Cognitive & neurologic, delirium & dementia spring 2014 abridged

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Cognitive & NeurologicDelirium & Dementia

NURS 4100 Care of the Older Adult Spring 2014Joy Shepard, PhD(c), MSN, RN, CNE, BC/ Riley Barwick, BSN, RN

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Objectives Describe the cognitive and neurologic effects of

aging Identify signs and symptoms of cognitive and

neurologic disorders in older adults Differentiate delirium from dementia Identify factors that cause delirium in older adults Lists causes of dementia in older adults Describe the symptoms, unique features, and

related nursing care for Alzheimer’s Dementia

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Key Terms Intelligence – Ability to think & learn new things Level of consciousness – Degree of cognitive

function involving arousal mechanisms Alert, responsive to voice, responsive to pain, or

unresponsive Most sensitive indicator of deterioration of Most sensitive indicator of deterioration of

neurological statusneurological status Memory – Ability to retain or store information

and retrieve it when needed

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Key Terms Orientation – Awareness with regard to

person, place, time, and situation Perception – Ability to experience,

recognize, organize and interpret sensory stimuli

Sensation – Ability to receive and process stimuli received through sensory organs

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Cognition – Mental Process of Knowing Mental activities: information

Receiving Comprehending Storing Retrieving Using

Includes Sensation & perception Attention Memory Problem-solving

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Age-Related Changes Affecting Cognitive & Neurologic Functioning

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Normal Changes of Aging – Cognitive & Neurologic

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Question Normal age-related changes in the

nervous system can include all of the following EXCEPT:

(A) Changes in sleep patterns (B) Delayed reaction time (C) Increased perception of pain (D) Reduced blood flow to the brain (E) Slower reflexes

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Aging & Cognitive Function

Not characterized by cognitive & mental disorders

Mental health & cognition remain stable

Functional changes: usually no significant impairment

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Aging & Cognitive Function Cognitive skills negatively affected by age

Remembering Solving complex problems Paying attention Reaction time Information processing

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Effects of Aging on the Neurologic System

Loss of nerve cell mass Atrophy: brain & spinal cord

Number of nerve cells declines Nerve conduction: slower Response & reaction times: slower Reflexes: weaker

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Some plaques, tangles, & atrophy of brain Free radicals accumulate Decrease in cerebral blood flow Intellectual performance unchanged Slowing in central processing

Delay in time required to perform tasks

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Verbal skills maintained Number and sensitivity of sensory

receptors, dermatomes, and neurons decrease Dulling of tactile sensation

Decline in function of cranial nerves affecting taste and smell

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Aging & Cognitive Function: Intellectual Function Basic intelligence maintained

Verbal comprehension & arithmetic Crystallized intelligence (wisdom) – improves with age

Accumulation of knowledge over lifespan Application of skills/ knowledge to solving problems Wisdom, practical knowledge Tasks using well-practiced skills or familiar information not

affected by age Wisdom, knowledge of ways of world, accumulation of

practical expertise = strength

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Aging & Cognitive Function: Intellectual Function Fluid intelligence (creativity) – declines with age

Information processing system (speed with which information can be analyzed)

Ability to plan, organize, or think abstractly (executive function)

Ability to learn new concepts Attention, memory capacity Complex tasks

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Aging & Cognitive Function: Memory Short-term (recent) memory – reduced (mild

forgetfulness) New information forgotten more rapidly More difficulty retaining information in the

presence of interference or shifting attention Memory aids, cues, or reminders can assist

Long-term (remote) memory – remains intact

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Question Cognitive functions that are negatively affected by

normal aging include (Select all that apply): A. Remembering B. Solving complex problems C. Vocabulary D. Paying attention E. Arithmetic F. Reaction time G. Speed of information processing H. Wisdom, judgment

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Question When teaching older adults, the nurse should

(Select all that apply): A. Allow more time for processing information B. Include shorter, more frequent sessions C. Provide a dim environment to reduce stimuli D. Limit background noise E. Provide information that is concrete rather than abstract F. Make sure there are as few distractions as possible G. Present one idea at a time H. Provide instructor-paced, rather than learner-paced sessions

