Chapter 14: Management Chapter 14: Management of Common Problemsof Common Problems

Bonnie M. Wivell, MS, RN, CNSBonnie M. Wivell, MS, RN, CNS

PolypharmacyPolypharmacy

DemographicsDemographics 34% of all prescription medications and 34% of all prescription medications and

40% of all nonprescription medications 40% of all nonprescription medications are for elderly (American Society of are for elderly (American Society of Consultant Pharmacists, 2000)Consultant Pharmacists, 2000)

Those in nursing homes take an average Those in nursing homes take an average of 6 – 8 medications per day; some of 6 – 8 medications per day; some take many moretake many more

Polypharmacy (cont’d)Polypharmacy (cont’d) Concurrent use of several drugs (ANA)Concurrent use of several drugs (ANA) Implications Implications

Med errorsMed errors Non-adherenceNon-adherence Drug-drug interactionsDrug-drug interactions ADRsADRs Increased hospitalizationsIncreased hospitalizations

Risk Factors for polypharmacyRisk Factors for polypharmacy Poor communication between physicians, Poor communication between physicians,

number of co-morbidities, age-related changenumber of co-morbidities, age-related change Beer’s list of potentially harmful drugsBeer’s list of potentially harmful drugs

Interventions/StrategiesInterventions/Strategies

Obtain a thorough historyObtain a thorough history Start low and go slowStart low and go slow Monitor lab valuesMonitor lab values Consider nonpharmacologic Consider nonpharmacologic

approachesapproaches Streamline the medication regimenStreamline the medication regimen Provide information to patient/familyProvide information to patient/family

FallsFalls DemographicsDemographics

In 2001, more than 1.6 million seniors were In 2001, more than 1.6 million seniors were treated in emergency departments for fall-treated in emergency departments for fall-related injuries and nearly 388,000 were related injuries and nearly 388,000 were hospitalized hospitalized

Implications Implications FracturesFractures Loss of independenceLoss of independence Decreased quality of lifeDecreased quality of life FearFear Death Death

At least 50% of elderly persons who were ambulatory At least 50% of elderly persons who were ambulatory before fracturing a hip do not recover their pre-before fracturing a hip do not recover their pre-fracture level of mobilityfracture level of mobility

Falls (cont’d)Falls (cont’d)

Risk for falling Risk for falling Intrinsic: r/t changes associated with agingIntrinsic: r/t changes associated with aging Extrinsic: r/t environmental hazardsExtrinsic: r/t environmental hazards Drugs are a major contributing factorDrugs are a major contributing factor

Fall assessmentFall assessment InitialInitial Regular intervalsRegular intervals Variety of assessment tools availableVariety of assessment tools available

Risk Factors for FallsRisk Factors for Falls AgeAge DiagnosisDiagnosis Altered physical capabilitiesAltered physical capabilities Altered mental stateAltered mental state Altered bowel and bladder functionAltered bowel and bladder function Cognitive/sensory impairmentsCognitive/sensory impairments Altered proprioceptionAltered proprioception Day of hospitalizationDay of hospitalization Medications Medications Psychological factors, i.e. fearPsychological factors, i.e. fear

Interventions/Strategies for Interventions/Strategies for CareCare

Evaluate gait and balance Evaluate gait and balance Up and Go TestUp and Go Test ExerciseExercise

Restraint useRestraint use Avoid physical restraintsAvoid physical restraints Limit use of “chemical restraints” – Limit use of “chemical restraints” –

effects number of certain medications effects number of certain medications that can be used in nursing homesthat can be used in nursing homes

Interventions (cont’d)Interventions (cont’d)

Modify the environment: Modify the environment: Minimize clutterMinimize clutter Throw rugsThrow rugs Hand railsHand rails Flooring – wax, loose carpet, wires/cordsFlooring – wax, loose carpet, wires/cords Be sure phone can be reached from floorBe sure phone can be reached from floor Raised toilet seatRaised toilet seat Grab barsGrab bars Educate client and familyEducate client and family

Interventions (cont’d)Interventions (cont’d) Medication reviewMedication review

DiureticsDiuretics NarcoticsNarcotics SedativesSedatives HypnoticsHypnotics TranquilizersTranquilizers AntidepressantsAntidepressants AntihypertensivesAntihypertensives LaxativesLaxatives History of drug/alcohol abuseHistory of drug/alcohol abuse

Develop a Fall Prevention PlanDevelop a Fall Prevention Plan Examine risk factorsExamine risk factors

AnxietyAnxiety

Prevalence Prevalence Most common mental health problem in older Most common mental health problem in older

adultsadults According to Surgeon General, 11.4% of adults According to Surgeon General, 11.4% of adults

over the age of 55 met criteria for anxiety over the age of 55 met criteria for anxiety disordersdisorders

Phobic anxiety disorders most prevalent in Phobic anxiety disorders most prevalent in older adultsolder adults

Non-specific anxiety rates up to 17% in older Non-specific anxiety rates up to 17% in older men and 21% in older women (U.S. Public men and 21% in older women (U.S. Public Health Services, 2000). Health Services, 2000).

