- Dementia Neurocognitive disorder with dysfunction or loss of " Memory " Orientation " Attention " Language " Judgment " Reasoning Other characteristics that can manifest " Personality changes " Behavioral problems such as Agitation Delusions Hallucinations 1 Dementia Problems ultimately disrupt individual s " Work " Social responsibilities " Family responsibilities " Ability to perform ADLs 2 Dementia Etiology and Pathophysiology Due to treatable and nontreatable causes " Treatable conditions can become irreversible with prolonged exposure or disease Most common causes " Neurodegenerative conditions " Vascular disorders Vascular dementia " Brain lesions caused by cardiovascular disease Ischemic lesions, Hemorrhagic brain lesions Mixed dementia - 2 or more types of dementia present at the same time " Hallmark abnormalities of Alzheimer s disease + another type of dementia " Usually vascular dementia Normal pressure hydrocephalus Obstruction of CSF flow Meningitis, encephalitis, head injury Treatable when diagnosed early 3 1
Dementia Clinical Manifestations Onset of dementia depends on cause " Gradual and progressive over time Neurologic degeneration " Abrupt Vascular dementia tends to be abrupt or progress in a stepwise pattern Difficult to distinguish etiology on the basis of symptoms alone " Acute or subacute pattern of change may be more indicative of an infectious or metabolic change " Manifestations of different types of dementia overlap Complicated by coexisting medical issues 4 Dementia Clinical Manifestations Initial symptoms are related to changes in cognitive function Family members often report Memory loss " Mild disorientation " Trouble with words and numbers 5 Audience Response Question The daughter of a patient with early familial Alzheimer s disease (AD) asks how AD is different from forgetfulness. You describe early warning signs of AD, including a. Forgetting a colleague s name at a party b. Repeatedly misplacing car keys or a wallet c. Leaving a pot on the stove that boils dry and burns d. Having no memory of preparing a meal and forgetting to serve or eat it 6 2
Dementia Diagnostic Studies Diagnosis is focused on determining the cause " Thorough medical, neurologic, psychologic history, and mental status testing Rule out other conditions " Neuroimaging techniques 7 Nursing and Interprofessional Management Similar to management and drug therapy of patients with AD " Vascular dementia can often be prevented through treatment of risk factors Hypertension, diabetes, smoking, hypercholesterolemia, cardiac dysrhythmias 8 Neurodegenerative Diseases Dementia with Lewy bodies (DLB) " Characterized by presence of Lewy bodies in brainstem and cortex Intraneural cytoplasmic inclusions " Features of Parkinson s disease Medication therapy may assist with symptoms 9 3
Chronic, progressive, neurodegenerative brain disease " Most common form of dementia " ~5.4 million Americans suffer from AD 11% people over age 65 have AD ~ 33% of those over age 85 have AD 6 th leading cause of death in the United States Only cause of death among the top 10 that cannot be prevented, cured, or even slowed " Burden of care is staggering " Known as the long good- bye or death in slow motion 10 Etiology Exact etiology is unknown but likely due to multiple factors " Greatest risk factor is age Most diagnosed at or after age 65 Not a normal part of aging Age alone is not sufficient to cause AD " Family history Those with a 1 st degree relative with dementia are more likely to develop AD Even higher risk with > 1 relative Family history is not necessary for an individual to develop AD 11 Small percentage of people < 60 years old develop AD Early- onset: <60 years old " Late- onset: >60 years old Genetic Link Familial Alzheimer s disease (FAD) " Clear pattern of inheritance " Onset before age 60 " Rapid disease course Sporadic Alzheimer s disease " No familial connection 12 4
Etiology Brain and heart/circulatory health are closely linked Many factors risk of CV disease " Diabetes " Hypertension " Obesity " Hypercholesterolemia " Smoking 13 Etiology Diabetes significantly risk of developing AD or other dementia " Diabetes mellitus Chronic high levels of insulin and glucose may be toxic to brain Insulin resistance may interfere with ability to break down amyloid Head trauma 14 Pathophysiology Changes in brain structure and function " Amyloid plaques " Neurofibrillary tangles " Loss of connections between neurons " Neuron death 15 5
Gene%c factors β- amyloid protein produc%on Plaques 1 st develop in areas of brain used for memory and cognitive function Eventually cerebral cortex becomes involved Neurofibrillary tangles " Abnormal collections of twisted protein threads inside nerve cells " Main component is a protein called tau Pathophysiology Gradual loss of connections between neurons and neuron death " Results in structural damage " Affected parts of brain shrink Brain atrophy Significant in final state of AD 16 Effect of on Brain Clinical Manifestations: Pathologic changes precede clinical manifestations by 5 to 20 years Alzheimer s Association has developed a list of 10 warning signs that are common manifestations of AD 17 Clinical Manifestations Early warning signs of AD 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 judgment 6. Problems with abstract thinking 7. Misplacing things 8. Changes in mood or behavior 9. Changes in personality 10. Loss of initiative 18 6
