Wepence in etient's pas-
-tickpation in basic actntities d d@ living:toile- dressiqp,
personal *gene and groan&% feeding, b a w t and &-
around inside and ouatde the home. Shopping, Using the Ed&-
phone, perfonnmg household tasks, and impmOemmt in the
&Q to understand situatiom are notvble W@when the
client is meedT@ti~nmmpliani. Re&%cruhds are makin$ rapid .
progress in.the d d o p m e n t of an Nzheimer'~va&e.
mereis no c n r ~atpresent ThP diaease d c o
with the client E?&g $om two tD twelve ye;trss
through stages,aWIoq& t P L q are nor al- easy
are not Wly defined and mi malap.
IYsease Progressian
rn the first saga -is m a o r y lass CfabLe U-53. As m d n e
lie, itis so $t@t lhat ft can b%&&lo&d or mefed up.The
getl~~dlapSian%d, to bme a d plaa He or she
First Slight memow loss: some behavlor changes: may wander ana
get lost: dlsorienteu as to tameand place
Second
FurfRwdeteriomti~n Ulth lmrwed Msmory loss; togrc, reah
sonlllg, atXijudgment are ulminrshwl; neglectsgroomng and
D F O D ~ Peatlng habltS; exmbies amisoclal wehavlor
Thlm ForgettmB increases; may not re~ognlzpfamllyand self; con- ;
VeWOn is irrelevant: may scream Incessantly:unsteady gait;
may be incontinent .1
mcontinent; seeurea occur p = J;,
-.
.
Not able to ambulate well or at ail; mwherent W c h : to$lty
be able to find the way to the comes store where the client had been
@ @hgfor years. His or her a b ~ ltoi &?~
t logically and judgmen? are
dected. There can also be emotioM or behavioral ehwes.
-
l h e is further reduction jn memory in the 8econdu sfage. L a %
"asoning ability, and judgment are also further dhmhhed. These
people can forget social standmdb They can neglect grooming and
proper eating habits. T h y can undress in public or use profanity
faces or objects. They u&y became mwntinent of both bowl and
bladder, Readmg, unitmg, md the a b w to problem solve are most
likely gone. Although the client can still pronuunee some words, con-
persation is irre1emt and, at tima, be unrecognizable. The dient
can s c r m and yell incessantlyand not know Why h d the end of
this stage, there can be an wteadygait and ftequent fXs may occur.
During the fourth or last stage, symptoms become worse,
CEew are probably bedridden and unable to feed seE They will have
no mntrol over their how& or bladda Their speech is incoherent,
and ifaey speak at all, it is wualtg only sounds. Seizmes ofteh occur.
Nursing care
%ere is no cure. Drugs
be used PO p&tidy mntrol specific
b&awia~r but they may or may not be U E m Though the con-
h i o n is irrewmfble, mality ofiatation shonld be employed Many
times these clients have a revmi& m ~ o sqa-hnposed
n over the
u e i m a ' s , making the condition appear m e than it is. Research
has shown that reaIity orientation slow down &e progress ofthe
COeion, even when it is due to organic reasons.
I Nurslsag Care PBa;n:
The tlient with kizlselmer's Disease I
J e s b Robbb, a sfny&gh~ye%r-oldformer $choolte&er, is
admitted to the Shady Oak Numing Radlitywith a diagnosis of
stage 3 Akheimefs d~sftase. She is awornPaa;ed by h a seven-
tyyearald husband foe, and aaugh6er who are asd5tb1g her to
walk by inta1ork;irig their arms. The dau@m states that
Jessica has become pragpessively more fag- and mnfused
over the last four y&s. She rwedygot last going to the gr6-
cay sfore inthe mall tow where she Em%. The police faund
her and mti5ed the daughter, The daugbrer relates &at Joe
reinin& hes to bathe and to change her do-, bshe
drmleb hemelf,she at times puts ha bra onthe out6irte afher
blouw and her sacks m r her shaes.Two weeks ago she staa-
ed vvetting hem% As the danghm elates the information to
the m e , term start rolling d m Joeia 6%FinallyIhe says 1
do not to admit her,but her we is heea- tao much
for me Recently she has stamdyehg at me when I &agee
withher.' ZAe nurse completres a thorough assesanem aacer-
taining whether data indicate p~9siblewuses for mmible
confY&on. He relam his assessment dab. to thephysh and
they agree that there is no euLdwce fm rwemiHe c&sion
and the diagnosis is i%heh&$ disease.

I L Jessica
w*).
bathe hm&three times a week [widin three
I
2. j&ca will apply dothiag in c o r n order twfthin six weeks3.
r Nursing Intenrentions Rationales
Detexdne and mntinue with
present habitual bathkg time
and mannef. prment memory pattern will
be d o m e d .
Develop a W q orientation A reality ~rientatisn board Win.'
b o d far Jessica and state assist in dentating Tessiira PO,1
bath day an appropriate days. date, time, plaee, a d bath $ay;.l
I
Assist with the bath as needed. Assistance with d e ba&!

Decrease exfernal stimidi d ~ r -

ing bathing task
focused an the twk at ,

Keep batlmom and water

t m p m m wann Ea d e n t s
preference

I Evaluation
 -
Eertatri~Mental Health &I&
--dL

F I G U ~11-15 ContriDuting f a e s to elderly sulclde.