Implications/RelevanceImplications/Relevance

Manifests asManifests as Tachycardia/PalpitationsTachycardia/Palpitations GI disordersGI disorders InsomniaInsomnia TachypneaTachypnea

Recurring and chronic can complicate Recurring and chronic can complicate illnessesillnesses

Increases duration of disabilityIncreases duration of disability Correlates with and predicts cognitive Correlates with and predicts cognitive

decline and impairmentdecline and impairment Elevates acute pain perceptionElevates acute pain perception

Warning SignsWarning Signs

Generalized anxiety disorderGeneralized anxiety disorder (GAD): (GAD): persistent, excessive worry with fluctuating persistent, excessive worry with fluctuating severity of symptoms, restlessness, severity of symptoms, restlessness, irritability, sleep disturbance, fatigue and irritability, sleep disturbance, fatigue and impaired concentration impaired concentration Chronic conditionChronic condition Associated with depressionAssociated with depression

Panic attacks: autonomic arousal that Panic attacks: autonomic arousal that includes tachycardia, difficulty breathing, includes tachycardia, difficulty breathing, diaphoresis, light-headedness, trembling, diaphoresis, light-headedness, trembling, and severe weaknessand severe weakness Symptoms may be masked in elderlySymptoms may be masked in elderly

Risk Factors/AssessmentRisk Factors/Assessment

Risk FactorsRisk Factors Chronic medical conditionChronic medical condition Psychosocial stressors/negative life eventPsychosocial stressors/negative life event Catastrophic events in early lifeCatastrophic events in early life

AssessmentAssessment ID risksID risks MedicationsMedications Medical conditionsMedical conditions Pay attention to verbalization of thoughts and Pay attention to verbalization of thoughts and

feelingsfeelings Most prominent presenting symptom in depressionMost prominent presenting symptom in depression

Intervention/Strategies for Intervention/Strategies for CareCare

Decrease environmental stimuliDecrease environmental stimuli Stay with the patientStay with the patient Make no demands or ask the patient to make Make no demands or ask the patient to make

decisionsdecisions Support current coping mechanisms (crying, talking)Support current coping mechanisms (crying, talking) Avoid confrontation or argumentAvoid confrontation or argument Speak slowly and softlySpeak slowly and softly Reassure the patient that the problem can be Reassure the patient that the problem can be

solvedsolved Reorient the patient to realityReorient the patient to reality Respect the patient’s personal spaceRespect the patient’s personal space Deep BreathingDeep Breathing Progressive Muscle RelaxationProgressive Muscle Relaxation Cognitive Behavioral therapyCognitive Behavioral therapy Anxiolytics (benzos, SSRIs #1)Anxiolytics (benzos, SSRIs #1)

DepressionDepression Most common mental health disorder in Most common mental health disorder in

elderly but NOT a normal consequence of elderly but NOT a normal consequence of agingaging

Depression rate is as high as 37% in older Depression rate is as high as 37% in older adults with co-morbid illnessesadults with co-morbid illnesses

Medical conditions that increase risk of Medical conditions that increase risk of depression: depression: Hypothyroidism, Arthritis, HTN, CVA, CHD, DM, Hypothyroidism, Arthritis, HTN, CVA, CHD, DM,

PD, MS, CA PD, MS, CA Significant risk for suicide; older adults Significant risk for suicide; older adults

have the highest rates of suicide in the UShave the highest rates of suicide in the US Often undetected or inadequately treatedOften undetected or inadequately treated

AssessmentAssessment

Geriatric Depression ScaleGeriatric Depression Scale Cornell Scale for Depression in Cornell Scale for Depression in

DementiaDementia Medication historyMedication history H & PH & P

Interventions/Strategies for Interventions/Strategies for CareCare

Early recognition and tx can increase quantity Early recognition and tx can increase quantity and QOLand QOL