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Question

The mental process most sensitive to deterioration with aging is: A. Creativity B. Judgment C. Intelligence D. Short-term memory

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Symptoms That Should Be Investigated

Memory & intellectual difficulties Change in sleep patterns Delusions, hallucinations, disordered

thinking Loss of emotional responsiveness (flat

affect)

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Impaired Cognition

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Impaired Cognition Fear of loss of cognitive function Losses that result from impaired cognition Aging increases the risk for:

Delirium: acute and reversible Dementia: chronic and irreversible

Differences between delirium & dementia

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How Does Delirium Differ from Dementia?

Delirium Rapid onset Fluctuates; worse at

night Altered LOC Easily distracted;

attention impaired

Dementia Chronic, insidious Symptoms progressive

but stable LOC usually not

affected Tries hard to do task;

great effort to recall

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Question Is the following statement true or

false?

A major difference between delirium and dementia is that delirium alters a person’s level of consciousness whereas dementia does not

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Delirium

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Definition of Delirium State of temporary, but acute mental confusion Syndrome – Rarely caused by a single factor; often result

of interaction of patient’s underlying condition with precipitating event

Characterized by disorganized thinking, difficulty in concentrating, and sensory misperceptions that last from 1 to 7 days

Reduced level of consciousness Difficulty focusing, shifting or sustaining attention

Cognitive change Deficit of language, memory, orientation, perception; not attributed to

dementia

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Definition of Delirium Cont’d… Develops rapidly (hrs to days) Varies (fluctuates) during the day Disturbances: attention, perception, thinking,

memory, psychomotor behavior, sleep-wake General medical condition directly causes it A key distinction between delirium and dementia is

that the person who exhibits sudden cognitive impairment, disorientation, or sensory misperceptions is more likely to have delirium rather than dementia.

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Recognition of Delirium Impaired attention,

distractibility Prominent disorientation

Disorganized & distorted thinking (fearfulness, paranoia)

Inability to recall recent events

Incoherent speech Inability to sleep

Disorders of perception Terrifying hallucinations,

vivid dreams Intense emotional

disturbances Strange, absurd

fantasies & delusions Psychomotor behavior:

lethargic, agitated, or mixed

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Confusion Assessment Method (CAM) DELIRIUM

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Delirium = Acute Confusion

Occurs frequently in older adults Delirium begins with confusion, can proceed to

stupor or excessive activity Time limited (hrs to days) Fluctuates over the course of day Reversible…

…With prompt treatment Treat underlying cause(s), coexisting factors Variable outcome

Can range from full recovery to death

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Delirium: Acute State of Confusion

A medical emergency High morbidity & mortality rate (20-30%),

longer hospital stay, increased risk nursing home placement Delirium has a fatality rate as high as Acute MI

or Sepsis (Cleveland Journal of Medicine, Nov 2004)

Reversible if Dx and Tx in time!!!

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Delirium – Risk Ractors Advanced age Advanced age higher risk!!! Cognitive impairment or dementia

(older people with dementia are especially susceptible to delirium)

Hx of previous episodes of delirium

Multiple medical conditions Multiple medications Severe stress (from events like a

move to a new environment, recent surgery or recent injury)

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Delirium: One of the Most Commonly Encountered Medical Disorders in Medical Practice!!!

10-40% of elderly general medical patients will experience a LIFE THREATENING CONFUSIONAL STATE

Up to 40% of long-term care residents 40-60% of surgical patients Up to 80% of patients in ICUs (“ICU Psychosis”) Do not accept symptoms as “normal” REQUIRES CONTINUOUS NURSING CARE

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Delirium – Causes (Box 33-1, p. 443)

Drugs Particularly anticholinergics, sedative-hypnotics, benzodiazepines, barbiturates, opioids; many medications (polypharmacy)

Electrolyte imbalance Especially from dehydration; Na+, K+

Lack of drugs Stopping certain medications, alcohol withdrawal

Infection Particularly urinary or respiratory tract infections (UTI or pneumonia); blood or wound infection after an injury or surgery