befote their death. Although hanging k+ the chiefmode of d& for

elda1y men, in the p u p seventy-fbet~ eighty-fourthere has been
an i n m e in deaths due to fkirms. Spousal hoxqicide+uicide occmrs
with lnanyofthe perpetcaro~~ bein$ &e eldetIy p e r m who has taken
on d ~ w e egiw! role.
Depression b probab1y the mo&cmmon problem of the eldet-
ly and the mest %as%treated,yer ff is the most underdiagnosed and
least treaEd of d. OPher conditions mask The. depression, and $ymp
tam, if apparenf, are often no* taken seriouslp

svmptoms
The p w n who is &pressed has prolonp3 or etrtrme sadness. E is
a g e n e r M sadness; that i$l it b not mmected to a p a r t l loss.
~
These diem are wT&dram and s~mtimesagitated, hostile, and
pmne to xumhati~n.They can also be confused Called psendode-
mentta [Table 11-63, depression inmhres amclaction in acttvq"obses-
Smemrqyhgand sleep disturbances.The clien.tZsabiliityto reason and
member is dhidhetl ahd he or she is mote pessimistitic
The elderly depressed person usuaUaf has more physical mm-
plaints. In In& h q i p o c h ~ B Wis wmmea Physical mmpainta: e m
even be the symptom ofdepres$ion. Eld* depressed c l h t s are
more apt tp be *qStipa;red. and they meven be inconihatt
 EwkttVc Mental Hmkh &&

lmpatrment is inconsistent Irnpalrrnent is cons~stentand

Onset is mpld
progressive

Onset ISstow and InSidiOUS

More llKelV to answer quetitons More likely to cover up bv givlng
--
with "Ido not know." an answer that may be close to
correct
More likely to give up easlly Tles to stay independent as long a!
possible
v
Communicating with t h e Depressed Client 1
WiththeclientTbirlets h i m o ~ h e r ~ w ~ i t i s a l l r i g h t . t o h e s i l e n O
and puts no presm-e on the client to taac It also lets him or her h e w
dat the nume cares aou.gh lo take the time
After sitting silentlyfor a tima the nurse m b e g ito talk abbof
nonthreatming things. He or she mu b@ to build &en@' s&

there needs be a h i t on the numher oftimes an incident an he,

repeaTed.
AS 6all other d$tregsed &ensI the n m e ne& to ETlX&!l
ralnz He or she usee simple, concrete sentences and does nut a W P ?
to argue, probe, or jntmagate. The n m accepts dim'ts'anger*hufp
above a& he or she eontindy strestres r d t y I

Treatment
Treatment o f dep~e$siohdepends on the mast%Depression can be a!
re%& of physic& illness or drugs. It It be the mdt of h g s in 9
 C&rWcMental Health

to &e surgical or KT unit by ;c or wheelG

Them i s some memory loss following the procedure that is usu-

MEDICATIONS
Because elderly d i e are de&rg with both their mental health proh-
lems and ftzeir ~oniclIlnesses,
it is extreme%i m p o m t to cmdnet a
d o t i o n =view. A hor teoim the number of meditations pre
w
%&bedM u i b i n g multiple medications is railed p&pharmacp; A
plwmdst nee& to be u)~SuItedto assist with information about
dnrgmos dmgdmg inw.meti0n.k Cnrrent d o q e is imp~rtant@ ?he
 -

- ~.<-,$
:@ @ chapter 11 Galati% Mental Heal-th

elderly needinitial low dosing and frequent asassessmentof body weight

&tentinee or we- 10s. Some clients. wperience paradecal ~mmunivttionis +he majpr tool when workmg with the
fbppbsitd &&fs h m medimtions. IrritabiliQ, coBfnsion, and diso~%- w&hdr;rwnclient Worein$:with an distressed &en@ mpixes some
@Won can occtti. d e s . Ranain &speak in simple8mncmte semence$;aubid qnes-
Working with tbe aged lyh0 he mental healrh pmbIemS is a ti-; and do not ptsh tke @lent to anewer Be very attentive to hig
s m f i t I job. It can be f%snaringring
and dem21nds enormausus patien- or her physical needs,Qberve nonverbal cues carefully
M d sup&wbw w g ,car@%eE.is one~irnp.o~it &@edient in &c-
inp joh ,ms, A pasite attitude b needed Although this will nat
change the disease proma, it can improw wnaitiom,and maBe good SUGGESTED-
ACTIVITIES
mte more &bie tethe ei8e~1yGmaalogknurse apeualkta are an
&mt mnum for support and w e plans.'Th& sonsultation should E-4Vohteer W Visit a dieat in a nUTSfng borne.
be sought when powi6Ye Ifa national p&o&yis to d u c e &life smi* Attend a d t J P orienwon class.
ad*, fh- to be increatid emphis onl@a~ernmiaIhealth
B Contacf a local Wzheimefs support group and plan to attend a
mw.
SU,MMART @ With a group, d b a s S €he effect of commonly.beliwed myths
.-... .
on the care the elderly xeceive.
group 14 tWms of'e~onomics~ b@%rnw, a Examine your own BeUngs about @rigs
mental &d ~pkpical.B e stereatvpe of the dddy % Find out ?.be mrimk€legishion &e&ag nursing hangs in your
en, aanky,a d mnfused js sirnp1y not Tma area Are t$ex helpN or ref;triaix?
The com.on m ~ t hdd t h p m H m in fhc! aged in:&
delirium. d&nQa, tind d&rwicia The @3&qft& do riot re@@.:
tmatmm bemuse wf ceaain m+s and &adea %,at eonfinue.~$@' REVIEW
pe&t %~&D*g am some -$@: ?&epb1- ofhe.& --
- -

furbed &q&'~:@@i@&?i @ di thm &n@Dseme iq-b

. KNOW AND COMPREHJ3ND
&emmor 'T&ing with the elderly i4 infaror to other fo,Wd$' '. A. Multiple choice. Selectthe one best answer.
heal& ism, and t h i ~ p q l e w h woik
a with.- are either ~&t$,:L@~Tii ' The arises ofmsibke mnfusion indude
atlpitdP &=em-$& anothelip&e p ~ ~ , ~ & ~ $ ~ ; l 5 h vascular acciden* and brain w e
itwill im:ipmW @n&ti@is a d ni& good b&rhcare m~e -axei. ' 5 B, dehydratlor?,eleva€ed€emperatme, and drug$.
bk to the elderly. 5 C. Euntington's disease and arkxiosderosis,
Conhion m = b em d i z or b e v d l e . krs&ble . U D. Alzheimer's &me and cerebral infarcts.
s m is &11& M a . f i ~~~~ she& be &dt&+J!'
?wers@l% The a w e sb$d beb6rrght out and Rm%-&1d 2,Thethree of conkion are
D d mrsibIe, k m s i b l e , and chronic
co&ionw $0~0 ghiw,saqdil ~ t s rdm . @6 'i 5 B. Ahhebnefs, rwersible, and m ~ a r c t .
ewimnmw&d f%Wm,
U C. psemiodementia, dementia, and delirium.
~h ro&&on, is due to b m . damage. A &@~'t~.@?)t'
ham&& m & l ema M=&Ie w & ~ ~ m e ti&? 5 D. demenria, m d W a r c t and reversible.
T& majority ofpeo@~3ew&&de-a &.vg 'ihe. AizheimePw W:Q, 3. Tbe poss%e m s e s oEAIzheimer's disease are unknown bsa
is a ppqpssiue &e@e for y&ii&e@ b !@ a@, l ! b r & 4 : . a dear effect of the disease is
but . s t f c ~*& up thepa@@,.B@$m
-''
n ~caused
t by 5 A. a rapidly developing delirium
modifimtiontmhqucsamt dmg&&e used to,w&d beh&@E6 b@ 5 B. an increased risk EBl. i n k m d hemorrhage
&notreatmmf&~&e ,&ad%& &&@, orientat&&b!a~@.i 4 Q C. an inabiliitp.to cope with stress.
ChaDm 1 4

