Progressive, degenerative brain dysfunction, including
deterioration in memory, concentration, language skills, visuospatial skills, and reasoning Progressive forgetfulness, memory loss, and loss of other cognitive function Interferes with a persons daily functioning Not considered a normal part of aging Dementia: Background 4 million older adults have some form of dementia How is dementia different from depression and delirium? Slower onset Progressive, not variable Irreversible Different causes Lowest MMSE Risk Factors for Dementia Age Family history Genetic factors Head trauma Vascular disease Infections Other modifiable factors Maintain ideal body weight Exercise Avoid smoking Control hyperlipidemia and hypertension Exercising the brain with lifelong cognitive activity may help lower the risk of dementia Causes of Dementia Drugs Environmental Metabolic Eyes/Ears sensory deprivation Nutrition Trauma/Tumor Infections Alcohol abuse or intoxication Assessing for Dementia Mini-COG A reliable and valid instrument used to screen for cognitive impairment consisting of 3-item recall test and a clock-drawing test (CDT) It is evidence-based, easy to administer, and not too taxing for patient or provider Is a screening test, doesnt provide diagnosis CLOCK DRAWING TEST Types of Dementia Alzheimers #1 Vascular Parkinsons Lewy body Frontal lobe dementia Lose inhibition and executive functioning skills earlier than AD Normal pressure hydrocephalus Rare but partially reversible with surgery Acute onset of a triad of symptoms slowed cognitive processes, gait disturbances, UI Alzheimers Disease (AD) The most common type of dementia seen in older adults Advanced age is the single most significant risk factor Estimated 5.2 million Americans affected in 2008 5 million over age 65 Estimated to reach 7.7 million in 2030 Projected 11 16 million by 2050 Alzheimers Disease (AD) May live from 3 20 years or more after diagnosis Seventy percent of people with AD live at home until the latest stages, being cared for mainly by family members (Alzheimers Association, 2005 Costs $61 billion annually Expected to exceed $163 billion/yr by 2050 Characterized by progressive memory loss Average life span of 8 years after dx Alzheimers Disease (AD) Two types of abnormal lesions in the brains of individuals with Alzheimer's disease: Plaques Neurofibrillary tangles Definitive diagnosis is still through biopsy Dx: early dx is important to maximize function and QOL as long as possible Diagnosing Alzheimers Memory impairment alone doesnt indicate AD Requires one of the following features Impaired executive function Aphasia word finding difficulties Apraxia cannot carry out motor skills Agnosia cannot name familiar object Must rule out delirium, depression, other CNS disorders, medication side effects, and other medical conditions first! Diagnosing Alzheimers (contd) H & P Review of medications Laboratory testing Neuropsychological screening/testing Mini Mental Status Exam (MMSE) no longer available in public domain Mini-Cog Imaging PET scan to rule out dementia Medications for Dementia Medications slow progression but do not stop decline over time Cholinesterase Inhibitors (CEIs) donepezil (Aricept) rivastigmine (Exelon) galantamine (Razadyne) N-methyl-D-aspartate (NMDA) Receptor Antagonist memantine (Namenda) approved for moderate to late stage Anticholinergics can worsen cognitive function AD: Warning Signs Ten warning signs of Alzheimers Disease Memory loss Difficulty performing familiar tasks Problems with language Disorientation to time and place Poor or decreased judgment Problems with abstract thinking Misplacing things Changes in mood or behavior Changes in personality Loss of initiative AD: Treatment Medications (Aricept, Namenda) may help slow progress but does not change disease course Symptom management Behavior Safety Nutrition Hygiene As dementia progresses, likely to be institutionalized Support for family/caregiver Support groups Respite Be aware of caregiver strain Other Types of Dementias Vascular dementia results from multiple cerebral infarctions more rapid and more predictable than AD risk factors: HTN, hyperlipidemia, history of stroke, smoking Lewy body dementia presence of Lewy body substance in cerebral cortex many gerontologists consider