Reduced sensory input Such as poor or uncorrected vision and hearing

Intracranial Such as from a stroke

Urinary or fecal problems Such as inability to empty bladder or bowel

Myocardial (heart) and lungs Heart attack, pneumonia, or other condition causing lack of oxygen in the blood and the brain

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UTI & Pneumonia UTI

Positive leukoesterace on urinalysis Positive nitrites WBCs in urine Danger of evolving into urosepsis (can occur very

rapidly) Confusion

Pneumonia – Anorexic, LOC changes

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Delirium – Nursing Care Roles of nurse: prevention, early

recognition, and treatment Focused on eliminating precipitating

factors Prevention of harm Establishing medical stability Minimizing stimulation (cluster care) Consistency in care Teaching and support

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Sundowner Syndrome (Box 33-2, p. 448) Nocturnal confusion Confusion “as the sun

goes down” Increased with unfamiliar

surrounding Often disturbed sleep

patterns May result from excess

sensory stimulation or deprivation

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Prevention/Management of Sundowner’s Keep familiar objects in view Provide physical activity during the day Avoid napping during day Use a nightlight in room Provide human contact and touch for

reassurance Control noise and visitors in evening Meet basic needs for fluids, food, toileting

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Question An 84-year-old patient with a diagnosis of delirium is admitted to the An 84-year-old patient with a diagnosis of delirium is admitted to the

hospital. In addition to being acutely confused, the patient is vomiting and hospital. In addition to being acutely confused, the patient is vomiting and jaundiced, and has bruises and petechiae on his trunk. jaundiced, and has bruises and petechiae on his trunk.

To evaluate the cause of the patient’s delirium, laboratory analyses of To evaluate the cause of the patient’s delirium, laboratory analyses of blood are ordered. The results are as follows: serum creatinine 1.0, blood blood are ordered. The results are as follows: serum creatinine 1.0, blood urea nitrogen 10, potassium 3.21, sodium 138, glucose 80, INR 5.3, Hgb urea nitrogen 10, potassium 3.21, sodium 138, glucose 80, INR 5.3, Hgb 7.0, Hct 21, serum albumin 2.1, elevated ALT / AST, and elevated bilirubin. 7.0, Hct 21, serum albumin 2.1, elevated ALT / AST, and elevated bilirubin.

Based on these laboratory results, the nurse should record which of the Based on these laboratory results, the nurse should record which of the following nursing diagnoses on the patient’s care plan?following nursing diagnoses on the patient’s care plan?

A. Acute Confusion r/t Hyperkalemia B. Deficient Fluid Volume r/t Vomiting C. Disturbed Sensory Perception r/t Hepatic encephalopathy D. Ineffective Cerebral Tissue Perfusion r/t Hypoglycemia

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Dementia

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Dementia – Impaired Cognitive Function Syndrome – dysfunction or loss of memory, orientation,

language, reasoning, and judgment Progressive, irreversible deterioration in the following

areas: Memory, orientation, language, reasoning, problem-solving,

sociability, mood, personality, & functionality Deterioration of cognitive function eventually becomes

extreme enough to INTERFERE with social and occupational functioning Judgment and moral/ethical behaviors decline Disorganization of the personality

Both chronic and terminal (fatal) illness

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Dementia – Impaired Cognitive Function Profound effect on MEMORY

Begins with difficulty remembering recent events (short-term memory impairment)

Deterioration progresses over time ATTENTION is preserved until late in the

disease ~8 million older adults affected Not a “Normal” Part of Aging

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Mini-Cog Assessment Instrument DEMENTIA

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Dementia: Clinical Diagnosis Dx of dementia – at least two cognitive

deficits: Short-term memory Aphasia – impairment in use of language Apraxia – impairment in coordinated movements Agnosia – loss of ability to recognize common objects Impaired ability to plan, organize, sequence, or think

abstractly (executive dysfunction) Delirium must be ruled out

How Common is Dementia? < 65 years Rare

Less than 4% of all cases of dementia

65 – 85 years 10% At age 65, risk increases 1% per year

86 – 100+ years 50% At age 86, risk increases 11% per year

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Causes of Dementia for People 71 Years of Age & Older