APPLY LEARNING
4. The most mmmon mental h
& problem inthe eider& iE;
o A. depmion 3. Multiple Choice. Select the one best answer.
P B. mnfasI.ot~. 1.A practical nurse contribbutes to the plan of w e for a 79-year-
C.Alzheimefs disease. old client with advanced &heimer"s disease. It would be
P D. dementia imponant to contribute interventions f w e d on
5. Beactitre ddq;l+essionis a r d t of D A. ~dacing the rigk of infection.
D & some stressfd event P B. @&ping different caregiwm ~ a c hday;
0 B. a change inneur0tWBmiEm. P C. indudiqg the cknt in @ouptherapy.
a C.byposhanWie. J2 D. isolating the dient from others.
a D. dm@. 2. An elderly client is diagnosed with pneumonia and admined
6, Em elderly client is d"pre9sed without a preripiBW cBz1se6 to a medid unit The client becomes irritable and sestIess
is &loa-, and feeJ.8 gtd&, the dient probably h;rS an$says fnthe nurse, '?need to feed my cat" A family mem-
0 A, req- depression. her Sate6 thed i d has been living indepenrtenty and manag-
D B. endegennm depzesgioa ing ahousehold. Which problem should the nurse smpect?
GIC, bipolar dlsordec R A dementia with irreversible confusion
P D. pseudodepfession D 3.dekiurn with rever~ibleconfwioh
CI C. depression accompanied byeodbion
0 D, ear& stage Alzheimer's disease
DA.af3~am
P B. blood chembay. 3. The nurse gathers data to defermine a client's orientation
P C.sisual ob$eMatioflof the brain. ~
Which question belm would thp nursemt use?
D D. a mental status e % ~with g o d %WW Q A. T h a t is trxbfs daWX
Q B. "What is pourfuII narae?"
8, The path010~in Alzheimer's &ease inel-udes 0 C. "Whatkind of place are we in?
0 A. ta@e8 aad plaques. inthe Brain. D D. m e r e were you born?'
O 8.d e m ~ ~ & W m mom.
of the
P C. de9m3ction a f the b l o o & - wb d m . 4. The nume ina. skilled care facility prepares a reality orienta-

12d. i n m e inmagnesium in fhe bmIn
9. Clients &a m coafw~dneed
U A. fimtmgb &ectim5.
P B. change and aabw.
ti C. simple directions.
R D. &&one given in a IOU& f%m
10. m e most &&ve tool fbt bdpbg the mafused client&
Q d pgychotherapy
0 B. arpmentation.
0 C, WE^ orientarion.
P D. conffmtatiotL
g
tion board. Which information would the m e incrude?
P R today's menu for breal$ast, lunch, and dinner
a B. daily visiting ham at the f a W
2 C, todify's day>d date, and identification of thc place
U D. namc and phonc numbcr of the client representative
,
mice. ., 5. A nurse p.lans care for a client in the secdnd stage of
dlzheimefs disease. Which inkerventianls?would be ma&
.. .
anaromiaw?
2 A. assist with grooming and fceding
2 B. provide dcviccs to aid ambulation
D C. strategies for care of incontinence
D D. a n t i - d e p medimtiom for hostility
2. List the nursing needs of the client with dementia.

4. Dierenfiata betweea dementia and pseudodemen~

2. The pros and cons of treat@ the elderkin n m homes

rather than rnenfal health facilitia.

3. The ways in whlch prevalent attitudes toward aging aff0.dtb

care of dients =&threumible confns'10n.
cent; thus inkacing alcohol prefepence and leading to an inmxsed
risk for aicohoUsa The role of environmental factors and genefic
cou~seliitgneeds to be moredearly delineated It is often a progressive
and fatal &east? and &aracmhd bv imvaired control over dridine, 7
'

preoccupation with alcohol. use of aiwhA with adverse consequences

and distortion in thinking, and denial of the siffnificanceof the drink-
ing and awarenas that aIwhol abuse is a probfan. There are a
of dehitions f a alcoholism but most de6nitions indude the ~oIIQw-
ing four k e n *
Excessive consumption of alcohol
PsyCholopical disturbances caused by alcohol
R Distmbanw of social and economic functioojng
Loss of control over alcbhol cansumption ... ..
EM. Jellinek, a pioneer in alcoholism research defines alco-
holism as any use of an alcoholic -age that causes damage to the
individual,sod* or both
The person with alcoholism is often thought of as a skid-TOW
bum. However, only seven percent of people w i t h alcoholism fit this
stereotype. The remaining 83 percent are found in every l e d of sod-
ety and in eve@y occupation, The rmmber of women wirh alcoholism
is inu'easing.
Clients with almholipmmay show signs of 6nd rejection of the
mrld about them. They may withdraw from personal contact with
othess and not evenattend to their needs of daily lming.The clientwith
alcoholism needs empathy and not misplaced sympatIq hovatke
approaches for care m necessary for each client The nurse should
demonstrate qualities of consistency, h f i r m n e s s , honesty, and patience
To do this, he or she must first determh p o n a l prejudices m-
cew the c k a withalcohelism.
Prejudice is a prejudgment UsuaIly, it is an unfavorable judg-
ment based on insufsdent reasons.Nurses need to examinetheir own
pmdices beeawe they canbe reflected in n m b g carp.Nurses should
think thmugh their prejudices and recognize their fears and lack of
information, FeWs of Weriorityand inseapityneedto be Wt with
Once prejudices are mghized, nurses can takeresponsib'ity for their
aM behavior with others. Nurses p&&iy need to be understand-
ing -in their interactions with a l l clients They render rare and do not
pass iudBment
- .
Th"& is no single cause of alcoholism Alcoholism is a disease,
not a habit Researchen have found that sodeties that induce milt and
confusion ~ g drinking
w b e h i o m are more m y to';u.oduee
. has been found that people w h o d d o p dnnlang
a l a h l i ~It~ alw
 1,
Y '
c 6
ad ~haptsrl2