Antidepressant medications (tricyclics, SSRIs Antidepressant medications (tricyclics, SSRIs #1)#1)

Psychosocial interventionsPsychosocial interventions CBT uses recognition and relaxation strategies CBT uses recognition and relaxation strategies

to change thoughtsto change thoughts Nursing interventionsNursing interventions

Alternative medicineAlternative medicine Life reviewLife review SocializationSocialization ExerciseExercise

Community resourcesCommunity resources

Urinary Incontinence (UI)Urinary Incontinence (UI) Involuntary leakage of urineInvoluntary leakage of urine Is common problem but NOT a normal part Is common problem but NOT a normal part

of agingof aging Requires evaluationRequires evaluation Types of UITypes of UI

StressStress UrgeUrge MixedMixed OverflowOverflow FunctionalFunctional TotalTotal

PrevalencePrevalence

30 - 50% in older women living in the 30 - 50% in older women living in the community community

9% – 28% in older men living in the 9% – 28% in older men living in the community community

Incontinence may affect up to 43% of Incontinence may affect up to 43% of acute care patients acute care patients

Prevalence rates in institutions rise Prevalence rates in institutions rise to 50% or higherto 50% or higher

ImplicationsImplications Depression/anxietyDepression/anxiety Decreased quality of lifeDecreased quality of life

RelationshipsRelationships ADLsADLs Decreased socializationDecreased socialization

Increased risk of hospitalization and/or admission Increased risk of hospitalization and/or admission to LTCFto LTCF

Increased risk of fallsIncreased risk of falls Increase risk of skin breakdownIncrease risk of skin breakdown StigmaStigma Fear of embarrassmentFear of embarrassment Perception that UI is a normal part of agingPerception that UI is a normal part of aging

AssessmentAssessment Transient (acute)Transient (acute)

Delirium, infection, meds, stool impactionDelirium, infection, meds, stool impaction Established (chronic)Established (chronic)

Stress, urge, overflow, functionalStress, urge, overflow, functional Evaluating bladder functionEvaluating bladder function

HistoryHistory Bladder diary Bladder diary

Physical Physical DRE, pelvic examDRE, pelvic exam

PVRPVR UAUA Cognitive statusCognitive status Environmental resources: location, accessibility Environmental resources: location, accessibility

of toiletof toilet

Stress IncontinenceStress Incontinence

Involuntary loss of small amounts of urine Involuntary loss of small amounts of urine during activities that increase intra-during activities that increase intra-abdominal pressureabdominal pressure Lifting, coughing, sneezing, laughingLifting, coughing, sneezing, laughing

Causes:Causes: Hypermobility of the bladder neckHypermobility of the bladder neck Urethral sphincter defectsUrethral sphincter defects Weakness of pelvic floor muscles r/t Weakness of pelvic floor muscles r/t

pregnancy, multiparity, obesity, surgery, pregnancy, multiparity, obesity, surgery, exercise, medicationsexercise, medications

Treatment: biofeedback, KegelsTreatment: biofeedback, Kegels

Urge IncontinenceUrge Incontinence

Strong, abrupt desire to void and the Strong, abrupt desire to void and the inability to inhibit leakage in time to reach inability to inhibit leakage in time to reach a toileta toilet

Moderate to large amounts of urine lostModerate to large amounts of urine lost Causes: Causes:

CNS disorders such as CVA, MSCNS disorders such as CVA, MS Local irritations such as infection or ingestion Local irritations such as infection or ingestion

of bladder irritants like caffeineof bladder irritants like caffeine Treatment: KegelsTreatment: Kegels

Reflex IncontinenceReflex Incontinence

A variation of urge, results from A variation of urge, results from uninhibited bladder contractions with no uninhibited bladder contractions with no sensation of needing to void or urgencysensation of needing to void or urgency

Large amount urine lostLarge amount urine lost Causes:Causes:

Spinal lesions transecting above T10-11 r/t Spinal lesions transecting above T10-11 r/t birth defects, spine or nerve damage, birth defects, spine or nerve damage, developmental disability, senility, pelvic traumadevelopmental disability, senility, pelvic trauma

Treatment: determine cause; may need Treatment: determine cause; may need intermittent cath, timed voidingintermittent cath, timed voiding

Overflow IncontinenceOverflow Incontinence

Over-distention of the bladder due to Over-distention of the bladder due to abnormal emptyingabnormal emptying

Causes:Causes: Weak bladderWeak bladder Neurological conditions like DM, spinal cord injury below Neurological conditions like DM, spinal cord injury below