70% Alzheimer’s Disease 17% Vascular dementia 13% Other dementias, including

Lewy body dementia

Source: Alzheimer’s Association

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Alzheimer’s Disease (AD)

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Alzheimer’s Dementia (AD)

Organic brain disease: affects memory, thinking & behavior 5th leading cause of death (65 and above) 1 in 3 seniors dies with AD or another dementia Most common form of dementia

One in eight older adults (12.5%) Aging biggest risk factor

~50% > 85 years old may develop AD Lasts 2-20 yrs with average duration 8 yrs

Not a normal part of aging!

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Alzheimer’s Dementia (AD) 5.4 million Americans diagnosed with AD (1 in 9 older Americans!)5.4 million Americans diagnosed with AD (1 in 9 older Americans!)

Projected 7.7 million by 2030 Projected 16 million Americans by 2050

80% of people with AD live at home until latest stages, being cared for mainly by family 15 million unpaid family/friend caregivers

Annual expenditures: $203 billion (an additional $216 billion when considering lost wages) 1.2 trillion by 2050

http://youtu.be/BXnZt5VMjZY http://www.alz.org/downloads/Facts_Figures_2011.pdf

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Alzheimer’s Effects on the Brain Nerve cells in brain affected:

1. Neuritic plaques with beta-amyloid protein (amyloid plaques) 2. Neurofibrillary tangles deep in the brain (cortex) 3. Loss of connections between nerve cells (neurons) and cell

death Loss of neurons and synapses Beta-amyloid protein fragments – cluster outside cells in

brain to form sticky clumps/ plaques (early in AD) Tau protein tangles – aggregates inside brain cells, forming

twisted strands of neurofibrillary tangles (later in AD, more direct effect on cognitive function)

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Alzheimer’s Effects on the Brain Changes in neurotransmitter systemsChanges in neurotransmitter systems

Serotonin and acetylcholine Disrupts three processes that keep neurons healthy Disrupts three processes that keep neurons healthy

memory failure + personality changes + difficulty with ADLsmemory failure + personality changes + difficulty with ADLs Communication Metabolism Repair

Results:Results: Loss of memory Thinking & language skills Behavioral changes

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Alzheimer’s Effects on Alzheimer’s Effects on the Brainthe Brain

http://www.alz.org/brain/10.asp

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How Alzheimer’s Spreads in the Brain

http://www.alz.org/brain/08.asp

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Risk Factors of Alzheimer’s Disease

1. Age - Likelihood of developing AD doubles every 5 yrs after age 65. After age 85, risk reaches ~50 %

2. Family hx/ genetics 3. Head injury 4. Heart health – Same risk factors as vascular dz (diabetes,

HTN, high cholesterol) 5. Latino & African American ethnicity 6. Lifestyle (healthy aging) – Weight; tobacco & alcohol,

physical exercise, healthy diet (whole grains, fruits & vegetables, low in saturated fat), regularly exercise the brain (learning a new language, puzzles, word searches)

http://www.alz.org/alzheimers_disease_causes_risk_factors.asp

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Possible Causes of Alzheimer’s Disease Majority of cases: complex interactions between Majority of cases: complex interactions between

genetic and environmental factorsgenetic and environmental factors (important point!)

GeneticsGenetics – Multiple genetic factors Chromosomal abnormalities Insulin-resistant neurons in brain

Environmental factorsEnvironmental factors Free radicals Aluminum and mercury?