I
HISTORY OF ALCOHOL ABUSE
/I,' The use, misuse, and abuse of alcohol is thought to date back to prim-
itive tunes. During the Stone Age, humans found that chewby: certain
berries made their heads light This accidental discoverybrought about
the international manufacture of alcoholic beverages. By 3,000 B.C.,
P@pt had perfected the IT of manufacturing beer a n d wine. The mak-
ing of wine also became popular in the Mediterranean countries.
Dun% the Middle Ages, grapes were cdtivated throughout Europe,
and monasteries began perfe* the manufacture of wines.
1 Distillation introduced a new and more potent alcoholic bever-
age. Instead ofbeers and wines containing G to 14 percent alcohol, hev-
eragm containing as much as 50 percent alcohol were made. The liter-
ature of this period reports drunkenness as a scrim problem. Alcohol
was available for rehgxous and medical use when the colonists settled
F~GURE12.1 FM, mends, and lots Of IfQuor.A good--or very in America Alcohol sometimes accompanied family meals. However(
dangerouS-trio. some rel.iom scorned the excessive use of alcohol. Factors such as the
diminishing family structure, the Iessening influence of relrpion, and
the dislocation ofwar helped cause an i n w e in alcohol consumption
Alcohol became a social concern toward the end of the eigh-
pmbfems m m &dy to experience interne relief a d re ha ti^^. teenth century. At this time the temperance movement which stressed
&om alcohol. The person with afcoholi~m Wa of- ' moderation in the use of intoxicating beverGesbegaa Strong support
sons form, he rrutsom may d u d e the fofI&(I: for the movement came from religious groups, legislators, fanners,
businessmen, and schools. By 1919, twentyfive states participated in
gg Relienngt m i o n ,,,, the Prohibition Amendment The amendment made it unlawful to
,,
B1 Helping UmKind . ,/'a manufacture, distribute, or sell alcoholic beverages. Thirteen ~ a r s
@ Droaatng mmow later, it was repealed as a failure. Denying people access to alcoholic
bevera$es was a simplisticway to deal with a complicated issue
pa Making one feel free Alcoholism is a problem among an ages. It can be seen in the
@ Helpin& one be sociable nmborn as a result of maternal alcoholism and in the child, adoles-
~~y people expdmce increclsedaCbIXyrh q h m , ad sma5fh-
'
cent and adult Alcohol eonsumption is a way that some people cope
flowing s p e d d t h the conmmption of alcoholic b~verW@j . with stress. One method to screen clients who have problems with
12-13. &coho1 can produce a tmporaty feeling of but ' alcohol is to have them complete the CAGE questio~aire(Table
n w ~
system. ~
Alcohol abuse can have negim .' 12-11.
$epresses the
sea m d ~~ezsonal co~~quences. AD& 1Far d nW while
I There is an increasing number of teenagers who drink on a reg-
(- and public intojration [PD can oulut With al] the hem~li*b I ular basis. Liquors such as vodka and tequila have become popular
s . problems &er disease, gamin*d
.ed lad ~ l v ~ m tI-Eealth ' among teenagers because they are difBcult to detect on the breath.
b l e w ~ o ~ ~ o - gvarices],
e a l a m m o H e and = @ o d acciden% Parents do not always recognize alcohol as a drug. When told their
and bpw job functioning can tuntribute to a &~1?td =@e. child a drinking problem. many parents are extremely th-
dependace causes an inmased ~ ~ U m P t i @falcabbJ
on that at least their child is not on drugs.
and an inam to sop dnnkuq:until intoxkated. Thhking becomes Parental influence can be a factor in teenage .d- ~nany
households, children see their parents enjoying daily cocks before
anfused and &oqanized M-, concentration, jdP-6 and
peroeptionaredulled Depression, &wkaZi0& a d d @ ? V are " and after dinner. Peer pressure is another influence in teenage drink-
tfie problem mused dehok %.When people have equaI standing within a group force or cajole
i .
 I
Alcoholism W~
- -
-
'&* la, -

Guilt f e w without drinking

Inability to dlsccus problem
Inuease in memov blackouts
CRUCIAL
Loss of contml
W&tion of drinking behavior
Failure in &brb to control drinking
Grandiose and aggressive behavior
Tmuble with f wand employer
Self-pip
Loss of outside interests
Unreasonable resentmeat
Neglect of food
Tremors
Morning drinldng
CHRONIC
Prolonged intoxication
Physical and moral deterioration
Impaired thinking
Indekdle meties
Obsession with drhkiq
Constam dibibis given

PHYSIOLOGICAL BFFECTS OF ALCQhDL

The nurse should have an mderstand'i of fhe physiologjcal effects of
alcohol. A small amount of aIcohol may bring about skeleml muscle
An maeased amount Can impair the respiratory and car-
rel?~xatibn.
d i o v systems.
~ AIcohol physically depwses; while tensions and
fear8 appear to ease. W1th alcohol constunption, mental activiw
STAGES OF ALCOHOLISM changes and judgment and seEconm are reduced With increased
LweIs of alcohol, a staggering gait is noted. DifBculty in standing Pol-
lows. Rnally the person falls and i s unable to get up. A larger dose of
alcohol can produce stupor. TBis is a serious comphca'tion that usual-
ly follows a prolonged drinking spree. Wheh almhol is taken on an
empty stomach it is absorbed immediaely and the effect an the cen-
Occasional drinking tral newom system is felt in Iemthan twenty minutes.
constant relief drinking
I n w e in dcohol tohance
PRODROMAL THE CLl@lUTWITH ALCOHOLISM IN THE HOSPITAL
,onsetand in- of memory bIackout8 The majoriw OfcJkrm with a l c o h o h in m & d and depart-
Seaetive drinking mem of a gaS@ ho~pftd are admirced wiih a diagnosis orheF rhan
~eoceup&n with alcohol almlroli$m,The COI dy seen dia@06& include
Gulping firstdrink
 -- - -