T10-11T10-11 Bladder outlet obstructionBladder outlet obstruction

No warning prior to incontinent episodeNo warning prior to incontinent episode Small to moderate amount of urine lostSmall to moderate amount of urine lost Continual or intermittentContinual or intermittent Treatment: treat cause, intermittent cath, Treatment: treat cause, intermittent cath,

bladder scans for post-void residualsbladder scans for post-void residuals

Functional IncontinenceFunctional Incontinence

Problems with factors external to the lower Problems with factors external to the lower urinary tract such as cognitive impairment, urinary tract such as cognitive impairment, physical disabilities, and environmental physical disabilities, and environmental barriersbarriers

Related to inability to get to bathroom facilities Related to inability to get to bathroom facilities due to functional reasonsdue to functional reasons

For example: obesity, clutter, immobilityFor example: obesity, clutter, immobility May be associated with urge incontinence May be associated with urge incontinence

(mixed incontinence)(mixed incontinence) Treatment: modify environment; modify Treatment: modify environment; modify

lifestylelifestyle

Mixed IncontinenceMixed Incontinence

Existence of symptoms of urge and Existence of symptoms of urge and stress at the same timestress at the same time

Interventions/Strategies for Interventions/Strategies for CareCare

Behavioral Management: modify behavior or Behavioral Management: modify behavior or environmentenvironment Scheduling regimensScheduling regimens Relaxation exercisesRelaxation exercises Pelvic muscle exercisesPelvic muscle exercises Urge suppression techniques with or withoutUrge suppression techniques with or without

Biofeedback, Vaginal cones, Electrical stimBiofeedback, Vaginal cones, Electrical stim Hydration managementHydration management Bowel regularityBowel regularity Prompted voidingPrompted voiding Bladder trainingBladder training

Interventions/Strategies for Interventions/Strategies for CareCare

Pharmacological managementPharmacological management Medications that alter detrusor muscle Medications that alter detrusor muscle

activity or bladder outlet resistanceactivity or bladder outlet resistance SurgerySurgery

Increase bladder outlet resistanceIncrease bladder outlet resistance Remove bladder outlet obstruction Remove bladder outlet obstruction

Devices and productsDevices and products Depends, catheter supplies, urinalsDepends, catheter supplies, urinals

Sleep DisordersSleep Disorders

Sleep Changes Associated with Aging Sleep Changes Associated with Aging Decreased deep stage IV (restores the Decreased deep stage IV (restores the

individual physically, and tissue healing occurs)individual physically, and tissue healing occurs) Decreased REM sleep (deepest state of Decreased REM sleep (deepest state of

relaxation)relaxation) PrevalencePrevalence

Chronic illness increases propensityChronic illness increases propensity 32% of adults reported a good night’s sleep 32% of adults reported a good night’s sleep

only a few nights each monthonly a few nights each month

Types of Sleep DisturbancesTypes of Sleep Disturbances InsomniaInsomnia Sleep apneaSleep apnea Restless leg syndromeRestless leg syndrome

Interventions/Strategies for Interventions/Strategies for CareCare

Sleep hygieneSleep hygiene Environmental restructuringEnvironmental restructuring RelaxationRelaxation AromatherapyAromatherapy Herbal therapyHerbal therapy MedicationsMedications

AmbienAmbien LunestaLunesta SonataSonata

Pressure UlcersPressure Ulcers

PrevalencePrevalence Acute care setting = 3-11%Acute care setting = 3-11% Long-term care facilities = 24%Long-term care facilities = 24% Community = 17%Community = 17% With a stage I ulcer, the older adult has With a stage I ulcer, the older adult has

a tenfold risk of developing further a tenfold risk of developing further ulcers ulcers

ImplicationsImplications Ischemia caused by unrelieved pressureIschemia caused by unrelieved pressure

Warning Signs/Risk FactorsWarning Signs/Risk Factors Thin or obeseThin or obese Poor nutrition/dehydrationPoor nutrition/dehydration ImmobilityImmobility Assistive devicesAssistive devices Patient on pain meds or sedativesPatient on pain meds or sedatives Decreased mental statusDecreased mental status Increased ageIncreased age Impaired circulation/sensationImpaired circulation/sensation Bony prominences/decreased muscle massBony prominences/decreased muscle mass IncontinenceIncontinence Friction/shearingFriction/shearing