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Symptoms of Alzheimer’s Disease Progressive, degenerative, and fatal (5th leading cause of

death) Terminal diagnosis

Symptoms develop gradually and progress at different rates among individuals

Staging of Alzheimer’s disease Global Deterioration Scale/Functional Assessment Staging (GDS/FAST), p. 415

Personal awareness: early stages of dz Dx: based on symptoms/ medical evaluation 10 Warning Signs of Alzheimer's Disease

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The difference between Alzheimer's and typical age-related changes

Signs of Alzheimer's Typical age-related changes

Poor judgment and decision making Making a bad decision once in a while

Inability to manage a budget Missing a monthly payment

Losing track of the date or the season Forgetting which day it is and remembering later

Difficulty having a conversation Sometimes forgetting which word to use

Misplacing things and being unable to retrace steps to find them Losing things from time to time

http://www.alz.org/alzheimers_disease_10_signs_of_alzheimers.asp

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Question According to the Alzheimer's Association, about

how many people in the United States over the age of 65 have Alzheimer's disease? A. 5.4 million B. 6.5 million C. 7.1 million D. 8.6 million

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Question The average time period from

diagnosis of Alzheimer's disease to death is A. 6 years B. 8 years C. 10 years D. 12 years

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Question The most common early symptom of

Alzheimer's is difficulty remembering newly learned information.

True or false?

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Ron Reagan on Father’s Alzheimer’s

http://www.cnn.com/video/#/video/bestoftv/2011/04/28/lkl.reagan.alzheimers.cnn?iref=videosearch

Ron Reagan talks to Larry King about his father's struggle with Alzheimer's disease.

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Stages of Alzheimer’s Disease

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Stages of Alzheimer’s (p. 446) Stage 1: Normal Adult Stage 2: Normal Older Adult Stage 3: Mild Cognitive Impairment/ Early AD Stage 4: Mild AD Stage 5: Moderate AD Stage 6: Moderately Severe AD Stage 7: Severe/ Terminal ADhttp://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp

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Stage 3: Mild Cognitive Impairment/ Early AD Cognitive impairments

recognized by others Word or name-finding Names of new people Impaired performance in

work/ social settings Forgetting recently learned

information Losing/ misplacing valuable

object Decline in ability to plan/

organize http://www.alz.org/

alzheimers_disease_stages_of_alzheimers.asp#stage3

Mild memory impairmentAnxiety

Easily flustered in social situations

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Stage 4: Mild AD Withdrawal, denial,

depression Flat affect Decreased ability to

perform IADLs/ complex tasks

Cognitive impairment apparent on exam

Diagnosis of Alzheimer’shttp://www.alz.org/


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Stage 5: Moderate/ Mid-Stage AD Major gaps in memory Deficits in cognitive function

Disoriented to time and place

May become lost in unfamiliar locations

Some assistance with IADLs becomes essential Clothing selectionhttp://www.alz.org/


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Stage 6: Moderately Severe AD Severe loss of cognitive function & memory

Recent memory Names of spouse & family

Inability perform many ADLs Dressing, toileting Some urinary/ fecal incontinence

Personality changes Sundowning Agitation, resistive to care Wandering

Disruption sleep/ wake cycle Institutionalization

http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp#stage6

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Stage 6: Moderately Severe AD

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Stage 6: Moderately Severe AD

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Stage 7: Severe/ Terminal AD Final stage Recent/ remote

memories lost Loss verbal &

psychomotor skills Impaired swallowing Incontinence Total assistance

http://www.alz.org/alzheimers_disease_stages_of_alzheimers.asp#stage7

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Question When assessing a client with early-stage

Alzheimer's disease, the nurse should expect to find which of these symptoms? A. Incontinence B. Aphasia C. Awareness of cognitive losses D. Total dependence for all activities of daily living

(ADLs)

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New Diagnostic Guidelines for Alzheimer’s Disease (04/19/2011)

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New Diagnostic Guidelines

for AD

Three stages of disease 1. Preclinical AD (biomarkers) –

intended purely for research purposes 2. Mild cognitive impairment (MCI) 3. AD dementia http://download.journals.elsevierhealth.com/pdfs/journals/1552-5260/

PIIS1552526011001002.pdf

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New Diagnostic Guidelines

for AD First update in 27 yrs Inclusion of AD biomarkers

PET scan, MRI scan, spinal taps Actual disease present decade or more

before dementia appears New guidelines = two to threefold increase

in number of people dx with AD

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Treatment for Alzheimer’s Disease