this the same type of dementia as AD Other Types of Dementias Creutzfeld-Jacob disease (Mad Cow) Rare brain disorder Rapid onset and progression Slow virus Familial tendency Destruction of neurons in cortex Symptoms more varied than AD Death with 1 year Other Types of Dementias Parkinsons disease Small percentage of those with dementia are this type Degeneration of neurons due to lack of neurotransmitter, Dopamine Delirium: Background Also called acute confusion Occurs in 22- 38% of older patients in the hospital Occurs in as many as 40% of long-term care residents Associated with increased length of stays in the hospital and higher mortality rates Delirium: Background Altered level of consciousness Temporary Reversible Many treatable causes Need to distinguish delirium, depression, and dementia Delirium Treatment of delirium requires the diagnosis and treatment of the underlying physiological problem while using pharmacologic and non- pharmacologic interventions to maintain patient safety and return the patient to the pre-delirium state (Mauk, pg. 445). Delirium: Potential causes Fluid and electrolyte imbalances Infection CHF Medications Pain Impaired cardiac or respiratory function Emotional stress Unfamiliar surroundings Malnutrition Anemia Dehydration Alcoholism Hypoxia Causes of Delirium Drugs Electrolytes Liver failure Infection Renal failure Impaction UTI or urinary retention Metastasis Delirium: Signs/Symptoms Sudden onset Disorientation to time and place Altered attention Impaired memory Mood swings Poor judgment Altered LOC Decreased MMSE score (less than depression, but more than dementia) Delirium: Treatment Detect promptly by good H & P MMSE, GDS and CAM are good assessment tools CBC, Lytes, LFTs, Renal function, Serum calcium and glucose, UA, CXR, EKG, O2 Sat For all Older Adults with Cognitive Impairment Maintain privacy and dignity Realize their value as a unique individual Maintain independence for as long as possible Minimize restraints find other answers to address wandering Continue human contact and environmental stimulation Repetition Delirium Acute confusion Four basic features Acute onset or fluctuating course Inattention Disorganized thinking Altered level of consciousness Primary treatment is to eliminate the cause Delusion of theft and phantom intruder Potential Causes of Delirium Inadequate or inappropriate pain control Medications (including new or change in dose) Fecal impaction Infection/fever Injury/severe illness Electrolyte imbalance (glucose, Na+) Dehydration Change in surroundings Hypoxia Age Male gender Cognitive impairment (dementia) Hypotension Malnutrition Depression Alcoholism Restraints Multiple IVs, lines, tubes Assessing for Delirium Delirium is often unrecognized by clinicians Hence patients should be assessed frequently using a standardized tool to facilitate prompt identification and management of delirium and underlying etiology Confusion Assessment Method (CAM) Sensitivity of 94-100% Specificity of 89-95% CAM The Short Version 1. Acute Onset Is there evidence of an acute change in mental status from baseline? 2. Inattention Does the patient have difficulty focusing attention; easily distractible; have difficulty keeping track of what is being said? Does this behavior fluctuate; come and go or increase and decrease in severity? 3. Disorganized thinking Is the patients thinking disorganized or incoherent, such as rambling or irrelevant conversation, unclear or illogical flow of ideas, or unpredictable switching from subject to subject? 4. Altered level of consciousness Overall, how would you rate this patients level of consciousness? Alert = normal Vigilant = hyper-alert, overly sensitive to environmental stimuli, startled very easily Lethargic = drowsy, easily aroused Stupor = difficult to arouse Coma = unarousable Uncertain CAM Continued Should assess patient on admission and during each shift Engage pt. in conversation for about one minute. Ask: What brought you to the hospital? How are you feeling now? Delirium is identified only if there is evidence of features 1 and 2, and either 3 or 4 (or both) Nursing Interventions/Strategies Use general strategies (as appear in next slides) Address specific issues/behaviors Wandering Aggression Restlessness Agitation Physical comfort Pain