AssessmentAssessment Braden ScaleBraden Scale

See pages 502-503 in textSee pages 502-503 in text Score of 18 or less = high risk of pressure ulcer Score of 18 or less = high risk of pressure ulcer

development in the older adultdevelopment in the older adult Determine baseline on admission and at Determine baseline on admission and at

regular intervalsregular intervals Determine stageDetermine stage Length, width, and depth need to be Length, width, and depth need to be

documenteddocumented PhotosPhotos

Stages of Pressure UlcersStages of Pressure Ulcers

Stage I: non-blanchable redness, skin Stage I: non-blanchable redness, skin intactintact

Stage II: partial thickness loss of the Stage II: partial thickness loss of the dermis, abrasion, blister, shallow dermis, abrasion, blister, shallow cratercrater

Stage III: full-thickness loss of dermis, Stage III: full-thickness loss of dermis, damage to subcutaneous tissuedamage to subcutaneous tissue

Stage IV: damage to muscle and bone, Stage IV: damage to muscle and bone, necrosisnecrosis

Ulcer CareUlcer Care Cleanse the wound with a noncytotoxic Cleanse the wound with a noncytotoxic

cleanser (saline) during each dressing cleanser (saline) during each dressing change.change.

If necrotic tissue or slough is present, If necrotic tissue or slough is present, consider the use of high-pressure irrigation.consider the use of high-pressure irrigation.

Debride necrotic tissue. Debride necrotic tissue. Do not debride dry, black eschar on heels.Do not debride dry, black eschar on heels. Perform wound care using topical dressings Perform wound care using topical dressings

determined by wound and availability.determined by wound and availability. Choose dressings that provide a moist Choose dressings that provide a moist

wound environment, keep the skin wound environment, keep the skin surrounding the ulcer dry, control exudates, surrounding the ulcer dry, control exudates, and eliminate dead space.and eliminate dead space.

Ulcer Care (cont’d)Ulcer Care (cont’d)

Reassess the wound with each dressing Reassess the wound with each dressing change to determine whether treatment change to determine whether treatment plan modifications are needed.plan modifications are needed.

Identify and manage wound infections.Identify and manage wound infections. Clients with Stage III and IV ulcers that do Clients with Stage III and IV ulcers that do

not respond to conservative therapy may not respond to conservative therapy may require surgical intervention.require surgical intervention.

Pressure Ulcer ManagementPressure Ulcer Management

Nutrition very importantNutrition very important ProteinProtein ZincZinc ArginineArginine Vit C, A, and BVit C, A, and B

Tissue load managementTissue load management Positioning devicesPositioning devices

PUSH ToolPUSH Tool

DysphagiaDysphagia Problems with swallowing that is an under-Problems with swallowing that is an under-

recognized, poorly diagnosed, and poorly recognized, poorly diagnosed, and poorly managed health problemmanaged health problem

Negatively impacts quantity and QOLNegatively impacts quantity and QOL Prevalence Prevalence

13-35% of elderly living in the community 13-35% of elderly living in the community 25-30% of hospitalized patients25-30% of hospitalized patients Approximately 30%-40% of persons in nursing Approximately 30%-40% of persons in nursing

homes homes It is estimated that by 2010, 16.5 million It is estimated that by 2010, 16.5 million

persons will require care for dysphagia (U.S. persons will require care for dysphagia (U.S. Census Bureau, 2000). Census Bureau, 2000).

Warning Signs/Risk Factors Warning Signs/Risk Factors

Effects of Aging on Eating Effects of Aging on Eating and Swallowingand Swallowing

Impaired mastication - denturesImpaired mastication - dentures Change in diet, change in appetiteChange in diet, change in appetite Diminished salivary secretionsDiminished salivary secretions Decreased esophageal peristalsisDecreased esophageal peristalsis Decreased production of digestive Decreased production of digestive

enzymesenzymes

AssessmentAssessment

Stages of swallowing:Stages of swallowing: Oral preparatory: chew and tasteOral preparatory: chew and taste Oral or lingual: move food to back of Oral or lingual: move food to back of

throatthroat Pharyngeal: involuntary, most critical, Pharyngeal: involuntary, most critical,

airway closureairway closure Esophageal: involuntary, movement Esophageal: involuntary, movement

down esophagus via peristalsisdown esophagus via peristalsis

Assessment (cont’d)Assessment (cont’d)