,,c&pwqg Alcoholism

a .~. ~ @ ~ & ~ B Vitamin therapy @he person with alcoholism usually has a defl-
dency of magnesium, thiamine, B complex vitamins, niacin,
g l q , ,..- , and f& atid]
r we m: ilMonitoring for alkmtion in serum gluwse
&=I*. ml $ q d m *rAntic~h~&ants fdilantin,phmobadzital)
&b&&B. U* The client with alcoholism needs to be observed closely fox

Gflmpli@tions associated with long-term alcoh~lism are

Wernitke-Ko+sakoffqnilromeand hdts disease:
s Wernicke-Ko~akoffsgmbme is chmara-ed by c o e ~
disorientation and amnesia witb confabulation.
Pick's disease is ehractwhed by early onset in the m i m e s
with p r m i l e dementia. There is a genetic predisposition.

NURSING CARE
Many diEculties that occur with dimts with alcoholism are a result of
withdrawal symptoms b e g h h g 6 to B hours the last drink
Clients m miIrTwitl&awal may suffer only trembling and agitatim A
more smre withdrawal.in~~Ives d-um trem& W3.In deh-
ilrm b m s the&eat has extreme restlessness and posS@&sekqes.
Delirum tremens may not o m u n t i l the second oftilM da~rdftreat-
mentor later. The client must be mefully observed for any w i t h h -
d sympxm. These may indude

r ETO* sweating

P increased agitation

Hallucinations
Increased blood pre&m
It is'impartant to noteZhar antimx&eQdrugSare intended to pre-
mt deliriumwemefls (DTc) and, therefore, should lye Ye l i b e r a
The presence of d ~ t r e m e n @s a m e d i d emergen9
.,may;s f i r @ ~ a@ii$t atfempts to feed orbathe them The
nurse mu strew^ thwdientstswgd f& be aware &.&
 Alcoholism
a
to alcohol? What has led to relapse iathe pmt? Rdapse is not *mu-
d and the Jislt nee& to pay irEenti0n to warnine; signs. %dayr m y
pmgmm hdu&ean aftercare pmgraun to help the client with the a-
sition &to abstinence and evqday life experiences. IndividualgroupX
and couple wansehg and job guidance are pravided to build self-
esteem and s e I f F d e n c ~

POSTACUTE WITHDRAWAL
P o s withdrawal
~ ~ initid9 w oaur wen to fourteen
PAW)
days abstinence but may peak at 3 to G months after abstinence
begins. Bymptoms indude
&3 habiUty to think clearly
a Emotional overreaction ar numbness
B Memory p~ohIemsCshon term and sign%oult pa& pasteat@
€8 Sleep disturbances (dreams m nightmares)
B Physi-1 coordination problems

REPLACEMENT THERAPY
Naltrexone (Revial is an opioid aniagonist ihat rednees chances that
the clic~ientwZldrink i n k f i b y h m f i n gplwurable &Q. Itis
well tdwated ly most clients, although side &eds can be nilusean
Wnm, headache, or an rmbappymood,hepatotoxicity rbhmustbe
mnsidefed lr is impor~ant to note tbat drug9 with opiate-Ifke proper-
ties [Le,, morphine, heroin) carmot be e e n with ndttexone. Naltrm
one therapy quires a cEentLs ibfbrmed c0nseXt a d the client needs
to cany a naltre?conewarning w d to show to doetom and den&ts.

REHABILlTATlON OF THE CLIENT

WITH ALCOHOUSM
In 1972, k-Deparmtent &Health, E d u e a b and V V b estabkhed
.
the National Institute of luwhol &we and Alwholism mIAAA1.Tn
purpose is to help thc nation @TI a bmerknowIedge of the &cfs of
alcohol and to bemme aware of the reresp~mibilitiesw d a t e d with
wing alwhol. The instifute encourages public discussion &cgrfmu-
nity drfnkmg prob1ems. Tbk brces w e fomedto study malor drink-
ing patterns Of problem @ups within the mnundtg, Prevention is
now behgremgnke+las eesential in the base to reduce alcohol abma
lb minimize alccllrol abuse, atteation should be given to the general
population and wt m 4 Y the problem dmker. It is important to a@
eady in discowaging primary alwhol abuse patterns.
 I
I 'T. Nursing Care Plan: 9
The Client with Aleoholl Abuse
NUrSlng Interventions
la. Spend time with Sarah
eneouraging her to discuss
her job respomibjlities.
Rationales
la Having &ah discuss pres
eat job r e s p o 1 1 s i ~will
assist h r in iden*
pz"t~mtsaesses
~ b~iamsa:
. $ 4 &-em@ lb. Discussing smsses will
Inher life. give b i g h t to &+hatSarah
sees as StreSSOrs,
Ba UtWe therapeutio e m - Za Diswiry: premzt stress
mmicatioti and cgwelin$ management &ts in
skills, a n d discuss wap iden-g &edive and
S m h is prmentIp handling in&* coping strate-
mess. gies.
2b. Make r~?fhaIs ta tom- 2b. O W resourcw may be
& ~ ~ l fmfbeemdngherektefto
~ i w the n W W & dm and communiy able to wsist Samb in cup-
Miif& a barin oBmand he has m a t e d alcohd on h@ orgadmtions a8 neaed. ing with ,%tress.
br& swerd time laply when she mmes 'home &omw d 3, h&t in helping Sarah 3. Newcoping metbods
Re states &at wfientbe couple
- &9h has be=. b d new ways to mpe give S ~ p o e i t i v 0urLetp
e
ha* two drinks,to his on% with swwes. for handling saw,
'NURSiNO W N O S i S ~'i Evaluation
krqh is ab1e ta list present swsors in her Job. She
I
a b l g e a that she is not effeslively hmdling sixes now.
Samh Iistens in* as the m e s b w some o p g m h t h u
that help people handle stress dkctively.