Clinical Manifestations Categorized Mild Moderate Severe Progression Highly variable from person to person Ranges from 3 to 20 years Normal memory decline does not interfere with ADLs Recent memory loss à Remote memory loss à Interference with ADLs 19 Clinical Manifestations As the disease progresses " Personal hygiene " Concentration and attention " Unpredictable behavior " Delusions and hallucinations Changes are not under control of patient Additional cognitive impairments " Dysphasia " Apraxia " Visual agnosia " Dysgraphia " Inability to recognize family and friends " Wandering 20 Clinical Manifestations Later stages " Unable to communicate " Cannot perform activities of daily living (ADLs) " Patient becomes unresponsive and incontinent " Total care is required Retrogenesis " Process where degenerative changes occur in the reverse order in which they were acquired Developmental stages in children compared with deterioration in AD patients 21 7
Preclinical Stage No current treatment successfully modifies the progression of AD Early intervention is a future goal " Modify disease before Plaques and tangles have formed Symptoms emerge " Ongoing research 22 No definitive diagnostic test exists for AD " Diagnosed by exclusion " Made once all other possible conditions causing cognitive impairment have been ruled out Diagnostic Studies Comprehensive patient evaluation " Complete health history " Physical examination " Neurologic assessment " Mental status assessment " Laboratory tests 23 Diagnostic Studies Brain imaging tests " CT " MRI " PET Help detect early changes in disease process Enable monitoring of treatment response Definitive diagnosis of AD usually requires an autopsy Biomarkers are promising, but more research is indicated " Level of β- amyloid accumulation in the brain " Injured or degenerating nerve cells 24 8
Biomarkers include " CSF neurochemical markers β- amyloid and tau proteins Plasma levels are not diagnostic " Imaging biomarkers Volumetric MRI and PET Brain volume correlates with neurodegeneration Diagnostic Studies Neuropsychologic testing can help document degree of cognitive impairment " Mini- Cog " Mini- Mental State Examination (MMSE) " Also used to determine a baseline from which to evaluate change over time 25 Diagnostic Studies 26 Interprofessional Care No cure " No treatment exists to stop the deterioration of brain cells in AD Interprofessional care is aimed at " Controlling undesirable behavioral manifestations " Providing support for family caregiver 27 9
Drug Therapy Drugs available today help many people but not for very long and not very well " Some modest in rate of decline of cognitive function " No effect on overall disease progression Memantine (Namenda) protects nerve cells against excess amounts of glutamate " Glutamate is released in large amounts by cells damaged by AD 28 Drug Therapy Treating associated depression " May improve cognitive ability " May help with sleep problems " SSRIs are often used Antipsychotic drugs " Manage behavioral problems " Risk of death in older patients 29 Impaired memory Self- neglect Risk for injury Wandering Nursing Diagnoses 30 10
Planning Overall goals for patients " Maintain functional ability as long as possible " Be maintained in a safe environment with a minimum of injuries " Have personal care needs met " Have dignity maintained Overall goals for caregivers Reduce caregiver stress " Maintain personal, emotional, and physical health " Cope with long- term effects of caregiving 31 Keep your brain healthy " Avoid harmful substances " Challenge your mind " Exercise regularly " Stay socially active " Avoid trauma to the brain Health Promotion " Take care of mental health " Treat diabetes " Take care of your heart " Get enough sleep " Get the right fuel Early recognition and treatment are important Inform patients and their families regarding early signs of AD 32 Diagnosis is very traumatic Patient often responds with " Depression " Denial " Anxiety and fear " Withdrawal " Feelings of loss Acute Care Assess your patients for depression and suicidal ideation " Counseling and antidepressants may be indicated Family caregivers may be in denial, delaying critical early care " Accept their ability to cope 33 11
Acute Care Ongoing monitoring important " Work in collaboration with patient s caregiver " Teach caregiver how to manage clinical manifestations effectively as they change over time " Patient and caregiver have overlapping but unique problems and needs 34 Acute Care AD patients subject to hospitalization for other problems. What are some? Inability to communicate symptoms places responsibility on caregiver and health care professionals Hospitalization can precipitate Worsening of dementia Development of delirium 35 Ambulatory Care Family members and friends care for most AD patients in their homes Various facilities should be evaluated " Consider stage of AD patient when choosing " Nursing care intensifies over time 36 12