Cranial nerves involved in eating and Cranial nerves involved in eating and swallowing:swallowing: Trigeminal (V) - mandibular, maxillaryTrigeminal (V) - mandibular, maxillary Facial (VII) - taste, submandibular and sublingual Facial (VII) - taste, submandibular and sublingual

salivary glands, facial expressionsalivary glands, facial expression Glossopharyngeal (IX) - taste, soft palate & uvulaGlossopharyngeal (IX) - taste, soft palate & uvula Vagus (X) - membrane of larynx and pharynxVagus (X) - membrane of larynx and pharynx Spinal Accessory (XI) - sternocleidomastoid muscleSpinal Accessory (XI) - sternocleidomastoid muscle Hypoglossal (XII) - intrinsic tongueHypoglossal (XII) - intrinsic tongue

Interventions/Strategies for Interventions/Strategies for CareCare

Positioning - uprightPositioning - upright Establish arousal and attention Establish arousal and attention Assist with head positioningAssist with head positioning Do not rushDo not rush Use small amounts of food - 1/2 Use small amounts of food - 1/2

teaspoonsteaspoons Place food on unaffected sidePlace food on unaffected side Push down tongue as remove food Push down tongue as remove food

from spoonfrom spoon

Interventions (cont’d)Interventions (cont’d)

Assist with lip closure if neededAssist with lip closure if needed Avoid use of straws (unless recommended Avoid use of straws (unless recommended

by speech therapist)by speech therapist) Provide frequent verbal cuesProvide frequent verbal cues Use thickener for liquids as recommendedUse thickener for liquids as recommended Stimulate the swallowing reflexStimulate the swallowing reflex Avoid milk and milk productsAvoid milk and milk products Use adaptive equipment designed for that Use adaptive equipment designed for that

personperson

Interventions (cont’d)Interventions (cont’d)

Oral careOral care Educate person and familyEducate person and family Thermal stimulation - cold stimulates Thermal stimulation - cold stimulates

the swallow responsethe swallow response Follow recommendations of speech Follow recommendations of speech

therapist (may have multiple steps)therapist (may have multiple steps)

Non-oral interventionsNon-oral interventions

G-tubesG-tubes PEG tubesPEG tubes

Percutaneous Endoscopic Gastrostomy tubePercutaneous Endoscopic Gastrostomy tube Check abdominal girth for distensionCheck abdominal girth for distension Check residual volumesCheck residual volumes Keep upright after feedingsKeep upright after feedings Monitor continually for aspirationMonitor continually for aspiration Treat GERDTreat GERD

Chapter 15: Nursing Chapter 15: Nursing Management of DementiaManagement of Dementia

Bonnie M. Wivell, MS, RN, CNSBonnie M. Wivell, MS, RN, CNS

DementiaDementia Progressive, degenerative brain Progressive, degenerative brain

dysfunction, including deterioration in dysfunction, including deterioration in memory, concentration, language skills, memory, concentration, language skills, visuospatial skills, and reasoningvisuospatial skills, and reasoning

Progressive forgetfulness, memory loss, Progressive forgetfulness, memory loss, and loss of other cognitive functionand loss of other cognitive function

Increased plaques and tangles in the brain Increased plaques and tangles in the brain (hallmark sign for Alzheimer’s)(hallmark sign for Alzheimer’s)

Interferes with a person’s daily functioningInterferes with a person’s daily functioning Not considered a normal part of aging Not considered a normal part of aging

Types of DementiaTypes of Dementia Alzheimer’s #1Alzheimer’s #1 VascularVascular Parkinson’sParkinson’s Lewy bodyLewy body Frontal lobe dementiaFrontal lobe dementia

Lose inhibition and executive functioning skills Lose inhibition and executive functioning skills earlier than ADearlier than AD

Normal pressure hydrocephalusNormal pressure hydrocephalus Rare but partially reversible with surgeryRare but partially reversible with surgery Acute onset of a triad of symptomsAcute onset of a triad of symptoms

slowed cognitive processes, gait disturbances, UIslowed cognitive processes, gait disturbances, UI

Risk Factors for DementiaRisk Factors for Dementia AgeAge Family historyFamily history Genetic factorsGenetic factors Head trauma Head trauma Vascular diseaseVascular disease InfectionsInfections Other modifiable factorsOther modifiable factors

Maintain ideal body weightMaintain ideal body weight ExerciseExercise Avoid smokingAvoid smoking Control hyperlipidemia and hypertension Control hyperlipidemia and hypertension Exercising the brain with lifelong cognitive Exercising the brain with lifelong cognitive

activity may help lower the risk of dementia activity may help lower the risk of dementia