NURSING DIAGNOSIS 2
Nur'singoutoomes h t e q t w d famf~p@W$@-@:aWi b,Siz+aorsiandinmeswd
Use ,ofali%hoI~
-. is &uide@& 'bS& a&% ,&&:she h~ job
&hhai-ge S a r a h d iden*
L ~ef01-e ~tms@inhe~Ef". a w * a 4 worW,:lerrghems, md her
he ha3 w&d &whOl on her br& InQE efrequqy and
mf
hwwd mnsrinztytion at $o@al.&&ts.
I. . _.--_

ofhospitalbation Nursing Outcomes

S M ' s family will c o m d c a t e eon- ofjob reqonsikdi-
I
tit% tD each other and implement effective coping m a -
hbllls.

&sesging 6id.y dynatni*~
in id@- mles and
r ~m
f i n ~ ~ ~ ~ q g e f f u n i l p d e BY to ~ w d *
verbalize their feelings. -bertosharehisorher
~t"+ons Qfthe mtidn,
the staff ga& a c k m p m e
of m y intern-.
~&e&&ml.sasdedlag, ~&lww-
t~ SON
work&, , o m n ~ h ~ m o m ta deal &&the siN-
p~&&~q&&&
ation.
e & s m - - m &&@- have fleedm to
b s , &pe Mim .&boa interact as needed
81~0- 4 n o n v . f
A s q p t W k W ~ t
eacomages aaustW6ns@
~the&&familBfaciW
ne&lecephreto&~b
didienrwithalcoho~
holic and needs rehabilitation. This is re&?& bytimilies,who m d
to protea persons with alcoholirm and frequently deny the problem
lbIeraalag stress is a probtern for p o n s with alcohoIism.
I m p e d methods of coping must be learned It is necessary to 6nd a
satisfactory substitute for alcohol because alcohol aas as a tehsion-
reducing agent
The values and mmms of the wmrnunitg in wbkh the individ-
ual influence his or her drinlring behavior. Par example, a l e
t a significant pmblem among N a t k Amaican9. A commu-
h ~ l i nis
n i y s attitudes, concerns, and involvement with the problem of a h -
hohm need to be Community resources such as m y serv-
ices agencies, mental health clinics,visiting nurse agencies,police, and
departments must be made available to help the alcoholic It is
interesting to note that recent stndie$ have shown that the black pop
ulation is dispropordonately targeted for liquor adm-kimnents.
Billboards are rammed into poor areas,and the piuwx%vividly con-
nect alcohol ~ t romance,
h p m , and succm. Cognac and malt
liquor are two beverages fiequatlydepicted In some neighhhoods,
community leaders are banding together and wbihwhing biIbmr&
as a show of d e h c e and to deliser a foreefol message to cha~ge
ad- approaches.
It is important that the community offer diversifred rehabilitation
programs. These pmgmm.9 might include emergency medical care,
11 OUtcIient dinics,inclient facilities,and haIfway houses. Outreach work-
can be helpful in oisiting ethic areas of communities to iden*
their particular needs.The nurse can play a role in m e finding, refer-
raL and morrtination of wmmwity services
The person w i t . a psychiatxic illness and a coexisti~gaIcohol
abuse pmblem is a major challqe The goal is to monitor within
cmmtmities seriously d~$~~~bional clients, attempt to stabilizetheir
behavior, and fmprove their social hctioning. Careful assessment of
combined alcohol and drug abuse isneeded because persons with dual
diagnoses can be noncompliant, and reshant to treatment These
clients d lusually deny or minimize their substance ese/abuse, yet an
astute mental hezlth professional will note increased psychiatric hos-
pifdhtions and exacerbation of e d psychotic symptoms
It is important to note that theincidence of alcoholism in womm
has risen and has contributed to increased suicide, death &om acd-
dents, and othea alcohol-related diseases. The literature desaibes
women as drinking in response ro many stressful events: ma&l pmb-
1-, POveap and single p a r e n . , midlife crisis, empty-nest syn-
drome, and w a n t e d pregnanw A great mncem with pregnmt
females who drink alchohol is fe&d alcohol syndmme WAS).PAS
a&% the cenid nemoua system of the fetus. Growth patterns are
 f a s crfpeerrelationsMps
~
Unprotected, unplanned sexual intercourse
U hff- risk of physid or sexual abuse
Suicidal thoughts and possay a pIan
If the youth has a parent who abus~salchohoI studies have
observed that these children are at high risk for delinquent behavior,
lmmbg disordem hyperactivity, psydbasomatic complaints, and prob-
lem d l h k h g as adults.
Adolescenrs at younger and younger ages are being presented to
91coh~lrehabilitatian emtiera They are brought inby their parents,
peers, or thejwenile judicial system,
The elderly are at risk for alwhdsm Many experience longperi-
ods of iaolatioo and lonehess and drhkiug go0rtre.g &we f e w .
Family members can mnttse their p e w s depression and p a ~ a ~ o i a
with growing old iaseniLiWand fail to recognize the need for alcohol
mafment The elrlery frequently a ~ excluded
e from intense alcohol
treatment pmgrams. Howeverhif alcohol use or abuse is suspected it
canJtopar6izeth& g-c health we and possibility for residentid
placement
Nurses can also develop alc~hohm.Impaired by alcohol con-
~ ~ U ,z.z
R E init+&wkl &I
alcohol syndrome. rinted wltn sumption, t h q will lack .sufficient insight and judgment to practice
permlsslan. Rtrelssguth kndesman-~wyer,S., Martin, J. C.. % thek profession It i s a moral and le@ Sef;poesibilityto report the
Smith, D. W. (qc~so).-rerat-,- r~c
effects of alcohol in humans andl impaired nurse. Many areas provide intensive therapy program rn
laboratOlV animals. science, 209tIS): 353-361) ather an inclient or outcIien? and the pmm'e job position remains
intact d w the rehabilitation period.
inhib'idtvith lowbirthwekghw and tad infwo.UnusudEa&&@*

ALCOHO'L USE &ND YOUTH

1
act&tics are present i n d u n g eye slits, low p l a m m t of ftre &,
and a wide Bat forehead with a flat nose @gae 1Z-2).