Ambulatory Care In early stages, memory aids may provide benefit " Depression often develops " Advance directives should be set Adult day care can provide " Caregiver respite " Stimulation for AD patient 37 Ambulatory Care Severity of problems and amount of care intensifies over time " Demands on caregiver can exceed resources " May need long- term care placement Special dementia units are becoming increasingly common Emphasis is on safety 38 Behavioral Problems Occur in most patients with AD These problems include " Repetitiveness " Delusions " Hallucinations " Agitation " Aggression " Altered sleep patterns " Wandering " Hoarding " Resisting care Can be unpredictable and challenging " Often lead to placement of patients in institutional care settings Are a patient s way of responding to precipitating factor " Pain " Frustration " Temperature extremes " Anxiety 39 13
Behavioral Problems Assess patient s " Physical status " Environment Move patient or remove stimulus Reassure patient about safety Rely on mood and behavior rather than verbal communication Don t ask patient why Nursing strategies to address difficult behaviors " Redirection " Distraction " Reassurance Do not threaten to restrain patient or call HCP Exhaust options before using drugs 40 Behavioral Problems Sundowning " Specific type of agitation " Patient becomes more confused and agitated in late afternoon or evening May be due to disruption of circadian rhythms Nursing interventions for sundowning " Create a quiet, calm environment " Maximize exposure to daylight " Evaluate medications " Limit naps and caffeine " Consult health care provider on drug therapy 41 Risks " Injury from falls " Ingesting dangerous substances " Wandering " Injury to others and self with sharps " Burns " Inability to respond to crisis Safety Minimize risks in home environment " Assist caregiver in assessing home environment for safety risks " Implement all possible safety strategies Supervision 42 14
Safety Wandering is major concern " Observe for precipitating factors or events " Patient can be registered with Medical Alert + Safe Return " GPS 43 Pain Management Pain should be recognized and treated promptly " Monitor patient s responses " Patients can have difficulty communicating complaints " May exhibit changes in behavior 44 Eating and Swallowing Difficulties Undernutrition is a problem in moderate and severe stages " Loss of interest in food " Decreased ability to self- feed (feeding apraxia) " Co- morbid conditions When chewing and swallowing become difficult, use " Pureed food " Thickening liquids " Nutritional supplements Quiet and unhurried environment Easy- grip utensils 45 15
Eating and Swallowing Difficulties Offer liquids frequently Finger foods may allow self- feeding Short- term possibilities " Nasogastric (NG) feedings " Percutaneous endoscopic gastrostomy (PEG) tube 46 Oral Care In late stages, patient will be unable to perform oral self- care " Dental problems are likely to occur " Patient may pocket food, adding to potential tooth decay " Inspect mouth regularly and provide mouth care 47 Infection Prevention Common " Urinary tract infection " Pneumonia Ultimate cause of death in many AD patients Manifestations need prompt evaluation and treatment 48 16
Skin Care In late stages, patients are at risk for skin breakdown " Incontinence, immobility, and undernutrition Tend to rashes, areas of redness Keep skin dry and clean Change patient s position regularly 49 Elimination Problems Urinary and fecal incontinence during middle to late stages Habit or behavioral retraining may episodes Constipation may relate to immobility, dietary intake, fluids 50 Caregiver Support AD disrupts all aspects of personal and family life " Very stressful " Caregivers also exhibit adverse consequences Employment and emotional and physical health Can result in family conflict and strain Caregiving increases risk for development of dementia " Chronic and severe stress can affect the hippocampus Hippocampus is a region of the brain responsible for memory Assess caregiver expectations 51 17
Evaluation Expected Outcomes " Functions at highest level of cognitive ability " Performs basic personal care activities of daily living including Bathing, dressing, feeding, and toileting by self or with assistance as needed " Experiences no injury " Remains in restricted area during ambulation and activity 52 Audience Response Question D.B. is admitted to a long- term care facility. He has a nursing diagnosis of impaired memory related to effects of dementia. An appropriate nursing intervention for him is to a. let him know what behavior is socially appropriate. b. assist him with all self- care to maintain self- esteem. c. maintain familiar routines of sleep, meals, drug administration, and activities. d. promote orientation at every encounter with the patient by asking the day, time, and place. 53 18