Causes of DementiaCauses of Dementia

DDrugsrugs EEnvironmentalnvironmental MMetabolicetabolic EEyes/Ears – sensory deprivationyes/Ears – sensory deprivation NNutritionutrition TTrauma/Tumorrauma/Tumor IInfectionsnfections AAlcohol abuse or intoxicationlcohol abuse or intoxication

Assessing for DementiaAssessing for Dementia

Mini-COGMini-COG A reliable and valid instrument used to A reliable and valid instrument used to

screen for cognitive impairment screen for cognitive impairment consisting of 3-item recall test and a consisting of 3-item recall test and a clock-drawing test (CDT)clock-drawing test (CDT)

It is evidence-based, easy to administer, It is evidence-based, easy to administer, and not too taxing for patient or and not too taxing for patient or providerprovider

Is a screening test, doesn’t provide Is a screening test, doesn’t provide diagnosisdiagnosis

Administration of Mini-COG Instruct the patient to listen carefully to and

remember 3 unrelated words and then to repeat the words.

Instruct the patient to draw the face of a clock, either on a blank sheet of paper, or on a sheet with the clock circle already drawn on the page. After the patient puts the numbers on the clock face, ask him or her to draw the hands of the clock to read a specific time, such as 11:20. These instructions can be repeated, but no additional instructions should be given. Give the patient as much time as needed to complete the task. The CDT serves as the recall distracter.

Ask the patient to repeat the 3 previously presented word.

CLOCK DRAWING TEST

Scoring of Mini-COG

Give 1 point for each recalled word after the CDT distracter. Score 1–3.

A score of O indicates positive screen for dementia.

A score of 1 or 2 with an abnormal CDT indicates positive screen for dementia.

A score of 1 or 2 with a normal CDT indicates negative screen for dementia.

A score of 3 indicates negative screen for dementia.

The CDT is considered normal if all numbers are present in the correct sequence and position, and the hands readably display the requested time.

Diagnosing Alzheimer’sDiagnosing Alzheimer’s

Memory impairment alone doesn’t indicate ADMemory impairment alone doesn’t indicate AD Requires one of the following featuresRequires one of the following features

Impaired executive functionImpaired executive function Aphasia – word finding difficultiesAphasia – word finding difficulties Apraxia – cannot carry out motor skillsApraxia – cannot carry out motor skills Agnosia – cannot name familiar objectAgnosia – cannot name familiar object

Must rule out delirium, depression, other CNS Must rule out delirium, depression, other CNS disorders, medication side effects, and other disorders, medication side effects, and other medical conditions first!medical conditions first!

Diagnosing Alzheimer’s Diagnosing Alzheimer’s (cont’d)(cont’d)

H & PH & P Review of medicationsReview of medications Laboratory testingLaboratory testing Neuropsychological screening/testingNeuropsychological screening/testing

Mini Mental Status Exam (MMSE) no longer Mini Mental Status Exam (MMSE) no longer available in public domainavailable in public domain

Mini-CogMini-Cog St. Louis University Mental Status (SLUMS) examSt. Louis University Mental Status (SLUMS) exam

ImagingImaging Medicare will pay for PET scan to rule out dementiaMedicare will pay for PET scan to rule out dementia

Medications for DementiaMedications for Dementia Medications slow progression but do not stop Medications slow progression but do not stop

decline over timedecline over time Cholinesterase Inhibitors (CEIs)Cholinesterase Inhibitors (CEIs)

donepezil (Aricept)donepezil (Aricept) rivastigmine (Exelon)rivastigmine (Exelon) galantamine (Razadyne)galantamine (Razadyne)

N-methyl-D-aspartate (NMDA) Receptor N-methyl-D-aspartate (NMDA) Receptor AntagonistAntagonist memantine (Namenda) approved for moderate to memantine (Namenda) approved for moderate to

late stagelate stage Anticholinergics can worsen cognitive Anticholinergics can worsen cognitive

functionfunction See page 540 in textSee page 540 in text

DeliriumDelirium Acute confusionAcute confusion Four basic featuresFour basic features

Acute onset or fluctuating courseAcute onset or fluctuating course InattentionInattention Disorganized thinkingDisorganized thinking Altered level of consciousnessAltered level of consciousness

Primary treatment is to eliminate the Primary treatment is to eliminate the causecause

Delusion of theft and phantom intruderDelusion of theft and phantom intruder

Another Fact About Another Fact About DementiaDementia

Study done in Japan: Study done in Japan: Delusion of theft and Delusion of theft and phantom intruder phantom intruder delusion are among delusion are among the most frequent the most frequent delusions in dementia delusions in dementia and these delusions and these delusions occur more frequently occur more frequently when pt. hospitalizedwhen pt. hospitalized