MI^& b I
TREATMENT
fa contrast to the. rapid respoase to treatment elf many physical ill-
nesses,response to treatment is genedyvety slow. Beatment meth-
Eyds for alcohobm v q . Mmy authorities believe &at a mnlti&ceted
appr0ar.h i s best in meetlng the needs of the cUent with alcoholism
'She media mess* to you& % ht&&&q batem*
-day life Mini-markets even seK beer and wine, dang With gaS0-- L%@k"=*q.
b e , food, add snacks. It is easy tO obtain an alcoholicbeverage ?aus% - --
m a rewad a h a sports victory or completion of a day at wurk ltifaceted Approach t o Treating AlGoholis
& o d Studies reveal bat addiction to alcohol is anderb@xosedM &[Coh~lhsAnunymous ~ omeal
t urommc hl%a
.-.,.,v.--.-...-
&e young although &t leading cause of death
~~

menqane years of age is alcohol-related mo

~ l : Wlerapy
@ ~ f i oemotive ce~tefs
!jet@gmmt@m
Plndustrlal alcohol program* Judtcta'lmhabilitatibn
.efFectsof alcohol we or abuse on youth are as folows: !Antabuse.
sl Family d c t s /&lcohoip r o g m for fhe aged ~~ansaceonal
an&i6
a Problems & school perfofmane :Walfwayh0ust.s
'-.mL? - - mK!&
S&QO~ a b ~ ~ C emmq,
6( inmeasea dropmt rates
I
Chapter 12 &
Alcoholism .&
' ."
"=

b1oohol~~cs
Anonymous
5Ieelildiw a P a n m 64AI is an organkition m @former
dcoholirs whose pezmnd expenen- with aIcoIrol enable theni t~
understand the p b 1 m of the persoa wi€hdmholfsrn. T h q learn
&om d i r e obsmtion ofthe ntanyremvered &om aleohoTism ia the
organization, B e goal of Aloohnlies h n y m o u s is for members to
ahstab &om drid&g gne day at a tirae Sobriety help to provide &g
person with dmholim wiih a grawing sense ufse&cn&%71, a&eve-
megt and mgsteqz This provides M e r mativation to &dm fr-oan
drhkhg. There is an inmaseda- of self as the p m m begh
to d e r s m d his or her prob1e.m and feeliqp- tlA meetings use a
stmdmed gmup approach with a w&-d&i?d W d d e p prognun
[.Table l2-32.%& membr has a sponsor and takes m e v&tb a
A lead is a presentation of a pesson's struggle wifh pltwln up it1~0hU1
and the devamjlfing &kc@ of al&l on bLs or her lifk Each persog
defines his or her own spiritual&? an6 hipher power and tbW&F
irmw selk+kemand hope AA bemmes a d]N&al part of8-
fd sob-
&&on (family p u p s ) and Ahteen ( v j &ircus on tkq :
eEects ofalcah- on family and dhil&rmACOQ (Adult Chjldren Q$
AlwholicsJ provides p e m d contaM vwreh other9 who grevv up in d p
f h m t i o ~f& network This p m n a l eontacf is therapeutic and
provides emutianal 6uppaR.

mtronral Emotive merapy

Almhobn b seenby proponents ofratiaQal bmotiye k a p y as b q , ,,
a means of coping, The gad of this the~apyis to help the pason
aleabolism Itam to tolere rhe stixssors &at eome with ]i&g @
use coping meihnbnm @@ are less seIf.de-. It teaches pwa;F
wlrh aleohobm to ~ e c o g n i z e i n a ~ din
e stheir By &@&
ing ffi& views ofthemsehrrs and t h e envitonment, they ma % -
!!heir behvior. The rational emottve thempi& ME%@ that imtiend
thinhg leads to irrational drfnkhg.

Transa~tLonalAndysis
~ a c e f o n adl y s k & another W a p y &pproa&to aItoholism tW-3
has f b d some sueow. The g d of transactional and* is to help
with &oholism stop playhg gain@ and M &e
satpta, AIwhoIism inoolves s
meir
d F e 8 and a variety ~fpa*
* Psychoanalysis
Psychoanalysis invalves the direct interaction of the client wftk a ther-
With ?he cafsatim of game plawg, t-he mderIiqg psohlemS met$@ apist The objective is to gain insightinto behavior throughtaIking.The
more cI&a~Ay.Clients are &en able to wpc with -theirprmhle~m9te therapist assists the client to clarify and work through stressful areas
dir%al$ in his or h a life. The client may be in therapy for a long time.
 Chapter 12
-

Group ~herapy
Group therapy involves meaningful interaction
group. The group members relate their p a d
other. The main objedive is for each group memb
her impact an others through i n m e d
~ r n mbehavior and relatiomhips. The
ichapm 77).

Antabuse (Disulfuram)

Antabuse (dimlfuram] is taken daily

nence from alaohol Antabme interferes with the metabolism
hol and poduces a toxic reaction when combined with it
how they will suffervery unpleasant reactions if they do nUat
&om deinking. The drug is usually well tolerated, but t h m
rimes side egects. These side eff& usually &appear as
adjusts to the druggThe most common side eff& indnde
fatigue, acne, and a metallic aftertaste
If clients drink alcohol while this drug is still in their

effects may last hmtbirtg minutes to several hours;