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Treatment of Alzheimer’s Disease Variety of nursing interventions,

interdisciplinary approach No treatment to prevent or cure the disease

Treatments for cognitive symptoms Treatments for behavioral symptoms

Clinical trials: improve function/ slow disease progression Antioxidants, anti-inflammatory agents, folic acid,

vitamins B6 and B12, gene therapy, and vaccine

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Tx for Cognitive Symptoms: Medications Medications (Aricept, Namenda): slow progress but

do not change disease course Temporarily delay worsening of symptoms (6-12 mos) Cholinesterase inhibitors

Donepezil (Aricept) – all stages Rivastigmine (Exelon) – mild to moderate Galantamine (Reminyl) – mild to moderate

Glutamine regulator Memantine (Namenda) – mild to moderate

http://www.alz.org/alzheimers_disease_standard_prescriptions.asp#2

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Tx for Behavioral and Psychiatric Symptoms: Non-Drug Behavioral problems occur in about 90% of

people with AD. Repetitiveness, delusions, illusions,

hallucinations, agitation, aggression, altered sleeping patterns, wandering, and resisting care

Nursing strategies for difficult behavior: Monitoring personal comfort, redirection,

distraction, and reassurance


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Tx for Behavioral and Psychiatric Symptoms: Non-Drug *Monitor personal comfort – check for pain, hunger, thirst,

constipation Do not confront or argue facts

Redirect attention Calm environment

Simplify environment & routine Familiar routines Ensure adequate rest

*Safety Locks on doors/ gates No guns/ car keys out of reach


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Tx for Behavioral and Psychiatric Symptoms: Medications Antidepressant medications:

Citalopram (Celexa) Sertraline (Zoloft)

Anxiolytics: Lorazepam (Ativan)

Antipsychotic medications: Haloperidol (Haldol) Ziprasidone (Geodon)


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Question The wife of a client taking donepezil (Aricept) asks

the nurse when her husband’s Alzheimer’s disease will be cured. The nurse’s best response is: A.“This medication takes about 6 weeks to cure

Alzheimer’s.” B. “Your husband will be cured in 2 weeks.” C. “This medication slows the degeneration of the disease.

It doesn’t cure it.” D. “This medication alone doesn’t cure Alzheimer’s; you

have to take two other medications to cure the disease.”

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Nursing Care

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Caring for Persons With Dementia: Safety Ensuring patient safety Environmental safety Poor judgment/ misperceptions Consistent, controlled environment Items to trigger memory Wandering behavior

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Caring for Persons With Dementia: Physical Care Close observation/ attention: physical

needs Eating and drinking Bathing and skin care Consideration of inability to communicate

needs Infection Consistency in caregivers

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Caring for Persons With Dementia: Resistance/ Agitation

Be alert to cues Distract Direct eye-contact Safe environment Be calm, clear Do not rush Pt

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Caring for Persons With Dementia: Respect Need to promote:

Individuality Independence Freedom Dignity Connection

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Caring for Persons With Dementia: Support for Family Don’t overlook the caregivers! Physical, emotional, and

socioeconomic difficulties of caregiving Education on basic care needs Feelings accompanying caregiver role Community resources

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Safe Environment & Support Tour home with caregiver to identify safety

issues and develop a plan to rectify them Make home safe with modifications Similar strategies as ones used to prevent injury

to toddlers to provide safer physical environment

Support family/ caregiver Caregiver role strainCPSC Home Safety Tips

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Advance Directives and Proxy Establishment While patients have decision-making capacity,

include them in discussions Initiate discussion about desired treatment

modalities Select a healthcare proxy Inform proxy about desired care to be provided

when patient is unable to make decisions As dementia progresses, likely to be

institutionalized

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Nursing Process

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Nursing Diagnoses/ Care Plan (pp. 450-452) – Review!Review! Self-Care Deficit Risk for Injury Disturbed Sleep Pattern Impaired Verbal Communication Disturbed Thought Processes Interrupted Family Processes Caregiver Role Strain

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Planning and Outcome Identification The client will

Remain safe and free from injury Experience a level of arousal that promotes

the meaningful perception of stimuli Remain oriented to time, place, person, and

situation to maximum extent possible Perform self-care activities appropriate to

own functional capability