Causes of DeliriumCauses of Delirium DDrugsrugs EElectrolyteslectrolytes LLiver failureiver failure IInfectionnfection RRenal failureenal failure IImpactionmpaction UUTI or urinary retentionTI or urinary retention MMetastasisetastasis

Potential Causes of DeliriumPotential Causes of Delirium

Inadequate or Inadequate or inappropriate pain inappropriate pain controlcontrol

Medications (including Medications (including new or change in dose)new or change in dose)

Fecal impactionFecal impaction Infection/feverInfection/fever Injury/severe illnessInjury/severe illness Electrolyte imbalance Electrolyte imbalance

(glucose, Na+)(glucose, Na+) DehydrationDehydration Change in surroundingsChange in surroundings

HypoxiaHypoxia AgeAge Male genderMale gender Cognitive impairment Cognitive impairment

(dementia)(dementia) HypotensionHypotension MalnutritionMalnutrition DepressionDepression AlcoholismAlcoholism RestraintsRestraints Multiple IVs, lines, tubesMultiple IVs, lines, tubes

Assessing for DeliriumAssessing for Delirium

Delirium is often unrecognized by Delirium is often unrecognized by cliniciansclinicians

Hence patients should be assessed Hence patients should be assessed frequently using a standardized tool to frequently using a standardized tool to facilitate prompt identification and facilitate prompt identification and management of delirium and underlying management of delirium and underlying etiologyetiology

Confusion Assessment Method (CAM)Confusion Assessment Method (CAM) Sensitivity of 94-100%Sensitivity of 94-100% Specificity of 89-95% 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 patient’s 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 patient’s 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 ContinuedCAM Continued

Should assess patient on admission Should assess patient on admission and during each shiftand during each shift

Engage pt. in conversation for about Engage pt. in conversation for about one minute. Ask:one minute. Ask: ““What brought you to the hospital?”What brought you to the hospital?” ““How are you feeling now?”How are you feeling now?”

Delirium is identified only if there is Delirium is identified only if there is evidence of features 1 and 2, and evidence of features 1 and 2, and either 3 or 4 (or both)either 3 or 4 (or both)

DepressionDepression Risk increases in older adults with chronic Risk increases in older adults with chronic

illnesses and/or dementiaillnesses and/or dementia Often a missed diagnosisOften a missed diagnosis See Box 15 – 12 on page 541 of text for See Box 15 – 12 on page 541 of text for

criteria of major depressioncriteria of major depression Most common screening tool is the GDSMost common screening tool is the GDS The Cornell tool can be used to screen The Cornell tool can be used to screen

persons with dementia for depressionpersons with dementia for depression Symptoms of dementia, delirium, and Symptoms of dementia, delirium, and

depression often overlapdepression often overlap

Nursing Nursing Interventions/StrategiesInterventions/Strategies

Use general strategies (as appear in Use general strategies (as appear in next slides)next slides)

Address specific issues/behaviorsAddress specific issues/behaviors WanderingWandering AggressionAggression RestlessnessRestlessness AgitationAgitation Physical comfortPhysical comfort PainPain

PainPain

Clinical observations Clinical observations of facial expressions of facial expressions and vocalizations are and vocalizations are accurate means for accurate means for assessing the assessing the presence of pain, but presence of pain, but not its intensity, in not its intensity, in patients unable to patients unable to communicate verbally communicate verbally because of advanced because of advanced dementia.dementia.

PainPain

Nonverbal ExpressionsNonverbal Expressions Agitation/combativeness/resistance to careAgitation/combativeness/resistance to care Increased confusionIncreased confusion Decreased mobilityDecreased mobility Guarding/rubbing or holding particular Guarding/rubbing or holding particular

body partbody part GrimacingGrimacing RestlessnessRestlessness Increase HR, RespirationsIncrease HR, Respirations

Interventions for PainInterventions for Pain

Ask older adults with dementia about their pain Ask older adults with dementia about their pain as they can often respond to simple questionsas they can often respond to simple questions

If pain is suspected, consider a time-limited If pain is suspected, consider a time-limited trial of an appropriate type and dose of an trial of an appropriate type and dose of an analgesicanalgesic

Nonpharmacological InterventionsNonpharmacological Interventions DistractionDistraction MassageMassage Heat/coldHeat/cold Gentle movement/repositioningGentle movement/repositioning Music therapyMusic therapy