times ouw~edDuring the reaction, the client is in
situation and should be

and consent W clients should be thoroughly m c d ag-

suming alcohol in any form. Over-the-countm medication

tal iuness. Success with Antabuse depends on a firm r

person wIthalcoholim to abstain from w g .
seldom used because it is a simptistic approach to a cornplW
T ,, p
people permission to do Eor t h e can be dtfRclalt to put into
practice. M a $ personal choices md developing the ab@y to say rn
M y djmiubhes their sympton~.in recawery,the codependent must
be aware of 9abof~girrg behaviors of other6 and identify those people
Nho m&ently "suck them innMonitoring passive or a@Rssive
behaviors wi!J assist with inmmed numbm of as&e&iveencawm
with &ers in their personal and workplace endronments. h o t l m
hcipful approach is ehe praetce of daily personal affirmation&
i4flkmdom are1 statements chmt~d sfienay or out bud to oneaPX
I desem satisfittion, cmtenfment a fmEIling rehtkmship
I d q x e s s my feelings todag~act fn an a s s e e
manner today
hewering codependen@make their own daily choice8 and w e
their beIi@vahxe s;ystems through acriofl-oried belmiors.
TREATMENT FAClLITlES
Various treatment fadlitie are mailable to meet s p d c or g a & d
need@of the & a t =with alcoholism Detoxffication cent= axe p h ~
where the &en€ with aleahobm r&es treatment and care duriiag
the withdrawal proces~.They comprise the ikfirst s%p in treafpeflt
Ia~w, the &nt patidpat@in a canttnuisgw e and rehabiliation prP
@a.m. Refen& ate fpequdy made to l a - t e r m f r e a ~ ~ eprogtam~.
nt
Other times, the & a t is transifered to a residentid treatmment center:
The h a h y home is a n i n m d i a t e r & h c e for the client befbi~
he or s h e ~ a t e t
nhe c m u n i v (Hgure; U3). PPequ&, the &We
is located in the client's commUrn:ty. W i v i d e d a n d o n d L
homelike atmosphee are just two advwtages of tbe program Mo~t
ihalfcvsv houses are oriented to AlAlcoIIes Amaymow aad enmm&ge
$SUE12-3 A halfway house may look like ally m e r home in
tne communiw.
environment is an exellent s e w for early-iden- and @eat-
m a ofproblem drinkm.
For more thaa 35Qyeam pubficimoxica6on w a under the jurb
dictian of aimhal law The penniless drunk; m h r e d through a
prows of afiegt jail, release, md reatTest Sn the past I IR prs,
p r o m h e been made toward fmn&king theproblem drinker 6om
thP penal $ys€emto treament pragrams. It is now recognize8 that the
person with aloohcJlism needs eat- treatnwt and rebabih-
rim.Legfslatim is providing the h e w o r k for this needed treatmeac
3chQal aIa,h01 program are a preventiw measme+T e e n m
need alcohol education programs .intke scfioeIr;.The rommticrtlea of
alcohol e sem in the media must be challeqgxt The r d facts and
patined Iiteratwre shonld be presented Alcaholism is the mst-
neglected health problem in America and msds to be p~smredto the
ado1esmt in fits true light
Few treatment W t i e s @tpe for the nee& of the aged with a
~ g p r o h l e mThe . a@d need therapeuticprogritms geared to t k k
underlying strpssors.%earmat fficUitles should have an h d i v t d u m
approach that attemp@to &cover the pmitcdar problems of each
a$tng ~ W D Dewl~ping
. new &adships and a sense ofwell-being
&+ goup tneetkgs helps all& lonelinms.
Lo%-- goals of a pmgram for tbe aged person with aicu
h~lismme to make we wmhdile to help him Qrher see h&ans,
12~ther than dead eads,
 Oganize a resource file on alcoholism. Obtain fnformation by
writing for literature concaning alcoholism &om
The National Cornoil fbr AlwholiFmInc.
2 ParkAvenw
New Yo&, IVY l 0 O l G
The National Institute ofAlcoho1 Abuse and Alcoholism
5600 Fiscber Lane
Room 11A 58
RoclaSlle, MD 20852

REVIEW
- --

XNOW AND COMPREHEND

A Mdtiple choice. Select t h e one best answer.
1. The amendment Eotbiddtng the manuFacture, distributian, and
sale of alcoholic beverages was the
D d Temperance Amendment
El B. Psohibition Amendmeat
P C. DBtinatim Amendment
O D. Alcoholic Amendment
2. The treatment method that fowes on changingbehavior by
changing the clients'piewrs of themsdw and their eravirok
ment is termed
P k transactionat analysis.
D B. rleto*cation method
0 C. Alcoholics Anonymous.
Cl D. rational emotiw therapy
3. h treatment approach Bat tries to help the client to stop
game playing and rewrite his or her life saipt is
P A. rational emotive therapy
0 B. transa&onal anal*.
P C. drug therapy
D D. AlfflholicAnonymous.
4. Which of the following below arcurately describes alw-
holiam?
D R a serious problem that develops &er adolescence
P B. a pmpsive, fatal, and mmplex disease
l C. an effective way to cnpe with stress
t
El D. a habit of drinking more than m e infended

APPLPTOURL-
B, WaMple Cholerr, &led fbP onefa&
Alcoholism
4. A practical nurse w& clients in an alcohol treamertt
center abwt their disease. XVhich client is in the earliest stage
ofthe rehabilltation process? The client who sap:
O A *I understand that alcoholisfn is a lifelong tiisease
proces8:
5 B."My chinkinghas a w e d prablens in my family rela-
ticinships?
U C. "I've never had a problem h d t n g or Keeping a job."
5 D. 'Tve often M guilry about my drinkhg?
5. The mrse cares For an Mtnt with feral alcohol syndrome
PAS). Qahich characteristic is moat likely present in the
infant?
Q A. low Weight &f & P
answet: U B. m w pointeil
~ nose
a c.wide, bulging q e s
5 D, edematous extremities
6 You are a nurse tYarking on a m & ~ ~ s q unit i d Durbg
the s h i change repm at the b e g i g of a new shiR you
notice the sm$ of alcohol on another nuwe's skin and
breath. Based on tbb o b m t i o n which action would you
hplement?
A in- the nutae of your obsemttion
5 B. observe fhg nume for impaired performance
5 C. ask a wwmker if they smeli alcohaI
5 D, noti@the nursing supervisur ofthe obsemtion
C. Briefly m w e r the following,
1. ?%%atis the pnrpose of the Wa'tionalInmimte for &&I
Abase and NcohoIlsm?
4- List siX sympt~msof almhol withdrsd

5. List ten nming interventionswhen caring for the client with

alcoholism.

6. B r a y desuibe the objdves of=& o f t h e folloMimg cor

rnunity programs.
A. AEcohoUres Anmyraous

I),hot meals psograms