Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 60: Nursing Management: Alzheimer's Disease, Dementia, and Delirium

Key Points – Printable

DEMENTIA
•	Dementia is a syndrome characterized by dysfunction or loss of memory, orientation, attention, language, judgment, and reasoning. Personality changes and behavioral problems such as agitation, delusions, and hallucinations may result.
•	The two most common causes are neurodegenerative conditions (e.g., Alzheimer’s disease) and vascular disorders. Vascular dementia, also called multiinfarct dementia, is the loss of cognitive function resulting from ischemic, ischemic-hypoxic, or hemorrhagic brain lesions caused by cardiovascular disease.
•	Depending on the cause of the dementia, the onset of symptoms may be more abrupt, or, as in the case of neurologic degeneration, insidious and gradual. 
•	Regardless of the cause, the initial symptoms are related to changes in cognitive functioning. Patients may have complaints of memory loss, mild disorientation, and/or trouble with words and numbers.
•	An important first step in the diagnosis of dementia is thorough psychologic, medical, and neurologic evaluations, including mental status testing. 
•	Depression is often mistaken for dementia in older adults, and, conversely, dementia for depression.
•	The management of the patient with dementia is similar to that of the patient with Alzheimer’s disease.

MILD COGNITIVE IMPAIRMENT
•	Mild cognitive impairment (MCI) is a state of cognitive functioning that is below defined norms, yet does not meet the criteria for dementia. 
•	Causes of MCI may include stress, anxiety, depression, or physical illness.
•	The nurse caring for the patient with MCI must recognize the importance of monitoring the patient for changes in memory and thinking skills that would indicate a worsening of symptoms or a progression to dementia. 

ALZHEIMER’S DISEASE
•	Alzheimer’s disease (AD) is a chronic, progressive, degenerative disease of the brain. It is the most common form of dementia.
•	The exact etiology is unknown. Similar to other forms of dementia, age is the most important risk factor for developing AD; multiple genetic factors have been linked to its development. 
•	Characteristic findings relate to changes in the brain’s structure and function: amyloid plaques, neurofibrillary tangles, and loss of connections between cells and cell death.
•	The manifestations of AD can be categorized as mild, moderate, and late.
•	An initial sign is a subtle deterioration in memory. With progression of AD, additional cognitive impairments are noted, including dysphasia, apraxia, visual agnosia, and dysgraphia.
•	No single clinical test can be used to diagnose AD; the diagnosis is one of exclusion.
•	At this time there is no cure for AD. The collaborative management is aimed at improving or controlling decline in cognition, and controlling the undesirable behavioral manifestations that the patient may exhibit.
•	Drug therapy may slow the worsening of symptoms, but does not cure AD.
•	The diagnosis of AD is traumatic for both the patient and the family. It is not unusual for the patient to respond with depression, denial, anxiety and fear, isolation, and feelings of loss. The nurse is in an important position to assess for depression and suicidal ideation.
•	Currently, family members and friends care for the majority of individuals with AD in their homes. Others reside in various facilities, including long-term care and assisted living facilities. 
•	The severity of the problems and the amount of nursing care intensify over time. As AD progresses to the late stages (severe impairment), there is increased difficulty with the most basic functions, including walking and talking. Total care is required.
•	Behavioral problems occur in most patients with AD. These problems include repetitiveness, delusions, illusions, hallucinations, agitation, aggression, altered sleeping patterns, wandering, and resisting care. Nursing strategies that address difficult behavior include redirection, distraction, and reassurance.
•	A specific type of agitation is termed sundowning, in which the patient becomes more confused and agitated in the late afternoon or evening. Managing sundowning is a critical nursing role and can be challenging for you, the patient, and the family. 
•	The person with AD is at risk for problems related to personal safety. These risks include injury from falls, injury from ingesting dangerous substances, wandering, injury to others and self with sharp objects, fire or burns, and inability to respond to crisis situations.
•	Wandering is a major concern for caregivers. As with other behaviors, the nurse should observe for factors or events that may precipitate wandering.
•	Loss of interest in food and decreased ability to feed self, as well as co-morbid conditions, can result in significant nutritional deficiencies that need to be addressed. 
•	During the middle and late stages of AD, urinary and fecal incontinence lead to an increased risk of urinary tract infection and the need for increased nursing care.
•	AD is a disease that disrupts all aspects of personal and family life. Caregivers exhibit adverse consequences relating to their employment and to their emotional and physical health, which then results in family conflict and caregiver strain. The nurse should work with the caregiver to assess stressors and to identify coping strategies to reduce the burden of caregiving.

OTHER NEURODEGENERATIVE DISEASES
•	Lewy body dementia is a condition characterized by the presence of Lewy bodies (intraneural cytoplasmic inclusions) in the brainstem and cortex. Since it has some features of Parkinson’s disease, medication therapy may assist with symptoms.
•	Pick’s disease, or frontotemporal dementia, is a rare disorder caused by shrinking frontal and temporal lobes of the brain. It is characterized by disturbances in behavior, sleep, personality, and eventually memory. Care is supportive.
•	Normal pressure hydrocephalus is an uncommon disorder characterized by an obstruction in the flow of cerebrospinal fluid (CSF), which causes a buildup of this fluid in the brain. If diagnosed early, surgical intervention is used to divert fluid away from the brain.
•	Creutzfeldt-Jakob disease is a rare and fatal brain disorder caused by a prion protein found in beef from animals infected with mad cow disease. Treatment is supportive.

DELIRIUM
•	Delirium, a state of temporary but acute mental confusion, is a common, life-threatening, and possibly preventable syndrome in older adults.
•	Clinically, delirium is rarely caused by a single factor. It is often the result of the interaction of the patient’s underlying condition with a precipitating event.
•	Acute delirium occurs frequently in hospitalized older adults. This transient condition is characterized by disorganized thinking, difficulty in concentrating, and sensory misperceptions that last from 1 to 7 days.
•	Manifestations of delirium are sometimes confused with dementia. A key distinction between delirium and dementia is that the person who exhibits sudden cognitive impairment, disorientation, or clouded sensorium is more likely to have delirium rather than dementia.
•	In caring for the patient with delirium, the roles of the nurse include prevention, early recognition, and treatment. Prevention of delirium involves recognition of high risk patients. 
•	Care of the patient with delirium is focused on eliminating precipitating factors. If it is drug-induced, medications are discontinued. It is important to keep in mind that delirium can also accompany drug and alcohol withdrawal. 
•	Care of the patient experiencing delirium includes protecting the patient from harm. Priority is given to creating a calm and safe environment. 
•	Comprehensive, multicomponent interventions to prevent delirium are the most effective and should be implemented through institutional-based programs that are interdisciplinary.